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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 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 standard survey, completed on 12/6/24, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (Residents #10 and #25) of six residents reviewed. Specifically, Resident #25 had visible food residue in their top and bottom dentures on multiple observations; Resident #10 had visible chin hair and long nails with brown debris underneath on multiple observations. The findings are: The policy and procedure titled ADL Care Guidelines dated 10/2021, documented care givers will review the resident's nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. It also documented that the resident will be assisted with oral hygiene as appropriate, and dentures will be removed nightly and placed in a labeled denture cup with a cleaning tablet. The ADL policy documented female residents with excessive facial hair will be shaved at least weekly, if indicated and routine hand care will be done with bath and as needed. Fingernails should be cleaned underneath, and shaped. The policy and procedure titled Fingernail and Toenail Care, dated 7/3/2012, documented resident's fingernails would be monitored during their weekly skin assessments or on bath days. 1. Resident #25 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool), dated 10/17/24, documented Resident #25 was moderately cognitively impaired, and always understood and understands. Resident #25 required partial/moderate assistance with oral hygiene, and partial/moderate assistance with transfers out of bed to their wheelchair. Review of Resident #25's dental consult, dated 2/8/24, revealed they had a full upper denture and a partial lower denture, with a note staff to assist patient with daily cleaning of dentures, nightly and as needed. The comprehensive care plan last revised 10/25/24, documented Resident #25 had an ADL self-care performance deficit related to muscle weakness, and limited physical mobility related to weakness. The care plan also documented the resident had oral/dental health issues related to poor oral hygiene, and to provide mouth care as per ADL personal hygiene. There was no documentation that the resident had dentures or how to care for them. Review of the Closet Care Plan (used by staff to guide care) updated on 11/25/24, revealed the area labeled personal care had blank boxes where upper and lower dentures should have been checked and there were no instructions for denture care. Review of the Certified Nurse Aide task documentation for Resident #25 revealed from 12/3/24-12/5/24 oral hygiene was documented as Not Applicable. During an observation and interview on 12/2/24 at 9:22 AM, Resident #25 was in bed, there was visible food debris in both their upper and lower dentures. Resident #25 stated staff did not clean their dentures very often and could not recall the last time they were removed and cleaned. During observations and interviews, on 12/4/24 at 8:28 AM and 12/5/24 at 8:53 AM, Resident #25 had visible food debris in both their upper and lower dentures. They stated staff had not remove them to soak them. During an interview on 12/5/24 at 8:58 AM, Licensed Practical Nurse #1 stated that if a resident wore dentures, it should be documented on their care plan, so the staff knew to clean them. During an interview on 12/5/24 at 9:24 AM, Unit Manager, Licensed Practical Nurse #2 stated that the care plan should reflect if a resident wore dentures so the certified nurse aides would know to clean them. They stated it was important for dentures to be removed at night and soaked for proper hygiene, because bacteria could grow underneath them. They were not aware that Resident #25's dentures were not documented on their care plan. During an interview on 12/5/24 at 10:54 AM, Certified Nurse Aide #2 stated they looked at a resident's care plan to determine what type of oral care a resident needed. Certified Nurse Aide #2 stated that resident's dentures should be removed at night and placed in a denture cup to be sanitized. It was important for good hygiene and for their dignity to have clean teeth. They stated they did morning care on resident #25 that morning and they did not remove their dentures. Certified Nurse Aide #2 stated they could not recall the last time Resident #25's dentures were cleaned; they were in their mouth whenever they did the resident's morning care. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated that nursing care plans should be updated by the unit managers. Dentures should be documented on the care plan, so staff know to properly clean them. They expected Certified Nurse Aides to remove residents' dentures every night to soak them because it was important for good hygiene and dignity. 2. Resident #10 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented Resident #10 was cognitively intact, understood and understands. Resident #10 required supervision/touching assistance with hygiene, and substantial/maximal assistance with bathing. The comprehensive care plan initiated on 11/4/24, documented Resident #10 had an ADL self-care performance deficit related to muscle weakness. Interventions included the resident was independent/set up for grooming and extensive assist of one for bathing. During observations on 12/2/24 at 12:43 PM and 12/3/24 at 11:11 AM, Resident #10 was observed to be lying in bed wearing their own personal night gown. Resident #10 was observed have long fingernails with brown debris underneath and ?é½ inch long white chin hairs. During an observation and interview on 12/4/24 at 9:42 AM, Resident #10 was observed to continue to have long nails with brown debris and chin hairs. Resident #10 stated they minded having long chin hairs and would like the staff to help remove them and they would also like to have their fingernails cut. Resident #10 added they would like to have their hands and nails cleaned but staff do not give them anything to wash them with. Resident #10 stated they were new to the facility and still were getting used to the ways staff did things. During an observation on 12/4/24 at 10:13 AM, Certified Nurse Aide #8 and #9 performed morning care for Resident #10 by washing, rinsing, and drying the resident's neck, underneath their breasts and armpits, peri area and buttocks. Resident #10 was dressed in their personal gown and was not gotten out of bed. Certified Nurse Aide #8 and #9 did not wash nor offer to clean Resident #10's hands and nails or assist with removal of their chin hair. During an interview and observation on 12/6/24 at 10:29 AM, Resident #10 was observed to continue to have long nails with brown debris and chin hairs. Resident #10 stated that no staff members had offered to cut and clean their nails or assist them with chin hair removal during the week. During an interview on 12/4/24 at 1:30 PM, Certified Nurse Aide #8 stated that they did not perform nail care to Resident #10 and that they usually were not responsible to provide nail care to residents. They stated they did not know who was responsible to provide nail care. Certified Nurse Aide #8 stated that they did not notice the debris under Resident #10's nails and should have looked at their hands during care. They stated they did not offer Resident #10 to wash their hands and they should have. Certified Nurse Aide #8 stated the Activities Department usually was the department that would shave and/or cut a resident's hair. Certified Nurse Aide #8 stated they also did not offer to assist Resident #10 with chin hair removal and probably | Plan of Correction: ApprovedJanuary 8, 2025 1. Resident #25's careplan and closet care plan was updated by IDT. Resident received oral care on day of survey. The staff on resident#25 unit was educated on resident #25 careplan that reflects oral care ccp.Resident #10 has facial hair addressed during survey. Resident #10's care plan and closet careplan was updated by IDT. The staff on resident's #10 unit was educated on facial care plan by RN Educator. A full house review of all residents were completed and all facial hair and nail care per preference was performed. Any deficient practices were corrected immediately. 2. All residents are at risk for deficient practices of ADL care not being completed per plan of care. 3. POlicy and procedure titled ADL Care was reviewed by Director of Nursing and no changes were made to policy. 4. All nursing staff were educated by outside consultant on ADL care specifically dental care and facial hair. 5. All residents were audited for facial hair and dental care by RN and compared to CCP. Any deficient practices were corrected immediately. 6. Unit Mgrs./designee will conduct Care Plan, Closet Care Plan audits of 5 residents weekly on each unit for grooming needs/preferences. Unit LPNs will conduct 5 random observation audits of residents ADL/grooming/hygiene each shift during medication passes. Observation audits will be turned into the RN Supervisor/Unit Mgr and then turned over to the DON for trending and analyzing. The Unit Mgrs will conduct 5 random interviews per week with residents regarding grooming and care preferences. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 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 Standard survey completed 12/6/24 the facility did not ensure that residents with an indwelling foley catheter (tube inserted into the bladder to drain urine) received the appropriate care for one (Resident #45) of two residents reviewed. Specifically, staff did not maintain proper infection control practices for a resident with a foley catheter. The finding is: The policy and procedure titled Indwelling Catheter Care dated 2/2019, documented to keep the drainage tubing/catheter junction closed. Ensure the catheter is properly secured to upper thigh with securement device. 1. Resident #45 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 11/20/24 documented Resident #45 had moderate cognitive impairment, required substantial/max assistance with toileting and had an indwelling urinary catheter. The Clinical Physicians Orders dated 11/14/24 through 12/5/24 documented to flush foley with 30 milliliters of normal saline every day and as needed, and document foley output every shift. There were no other catheter care orders. The comprehensive care plan initiated 11/15/24 documented Resident #45 had an activities of daily living self-care performance deficit related to weakness. Interventions included extensive assist was required for toileting, bedpan use and foley care. The Kardex provided as of 12/6/24, documented Resident #45 required extensive assist was required for toileting, bedpan use and foley care. The Kardex posted in the resident's room on 12/5/24 during the observation did not indicate Resident #45 had a foley catheter. During an observation on 12/2/24 at 11:15 AM, Resident #45 was in bed. The foley catheter bag was attached to the bedframe and the bottom of the urinary drainage bag was directly on the floor; the spigot (spout used to empty urine from the collection bag) was not secured and was also touching the floor. The urinary drainage bag was dated 11/18/24 and the catheter tubing and bag contained yellow urine. During an observation on 12/5/24 at 9:18 AM, Resident #45 was in bed and the urinary drainage bag was attached to the bed frame, the catheter tubing and urine collection bag was on the floor. The urinary drainage bag was dated 11/18/24 and the catheter tubing contained cloudy yellow urine with mucous shreds. During an observation and interview on 12/5/24 at 1:04 PM to 1:21 PM, Certified Nurse Aide #5 placed the urinary collection bag spigot inside an undated urinal to empty urine from the collection bag. After draining the urine from the bag, they tapped the inside of the urinal with the spigot several times, clamped the spigot and then reconnected the spigot to the urinary drainage bag without sanitizing it. Resident #45's foley catheter was not secured to the securement device (leg strap) on the residents left thigh. Certified Nurse Aide #5 stated the securement device should be used so the resident's urine can flow better. They stated they should have wiped the spigot with an alcohol pad after emptying the drainage bag for infection control purposes. They stated they didn't have any alcohol pads and it slipped their mind to clean the spigot. Additionally, they stated they could have gotten alcohol pads from the clean utility room or from the nurse. During an interview on 12/5/24 at 1:44 PM, Licensed Practical Nurse #4 stated the spigot should be drained over a graduate, cleaned with alcohol to remove bacteria and germs for infection control purposes. During an interview on 12/5/24 at 2:00 PM, Unit 500 Manager Licensed Practical Nurse #2 stated an alcohol wipe should be utilized after draining urine from spigot to ensure nothing yucky was being left behind for infection control purposes. During an interview on 12/6/24 at 8:59 AM, the Infection Preventionist stated the process for emptying a foley catheter would be to perform hand hygiene, wear gloves, pull the spigot out of its holder, cleanse the spigot with an alcohol swab, empty the bag contents into a cylinder or urinal, cleanse the spigot again with an alcohol swab and replace into the holder. The Infection Preventionist stated they would expect the nursing staff to be careful not to hit the insides of the urinal/graduate with the spigot. The urinary drainage bag spigot should never be out of its holder laying on the floor nor should the foley drainage bag and tubing ever be laying directly on the floor because it could introduce bacteria into the bladder. During an interview on 12/6/24 at 9:56 AM, Licensed Practical Nurse #7 stated the foley catheter bag and tubing should not be touching or on the floor. The foley drainage bag should be replaced if it had been on the floor. Additionally, they stated the catheter drainage bag should be dated and changed every month or as needed. During an interview on 12/6/24 at 10:18 PM, Unit 500 Manager Licensed Practical Nurse #2 stated they expected foley catheter drainage bags and tubing to be kept off the floor for infection control purposes. It was the nursing teams responsibility to ensure catheter drainage bag and tubing weren't on the floor. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated they expected foley catheter drainage bags and tubing to be kept off the floor. They stated the spigot should not touch the graduate and should be cleaned, disinfected after use for infection control purposes. 10 NYCRR 415. 12(d)(1) | Plan of Correction: ApprovedJanuary 8, 2025 1. Resident #45 was assessed by RN for foley catheter care per policy and procedure including proper care of foley catheter care by staff. Any deficient findings were immediately addressed. All staff who provided care for Resident #45 was educated on policy and procedure for foley catheter care including proper infection control practices by RN Educator. All residents with foley cathers were audited by RN to ensure proper/appropriate practices were followed. Any deficient practices were corrected immediately. 2. All residents with foley catheter care are at risk for deficient practice of not following policy and procedure for proper foley catheter care including proper infection control practice. 3. Director of Nursing reviewed policy on foley catheter care and no changes were made to policy. 4. All nursing staff were trained by RN Educator on foley catheter care including proper infection control practices related to foley catheter care. 5. All residents with foley catheters will be audited weekly by unit manager/designe for month and monthly for 5 months for proper care of foley catheter care including proper infection control techniques This will include staff competency to ensure they are following all practices per policy on foley catheters.Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review conducted during the Standard survey completed on 12/6/24, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, one (Employee #3, Housekeeping Aide) of eight employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, was not reviewed through the New York State Nurse Aide Registry prior to their employment as required. The finding is: The undated policy and procedure titled New York State Nurse Aide Registry Check documented all individuals hired to work at the facility will undergo a review of qualifications, performance and will be checked against the New York State Aide Registry. The Human Resources or Administrative department will check all applicants against the New York State Nurse Aide Registry upon hire. Review of Employee #3's (Housekeeping Aide) personnel file revealed the employee was hired on 8/14/ 24. Review of the electronic timecard information provided by the facility revealed Employee #3 had worked in the facility on: - 8/15/24 from 10:00 AM to 2:00 PM. - 8/16/24 from 8:00 AM to 3:51 PM. - 8/17/24 from 7:54 AM to 4:02 PM. - 8/18/24 from 8:00 AM to 4:07 PM. Review of the New York State Nurse Aide Registry Verification Report for Employee #3 revealed the verification date on the report was 8/19/ 24. During an interview on 12/5/24 at 9:01 AM, the Human Resources Director and Staffing stated they were out of the building when Employee #3 went to General Orientation on 8/15/24 and conducted the Nurse Aide Registry Verification Report for the employee on 8/19/24 when they returned to the building. The Human Resources Director and Staffing further stated they were the only employee that conducted the New York State Nurse Aide Registry Verification Reports for the facility's employees. 10 NYCRR 415. 4(b) | Plan of Correction: ApprovedDecember 30, 2024 1. Employee #3 had nurse aide registry check completed by HR Director. The HR Director reviewed all employees for Nurse Aide Registry that had deficient practice of not having Nurse Aide Registry check completed prior to employment. Any deficient practices were corrected immediately by HR Director. 2. All residents are at risk for the deficient practices of new employees not having nurse aide registry check completed prior to employment. 3. Administrator reviewed policy and procedure for Abuse, Neglect and exploitation including process for New York State Nurse Aide registry verification. No changes were made. 4. The HR director was educated by Administrator on policy and procedure for Abuse, Neglect and exploitation including process for New York State Nurse Aide registry verification. 5. The Administrator will conduct weekly audits of new hires for 6 months and monthly for 6 months of all new hires including all new employees to ensure New York State Nurse Aide registry check is completed prior to hire. Any deficient practices will be corrected immediately and brought to QAPI for further review. Person Responsible: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during the Standard Survey completed on 12/6/24, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for six (Residents #10, #25, #36, #41, #43, and #65) of 28 residents reviewed for care planning. Specifically, Resident #10 did not have a care plan developed for skin integrity and had pressure ulcers; Resident #25 did not have a care plan developed for dentures; Residents #36 and #41 did not have a care plan developed for an alleged resident-to-resident altercation; Resident #43 did not have a care plan developed for skin care and incision care with treatments ordered, depression, cardiac, vision, dry nasal passages and supplements with medications ordered, and discharge planning; and Resident #65 did not have a care plan developed for bowel incontinence, safety, falls, and psychoactive medication use. The findings include: The policy and procedure titled Comprehensive Care Planning & Baseline with a revision date of 6/2021 documented a Care Plan will be individualized for each resident using a person-centered approach. The Comprehensive Care Plan will include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs that are identified from admission assessments, the comprehensive assessment and application of the Care Area Assessment. Additional problems, strengths or needs identified by the Interdisciplinary Team will be included in the Comprehensive Care Plan. The Comprehensive Care Plan will be completed no later than seven days following completion of the admission comprehensive assessment. The care plan must be individualized for each individual. All disciplines are responsible for reviewing the plan of care and documenting goals, interventions, monitoring notes and updating as needed. Chronic active [DIAGNOSES REDACTED]. 1. Resident #10 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented Resident #10 was cognitively intact, understood and understands. The assessment tool documented that Resident #10 had one stage III (wound that involves full thickness loss of tissue) pressure ulcer and one unstageable (full thickness skin and tissue loss where the depth of the wound is hidden by eschar (dead tissue) and slough (yellow/white soft, stringy, thick substance)) pressure ulcer upon admission. The comprehensive care plan, initiated on 11/4/24, documented Resident #10 had pressure ulcers on their left ischium and coccyx related to [MEDICAL CONDITION], diabetes mellitus and limited mobility. There were no care plan interventions developed for the pressure ulcers until 12/4/ 24. Review of the Wound Evaluation and Management Summary noted dated 11/25/24, the Wound Consultant documented that Resident #10 had chronic wounds on their sacrum and left ischium with history of osteo[DIAGNOSES REDACTED] (a serious bone infection). It was documented that Resident #10 had a stage IV (full thickness skin and tissue loss that exposes bone, muscle, tendon, ligament, or cartilage) pressure ulcer to their sacrum and left ischium with moderate serous drainage (clear/yellow drainage from a wound). During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that they added care plan interventions on 12/4/24 to Resident #10's comprehensive care plan for pressure ulcers after the surveyor requested a copy of the care plan. The Director of Nursing stated they added the care plan interventions because the care plan did not have any and they felt Resident #10 needed them. 2. Resident #25 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/17/24, documented Resident #25 was moderately cognitively impaired, and always understood and understands. Resident #25 required partial/moderate assistance with oral hygiene. The comprehensive care plan last revised 10/25/24, documented Resident #25 had an ADL self-care performance deficit related to muscle weakness, and limited physical mobility related to weakness. The care plan also documented the resident had oral/dental health issues related to poor oral hygiene, and to provide mouth care as per ADL personal hygiene. There was no documentation that the resident had dentures or how to care for them. Review of the Closet Care Plan (used by staff to guide care) updated on 11/25/24, revealed the area labeled personal care had blank boxes where upper and lower dentures should have been checked and there were no instructions for denture care. During an interview on 12/5/24 at 8:58 AM, Licensed Practical Nurse #1 stated that if a resident wore dentures, it should be documented on their care plan, so the staff knew to clean them. During an interview on 12/5/24 at 9:24 AM, Unit Manager, Licensed Practical Nurse #2 stated that the care plan should reflect if a resident wore dentures so the certified nurse aides would know to clean them. They stated it was important for dentures to be removed at night and soaked for proper hygiene, because bacteria could grow underneath them. They were not aware that Resident #25's dentures were not documented on their care plan. Unit Manager, licensed Practical Nurse # 2 stated that care plans had not been updated recently. They stated that care plans should be reviewed, at least annually if not quarterly, by the entire interdisciplinary team and involve the resident and/or their family. They stated they only worked in the facility for a few weeks, so they had not updated care plans yet. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated that nursing care plans should be reviewed/updated quarterly, by the unit managers and the interdisciplinary team. Dentures should be documented on the care plan, so staff know to properly clean them. 3. Resident #36 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented Resident #36 was cognitively intact, and always understood and understands. The assessment tool documented that the resident did not have any behaviors. Resident #41 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented Resident #41 was cognitively intact, and always understood and understands. The assessment tool documented that the resident did not have any behaviors. Review of a facility investigation summary dated 7/11/24, the Former Administrator documented that on 7/11/24 Resident #36 alleged that Resident #41 rolled up to them in their wheelchair in the lobby area of the facility. Resident #36 alleged that they told Resident #41 you are supposed to stay away from me (due to a previous allegation's intervention) and Resident #41 responded by hitting them in the arm. Resident #36 had no injuries and Resident #41 denied the accusation. The investigation documented the interventions included that both residents were re-educated and reminded to stay away from each other. The comprehensive care plan, date initiated 2/6/24, documented Resident #36 had impaired self-care skills related to muscle weakness. Interventions included that resident was independent with personal powered wheelchair. The care plan documented that Resident #36 had potential for alteration in mood related to [DIAGNOSES REDACTED]. There was no care plan development for the allegation of a resident-to-resident interaction including interventions to keep away from Resident # 41. The comprehensive care plan, date initiated 9/16/22, documented Resident #41 had limited self-care skills related to weakness. Interv | Plan of Correction: ApprovedJanuary 6, 2025 1. Resident #10 's careplan was reviewed by IDT Team and was updated to reflect wounds. The admissions nurse was reeducated on having careplan in place upon admission.Resident #25's careplan and closet care plan was reviewed by IDT and careplan was updated to reflect denture care. Resident #36's and resident #41 had careplan reviewed by IDT for behaviors by IDT and plan was updated to reflect residents status.Resident #43's careplan was reviewed by IDT and careplan and closet care plan was updated to reflect current status. Nurse who did residents admission was updated on policy and procedure on careplans by Director of Nursing. Resident #65 careplan and closet careplan was reviewed by IDT and updated to reflect current status. All residents Careplans were reviewed by RN for updated careplans reflecting current status. 2. All residents are at risk for deficient practice of not completing the careplan on admission and updating the careplan during the 21 day admission period as well as Quarterly and Annually to reflect changes occurred by resident. 3. Policy and procedure for baseline careplans and comprehensive careplan was reviewed by Director of Nursing. No changes were made to policy. 4. Outside consultant educated IDT on comprehensive careplan process and baseline careplanning. All licensed nurses were educated on careplan and closet care plan process by RN Educator.The Director of Nursing will be educated on the comprehensive careplan policy and procedure by the Consultant 5. All new admissions will be audited weekly for 4 weeks and monthly for 6 months to ensure all areas are careplanned and on closet careplan for staff to provide care to residents. 5 CCP will be audited by MDS coordinator to ensure CCP reflects all areas weekly for 1 month and monthly for 6 months. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review conducted during a Standard survey completed 12/6/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being either unlabeled or outdated in the refrigerator. The findings are: The undated facility policy and procedure titled Food Storage Refrigerator/ Freezer documented purpose is to ensure foods are stored properly to minimize spoilage and contamination, and to ensure taste and quality of food. All refrigerated foods should be labeled/ dated and discarded after three (3) days. The facility policy and procedure titled Food Safety Requirements Policy - use and storage of food and beverage brought in for resident's food procurement dated 11/2017 documented the policy is to provide safe and sanitary storage, handling, and consumption of all food. This includes the storage, preparation, distribution, and serving food in accordance with professional standards for food safety. The food service supervisors, cooks, dietary aides, or any persons who are in the kitchen working with any type of food, are responsible for adhering to the food safety requirements. During an observation of the main kitchen on 12/2/24 at 8:51 AM revealed the reach in refrigerator labeled #6 across from the walk-in refrigerator had nine plastic containers revealing the following: -3/4 quart of mixed fruit was not labeled or dated and had black debris floating on the mixed fruit and on the inside sides of the container. -1/4 quart of sliced pears was not labeled or dated and had green/grey debris on the pears. -1 ?é½ quarts of chopped peaches were not labeled and marked with a date of 11/ 11. -1 ?é½ quarts of chopped peaches were not labeled and marked with a date of 9/24/ 24. -2 quarts of chopped pears were not labeled or dated. -1/4 quart of chopped peaches were not labeled or dated. -1/2 pitcher of unidentifiable brown liquid was not labeled or dated. -1/4 pitcher of unidentifiable yellow liquid was not labeled or dated. -2 ?é½ quarts of orange pudding like consistency was not labeled or dated. During an interview on 12/2/24 at 9:16 AM, dietary Cook #1 stated all food items should be labeled and dated when opened and disposed of after 3 days. They stated all the items identified must be disposed of as they do not know when they were placed in the refrigerator. They stated they believe the black floating debris in the mixed fruit and green/grey debris on the pears is mold and must have been in the refrigerator greater than 3 days. During an interview on 12/2/24 at 9:32 AM, the Dietary Department Director stated all opened food items are to be labeled and dated and disposed of after 3 days from opening. They stated the dietary aides are responsible to date and label the items, although they are ultimately responsible to ensure the staff are following the facility's policies and procedures, and regulations. They stated they believe the black debris and green/grey debris identified in the containers was mold and would have been opened greater than 3 days.They stated this is for food safety to prevent contamination and molding. 10 NYCRR 415. 14(h) 14- 1. 43(e) | Plan of Correction: ApprovedJanuary 3, 2025 1. Administrator reviewed policy and procedure titled Food safety requirements. No changes were made. All items listed that were outside of the 3 days were thrown away. All kitchen staff were immediately educated on the Food Safety requirements by Food Service Director. 2. All residents are at risk for deficient practice of having refrigerated foods past 3 days. 3. The refrigerator was reviewed for all food past 3 day requirements and any undated food by Food Service Director. Any deficient practices were corrected immediately. 4. All dietary staff were educated by outside consultant regarding food safety. 4. The refrigerator and freezer will be audited daily by Food Service Director and supervisor for undated food and food outside of the 3 day period. This will occur daily for 6 months and weekly for 6 months. All deficient findings will be corrected and brought to QAPI for further review. Person Responsible: Food Service Director |
Scope: N/A
Severity: N/A
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey completed on 12/6/24, the facility did not assure that criminal history information was requested, received, reviewed, and acted upon in a timely manner. Specifically, the facility did not submit fingerprint information to the Criminal History Record Check Legal Review Unit in a timely manner. This affected one (Employee #3) of five employees that were hired in the last for months and were subject to be reviewed for compliance with Criminal History Record Check regulations. The finding is: According to New York State Part 402: Criminal History Record Check, effective 12/2/09, each provider shall assure that criminal history information is requested, received, reviewed, and acted upon in a timely manner. Review of the policy and procedure titled Criminal Background Check with a date of revision of 2023 documented, Fingerprinting: The applicant shall be fingerprinted, at an official fingerprinting site and return official documents from the site to the Human Resources department. Review of Employee #3's (Housekeeping Aide) personnel file revealed the file contained no documentation that the employee had been fingerprinted and that that fingerprint information was provided to the Criminal History Record Check Legal Review Unit. Review of the electronic timecard information provided by the facility revealed Employee #3 had worked in the facility for 83 days between 8/14/24 and 12/4/ 24. During an interview on 12/4/24 at 1:24 PM the Human Resources Director and Staffing stated they started working at the facility on 7/15/24 and the facility had been having issues with the credit card that the facility had on file with the contractor that conducted digital fingerprinting for the Criminal History Record Check process. The Human Resources Director further stated they had scheduled two fingerprinting appointments for Employee #3, but the employee had not been fingerprinted because the contractor did not approve the code the employee had been provided for the fingerprinting appointment due to issues with the credit card that was on file with the contractor. The Human Resources Director and Staffing also stated sometimes the credit card worked and the employees would be fingerprinted and sometimes the credit card did not work, and employees would not be fingerprinted. During an interview on 12/4/24 at 2:07 PM the Administrator stated they were aware of the issues with the credit card that was on file with the contractor that conducted digital fingerprinting for the facility for the Criminal History Record Check process. The contractor was not able to charge the facility for the fingerprinting fee on the first card that was on file with the contractor and the contractor would not fingerprint the employees. The Administrator further stated they had contacted the contractor through email starting on 8/5/24, to address issues with the credit card. The facility had to fill out and submit a form and provide information for a second credit card to be on file with the contractor. The facility also had to fill out and submit new contact information forms for the facility staff that were conducting the Criminal History Record Check process. The contractor had to be emailed several times and the process for the contractor to review and approve the forms was a lengthy process. The Administrator also stated they had informed all department heads to ensure supervision was being conducted and documented, for all staff that were subject to the Criminal History Record Check process. Review of emails between the Administrator and the contractor that conducted digital fingerprinting for the facility for the Criminal History Record Check process revealed the facility had been in contact with the contractor regarding updating the facility contact information and the credit card information on 8/28/24, 9/11/24, 9/24/24, and 10/15/ 24. During an interview on 12/5/24 at 9:01 AM the Human Resources Director and Staffing stated they were the only Authorized Person that conducted Criminal History Record Checks on the facility's employees and that they had to schedule a fingerprinting appointment for Employee # 3. 10 NYCRR 402. 4(a)(1) | Plan of Correction: ApprovedDecember 30, 2024 1. All employees hired in past 6 months were audited by HR Directed to ensure all CHRC fingerprinting was completed per policy and procedure for CHRC. Any Deficient practices were corrected immediately. Administrator was added for CHRC processing. 2. All residents are at risk for CHRC not being completed per policy. 3. Administrator reviewed policy on CHRC and no changes were made. 4. Administrator educated HR Director of CHRC. 5. Administrator to conduct weekly audits of all new hires and CHRC checks to ensure policy and procedure for CHRC is being followed. Any Deficient practices will be corrected and brought to QAPI for furthe review. Person Responsible: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview and record review conducted during a Standard survey, completed on 12/6/24, the facility did not ensure information on how to file a grievance or complaint was available to the residents and that they had an established grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights. Specifically, Resident Council was unaware of the process and policy on how to file a grievance or a compliant. The facility did not have a policy to ensure prompt resolution of all grievances regarding resident rights that included all required information. The findings are: During a Resident Council meeting on 12/3/24 at 10:30 AM, 7 of 7 Resident Council attendees stated they did not know how to file a grievance or who acted as the Grievance Officer. The residents stated the facility does not always respond to concerns voiced (staffing concerns, and customer service issues). This involved Resident's #17, 34, 36, 61, 70, 82 and 96. During an interview on 12/6/24 at 11:18 AM, Activities Department Director stated they were not aware if the facility had of a Grievance Officer. They stated when concerns, grievances were expressed during Resident Council meetings, they believed the Social Worker addressed them. They stated some concerns go to a specific department or the Administrator. They stated they weren't aware of a grievance policy or where the grievance forms were kept. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated it was important for residents to know how to file a grievance. They stated residents always need to be advocated for, so they feel comfortable while in the facility and that their concerns were addressed. The Director of Nursing stated blank grievance forms were kept at the receptionist desk and maintained by the Social Worker. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 3:01 PM, the Receptionist stated they had not had any blank grievance forms available in a long time. They stated no families or residents had asked for a form but they should have them available if needed. During an interview on 12/6/24 at 4:18 PM, the Administrator stated they didn't have a specific Grievance Officer and the Social Worker would be responsible for grievances. They stated grievance forms should be available at the reception so anybody can have access to them. The Administrator stated grievances provide a paper trail and allows for facility follow up. The Administrator stated grievances should be reviewed during morning meeting and they should have ensured grievances were followed up on. Additionally, they stated they hadn't changed the grievance process. During an interview on 12/6/24 at 4:40 PM, the Director of Nursing stated the facility did not have a grievance policy and procedure. During an interview on 12/6/24 at 5:26 PM, the Administrator provided a grievance binder that included filed grievance forms. Review of grievance forms within the binder revealed there was no department head follow up or signatures. The Administrator stated grievances were not being reviewed and process was not being followed. 10 NYCRR 415. 3 (d)(1)(i) | Plan of Correction: ApprovedJanuary 6, 2025 1. Social Worker met with resident 17, 34, 36, 61, 70, 82 and 96 and copy of the updated policy and procedure was provided to explain the grievance process. Social Worker also explained to resident that the Social Worker is the grievance coordinator. All residents were provided a copy of the grievance policy and procedure with Grievance Coordinator name by Social Worker. A resident Council meeting was held with Social Worker to review process. Grievance posters and Ombudsman Posters are posted on all floors, front desk and chapel. Ombudsman will be provided the resident council schedule to allow them the ability to participate.Resident rights will be reviewed at monthly resident council meeting. 2. All residents are at risk for deficient practice of not having process in place for residents to voice concerns. 3. Administrator created new policy and procedure of Grievances including who is the grievance coordinator. 4. All residents were given copy of new grievance procedure including who is the grievance coordinator. Family Meeting held on (MONTH) 15, 2025 to discuss new policy and procedure on grievances.All staff were educated by RN Educator on new grievance policy and with all new general orientation for all new hires. 5. Social Worker was educated by Administrator regarding new policy and procedure. 6. All grievances will be reviewed monthly at QAPI for trends. Any deficient findings will be corrected. Person Responsible: Social Worker |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 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 a Standard survey completed on 12/6/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #30) of one resident reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #30's left and right palm guards (assistive device that positions the fingers away from the palm) were worn as recommended by occupational therapy. In addition, there was inconsistent documentation that range of motion exercises were provided to the resident per their care plan. The finding is: The policy and procedure titled Range of Motion and Ambulation revised 9/15/2020, documented that every effort would be made to ensure that residents do not lose range of motion, ability to walk or activities of daily living abilities unless the loss is unavoidable. Certified nursing assistants are expected to assist with range of motion in accordance with the care plan and document that range of motion has been provided prior to the end of their shift in the electronic medical record. The policy and procedure titled Splint revised on 10/19/2015, documented that physical therapy/occupational therapy will determine the need of splint for the resident. Nursing, resident, and family members as indicated will be instructed in the wearing schedule and would be written on the plan of care/care guide. Resident #30 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 11/26/24, documented Resident #30 had severe cognitive impairment, was rarely/never understood, and rarely/never understands. The Minimum Data Set documented Resident #30 had upper extremity functional limitation in range of motion on one side. The comprehensive care plan dated 12/13/17, documented that Resident #30 had limited mobility and was on a restorative nursing program. The program included assistive active range of motion (exercises performed by resident with some help from staff) to bilateral (both) lowers extremities and passive range of motion (exercises performed on the resident by nursing staff) to bilateral upper extremities three times weekly on Mondays, Wednesdays, and Fridays. Resident #30 wore right and left palm guards as tolerated except for range of motion, hygiene, meals and when asleep. Review of the Occupational Therapy Discharge Summary dated 9/20/24 documented nursing caregivers were instructed on the restorative nursing program which included bilateral upper extremities passive range of motion. The splinting/orthotic schedule was reviewed with nursing staff to preserve Resident #30's current level of function. During intermittent observations on 12/2/24 at 3:27 PM, Resident #30's right hand was curled into a fist. The left hand was gripping the wheelchair seat, there were no palm guards in the resident's hands. On 12/4/24 at 9:16 AM, 3:54 PM, and 12/5/24 at 10:48 AM there were no palm guards in Resident #30's left or right hand. Review of the Order Audit Report dated 12/5/24 revealed an active standing physicians order dated 11/30/22 for right and left palm guards to be worn except for range of motion, hygiene, and while asleep. The Medication Administration Record [REDACTED]. There were no start or end dates and there were no staff initials that documented the palm guards were worn. There was an x documented from 12/1/24-12/31/ 24. Review of the Documentation Survey Reports for 9/2024,10/2024,11/2024 and 12/2024 revealed Resident #30 was on a restorative nursing program for upper extremity and lower extremity range of motion three times weekly on Mondays, Wednesdays, and Fridays. There were multiple blanks where the range of motion wasn't documented as completed. During observation and interview on 12/5/24 at 1:48 PM, Certified Nursing Assistant #5 stated that palm guards prevented worsening contractures (loss of joint mobility) and verified Resident #30 had no palm guards in their hands per the care plan. They checked Resident#30's room, and the palm guards were missing. They never realized that Resident #30 did not have them on this morning. Rolled up wash cloths should have been used for Resident #30 to hold onto until the palm guards were located. Certified Nursing Assistant #5 stated the night shift was responsible for dressing Resident #30 and they got the resident out of bed. Certified nursing assistant's provided range of motion with morning care or when they go back to bed in the afternoon. Documentation was completed after the task was provided or by the end of the shift. During an interview on 12/5/24 at 10:23 AM, Certified Nursing Assistant #6 stated Resident #30 tolerated the palm guards when they wore them. Certified nursing assistants were responsible to provide range of motion and the blanks in the documentation indicated range of motion was not done. During an interview on 12/5/24 at 2:06 PM, Licensed Practical Nurse #1 stated that Resident #30 should wear right and left palm guards. Licensed Practical Nurse #1 observed the resident and stated they were not wearing their palm guards. Licensed Practical Nurse #1 checked the residents care plan and stated the resident was care planned to wear the palm guards at all times except for range of motion, hygiene, meals and while sleeping. Licensed Practical Nurse #1 stated palm guards prevented contractures and skin potential breakdown. Certified nursing assistants were responsible to ensure residents had their devices when they were gotten up for the day. Certified Nursing Assistant #5 should have checked the care plan and Licensed Practical Nurse #1 would have expected to be notified if the palm guards were missing. During an interview on 12/5/24 at 2:30 PM, Licensed Practical Nurse #2, Unit Manager stated Certified Nursing Assistant #5 should have read the care plan and communicated to Licensed Practical Nurse #1 the palm guards were not in Resident #30's room. Licensed Practical Nurse #1 should have informed them, and they would have notified therapy to replace the palm guards. Licensed Practical Nurse #2, Unit Manager stated there was no process of monitoring documentation for range of motion and it was a team effort. During an interview on 12/6/24 at 10:36 AM the Director of Therapy #1 stated Resident #30's palm guards were recommended by occupational therapy and updated on the care plan. Certified Nursing Assistant #5 should have made sure the palm guards were on after reading Resident #30's care plan. Nurses were responsible to ensure that the certified nursing assistants put on the palm guards, performed range of motion, and completed the documentation. The blanks on the Documentation Survey Report indicated uncertainty that range of motion was being done as recommended. Palm guards were important because they prevented further contractures for Resident # 30. During an interview on 12/6/24 at 2:10 PM, the Director of Nursing stated they expected that Resident #30 would wear the palm guards if they are care planned and Certified Nursing Assistant #5 should have put them on. The Unit Manager, Licensed Practical Nurses and all staff were responsible to make sure the resident's care plan was followed. The palm guards were a standing physician's orders [REDACTED]. Range of motion exercises were expected to be done with morning care and documented when completed in the electronic medical record by the assigned certified nursing assistants. If the resident was unavailable or refused, they would expect the resident to be reapproached later. During an interview on 12/6/24 at 2:05 PM, the Administrator stated it was important to | Plan of Correction: ApprovedDecember 30, 2024 1. Resident #30 was reviewed by PT/OT for range of motion. Resident #30 had left and right palm guards applied per plan of care. All staff on resident #30 was trained on residents plan of care for left and right palm guards. All staff on resident #30's unit was trained on documentation for range of motion and residents plan of care by RN Educator. 2. All residents with Range of motion orders are at risk for deficient practice of not providing Range of motion or adaptive equipment per plan of care. 3. Director of Nursing reviewed policy and procedure on Range of motion and splints. No changes were made to policy. 4. All Residents with Range of motion orders and/or splints were audited to ensure resident had adaptive equipment applied per plan of care by RN. All residents documentation for past 30 days was audited by RN for documentation regarding ROM and splint use. Any deficient practices were immediately corrected and brought to QAPI for further review. 5. All nursing staff were trained on policy and procedure of ROM and policy and procedure for splint care by RN Educator. 6. 5 residents on Range of Motion will be audited by MDS weekly for 2 months and monthly for 3 months for documentation on range of motion. Any deficient practices will be immediately corrected and brought to QAPI for further review. 5 residents with splint application will be audited by therapy to ensure splints are applied per plan of care, this will be done weekly for 2 months and monthly for 3 months. Any Deficient practices will be corrected immediately. Person Responsible: Therapy Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 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 a Standard survey completed 12/6/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for two (Resident #10 and #43) of four residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) during care. Specifically, Resident #10 had chronic pressure ulcers (injury to the skin and tissues from prolong pressure to the area) and the Certified Nurse Aides did not wear proper personal protective equipment during morning care. Additionally, Resident #42 had an [MEDICAL CONDITION] (a surgical operation in which a piece of the intestine is diverted to an opening in the stomach wall) and the nurse did not wear proper personal protective equipment during care. The findings are: Review of the policy and procedure titled Enhanced Barrier Precautions dated 4/2024 documented that residents in nursing homes are at increased risk of becoming colonized and developing infection with multi-drug resistant organisms, especially those with risk factors like indwelling medical devices or wounds. It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of the organisms. The policy documented that enhanced barrier precautions involve gown and gloves use during high-contact resident care activities for residents who were at increased risk of multi-drug resistance acquisition. High contact resident activities include dressing, bathing, providing hygiene, device care or use, and wound care. 1. Resident #10 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 11/11/24, documented Resident #10 was cognitively intact, understood and understands. Resident #10 required substantial/maximal assistance with bathing and had one stage 3 (wound that involves full thickness loss of tissue) pressure ulcer and one unstageable (full thickness skin and tissue loss where the depth of the wound is hidden by eschar (dead tissue) and slough (yellow/white soft, stringy, thick substance)) pressure ulcer. The comprehensive care plan revised on 12/4/24, documented Resident #10 had pressure ulcers related to [MEDICAL CONDITION], diabetes mellitus and limited mobility. Interventions included to administer treatments and medications and to follow facility policies/protocols for prevention/treatment of [REDACTED]. Review of the Wound Evaluation and Management Summary noted dated 11/25/24, the Wound Consultant documented that Resident #10 had chronic wounds on their sacrum and left ischium with history of osteo[DIAGNOSES REDACTED] (a serious bone infection). It was documented that Resident #10 had a stage IV (full thickness skin and tissue loss that exposes bone, muscle, tendon, ligament, or cartilage) pressure ulcer to their sacrum and left ischium with moderate serous drainage (clear/yellow drainage from a wound). During an observation on 12/2/24 at 12:43 PM, Resident #10 was noted to have a precaution sign on the door indicating stop, staff to wear gloves and gown during care. A plastic bin was observed to be outside the resident door in the hallway filled with gowns and masks. During an observation on 12/4/24 at 10:13 AM, precaution signage remained on the door and the plastic bin was now located inside the door entrance to the right-hand side. Certified Nurse Aide #8 and #9 performed morning care to Resident #10 by washing, rinsing, and drying the resident's neck, underneath their breast and armpits, peri area and buttocks. Resident #10 was observed to have open areas to their sacrum and left ischium that were not covered with any dressings. Certified Nurse Aide #8 and #9 did not wear gowns during the morning care observation. During a wound care observation on 12/4/24 at 10:42 AM, immediately following the completion of morning care, Licensed Practical Nurse #10 donned a gown prior to initiating the care. Resident #10's left ischium wound was noted to be moist with area of slough in the wound bed. Serosanguinous drainage (watery drainage mixed with blood from a wound) was noted on the gauze pad as the wound was cleansed with wound cleaner and prior to the application of the ordered ointment the wound began to actively bleed. During an interview on 12/4/24 at 1:30 PM, Certified Nurse Aide #8 observed the precaution signage on Resident #10's door and stated they did not pay attention to the signage on the door. They stated they should have worn a gown during morning care. Certified Nurse Aide #8 stated Resident #10 had a wound and because they did not wear a gown, they did not protect themselves from possible germs. During an interview on 12/4/24 at 1:59 PM, Certified Nurse Aide #9 observed the precaution signage on Resident #10's door and stated the sign meant that they were to wear a gown when providing care to Resident # 10. They stated that themselves and Certified Nurse Aide #8 did not wear gowns during morning care for Resident #10 because they were not used to being observed performing their duties and they both were nervous being observed. Certified Nurse Aide #9 stated the purpose of wearing gowns for residents that were on enhanced barrier precautions was for infection control reasons. During an interview on 12/5/24 at 12:16 PM, Licensed Practical Nurse #10 stated enhance barrier precautions were when any type of care was given to a resident that had a wound and the area was exposed. Licensed Practical Nurse #10 stated that Resident #10 had chronic pressure ulcers. They stated that at any point during care Resident #10's dressing could come off and that it often did. Licensed Practical Nurse #10 stated staff needed to wear a gown when providing care to Resident #10 because the area could become infected at any time. 2. Resident #43 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/28/24 documented the resident was understood, understands, was cognitively intact. The comprehensive care plan for Resident #43 dated 10/24/24 identified as current by the Director of Nursing, did not have a focus area, goals or interventions for enhanced barrier precautions. Observation on 12/2/24 at 11:10 AM, revealed signage on Resident #43's room door for precautions with directions to don a face mask, gloves, and a gown. There was a multi-pocket storage container hanging on Resident #43's door with gowns, gloves, masks, and face shields available. There was a bin located outside Resident #43's doorway in the hallway with additional personal protective equipment including masks, gloves, and gowns. During an observation and interview on 12/4/24 at 9:42 AM, Licensed Practical Nurse #9 donned gloves and a mask and performed changing Resident #43's [MEDICAL CONDITION] bag/flange, they did not wear a gown. Licensed Practical Nurse #9 stated Resident #43 was on Enhanced Barrier Precautions because of the [MEDICAL CONDITION]. They stated they applied gloves and a mask and should have also donned a gown before changing the [MEDICAL CONDITION] flange, for infection control, and they stated they have no excuse why they didn't, just that they had forgotten to put on a gown. During an interview on 12/6/24 at 10:42 AM, Nursing Supervisor/Unit Manager Licensed Practical Nurse #5 stated Resident #43 was on Enhanced Barrier Precautions because they had an [MEDICAL CONDITION] and would have expected Licensed Practical Nurse #9 to have donned gloves, mask and a gown prior to changing Resident #43's [MEDICAL CONDITION] bag/flange for infection control purposes to protect the resident. During an interview on 12/6/24 at 8:59 AM | Plan of Correction: ApprovedJanuary 8, 2025 1. Resident #10, #43 and Resident #42 was reviewed by the Infection Preventionist. The careplan was review and closet careplan was updated by Director of Nursing to reflect the Enhanced Barrier precautions needed to provide care. All staff assigned to Resident #10, Resident #43 and Resident #42 will educated by Infection preventionist on proper Enhanced Barrier PPE needed to provide care.IDT team makes decisions based on current criteria for EBP for enhanced barrier precautions. It is the Unit manager/designee who ensure compliance of all residents on EBP. Any deficient practices corrected and brought to DON for review. 2. All residents with Enhanced Precaution Barriers are at risk for the deficient practice of staff not wearing proper PPE when providing care. 3. Director of Nursing reviewed the policy and procedure on Enhanced Barrier Precautions and no changes were made to policy. 4. All staff were educated by consultant on Enhanced Barrier Precutions. 5. An Audit of all residents on Enhanced Barrier Precaution was conducted by Infection Preventionist to audit staff wearing of PPE. Any deficient practice will be corrected immediately and brought to QAPI for further review. 6. 5 residents on Enhanced Barrier Precautions will be audited weekly to ensure staff are wearing proper PPE when providing care. Any deficient practice will be corrected and brought to QAPI for further review. Person Responsible: Infection Preventionist |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during a Standard survey completed 12/6/24, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight for one (Resident #65) of two residents reviewed. Specifically, Resident #65 had a significant weight loss and there was a lack of meal and nourishment acceptance being documented or recorded. In addition, the medical provider was not made aware of the significant weight loss. The finding is: 1. Resident #65 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #65 had severe cognitive impairment, required supervision/touch assist for eating, weight was 105 pounds and weight loss marked no or unknown. Additionally, Resident #65 was on a therapeutic diet. During breakfast and lunch meal observations on 12/5/24 at 9:11 AM and 12:53 PM, Resident #65 was sitting in the unit dining room with meal. Meal ticket on tray it was noted alert- extensive assist feeding. No staff present at table to provide assist during meal. Staff that were present were observed assisting other residents in the unit dining room. Meal ticket did not indicate what supplements they were to receive. Shake was observed on breakfast tray and boost was present on lunch tray. The Order Summary Report dated 12/6/24 documented No Added Salt diet, Regular texture, thin consistency with start date 7/3/ 24. Obtain admission weight and height, one time only for admission. Review of the Medical Orders for Life Sustaining Treatment (MOLST) last updated 9/18/24, revealed Resident #65 had a do not attempt resuscitation, do not intubate, send to hospital order when medically necessary. There were limited medical interventions which included no feeding tube, administer intravenous fluids, and use antibiotics to treat infections. The comprehensive care plan for Resident #65 initiated on 7/3/24 identified as current by the Director of Nursing, documented the resident had potential for nutritional risk related to body mass index 19. 6, dietary restrictions secondary [DIAGNOSES REDACTED]. Dated 8/20/24 significant weight loss and 11/8/24 weight loss trend noted. Goal was to maintain adequate nutritional status as evidenced by maintaining weight within 1-5 pounds of current weight. Interventions included monitor meal consumption records, monitor weights as per policy, provide and serve supplements: shake at lunch and dinner, monitor acceptance and effects. On 8/29/24 shake was changed to Boost plus, on 9/20/24 shake added at breakfast and on 11/8/24 magic cup added every lunch. Report significant weight losses to medical doctor and interdisciplinary care team for input. Additionally, Resident #65 had limited self-care skills related to weakness, required extensive assist for feeding. Review of the Closet Care Plan last revised on 10/2/24 documented eating as extensive assist of 1 on unit. Review of the Weights and Vitals Summary dated 12/6/24 revealed the following weights and weight status: -7/2/24 admission weight was 114 pounds. -8/20/24 weight was 107 pounds. -9/13/24 weight was 105 pounds which showed a change/loss of 7. 9 percent or 9 pounds since 7/2/ 24. -10/7/24 weight was 103 pounds which showed a change/loss of 9. 6 percent or 11 pounds since 7/2/ 24. -11/11/24 weight was 100. 5 pounds which showed a change/loss of 11. 8 percent or 13. 5 pounds since 7/2/ 24. -12/6/24 weight 98 pounds which showed a change/loss of 14 percent or 16 pounds since 7/2/ 24. Review of the Initial Nutrition Assessment completed by the Dietary Technician dated 7/3/24, revealed admission weight on 7/2/24 was 114 pounds with a body mass index of 19. 6. Diet order of No Added Salt regular consistency thin liquids provides 1600-1700 kilocalories, 65-75 grams protein and 1200 milliliters fluids. Shakes at lunch and dinner provided 600 kilocalories, 22 grams protein and 360 millimeters of fluids. Estimated needs were 1554-1813 kilocalories, 51. 8- 62. 2 grams of protein and 1544 milliliters of fluid per day. Actual intake for solids, liquids, and supplements to be monitored. Review of the dietary progress note dated 8/29/24 revealed weights reviewed, 8/20/24 weight was 107 pounds indicating a significant loss from previous weight. Intake of meals 26-100 percent. Shake provided at lunch and dinner with acceptance generally greater than 50 percent. Shake was changed to Boost plus for increased kilocalories. Monitor acceptance and effects. Review of the dietary progress note dated 9/20/24 revealed weights reviewed, 9/13/24 weight was 105 pounds indicating a 2-pound loss from previous weight. Intake of meals 26-100 percent. Supplements provided, acceptance 25-100 percent. Shake was added at breakfast for increased kilocalorie, monitor acceptance and effects. Review of the Quarterly Nutrition assessment dated [DATE] completed by the Dietitian revealed documented weight on 9/13/24 was 105 pounds with no significant weight change noted. Current diet and supplements provided met residents estimated needs. Intake was fair to good. Meal plan supplemented with Boost plus twice daily and shake daily. Weight indicates some decline since admission. Review of the dietary progress note dated 11/11/24 revealed weights reviewed, 11/8/24 weight 100. 5 pounds with weight loss trend noted. Intake of meals usually 26-75 percent. Supplements provided with meals, acceptance generally 100 percent. Magic cup added daily to lunch for increased kilocalorie, monitor acceptance and effects. Review of the undated Nutrition-Amount Eaten 30 day look back revealed out of 90 meals only 20 were documented for meal intakes. Review of the undated Nutrition-Supplement for Breakfast: Boost plus, Lunch: Boost Plus, Dinner: Boost Plus 30 days look back revealed out of 30 days only 13 days were documented and out of 90 supplement opportunities only 25 were documented. Review of all the departments progress notes dated between 9/2/24- 12/6/24 revealed no evidence that the medical provider or the resident representative were notified of Resident #65's significant weight loss. Review of the medical provider notes dated 9/18/24, 9/19/24, 10/24/24, and 11/15/24 revealed no evidence of notification of weight loss. 9/19/24, 10/24, and 11/15/24 documented review of systems, denied weight loss. Review of the Speech Screening dated 7/4/24 revealed swallowing regular consistency with thin liquids within functional limits. Review of Occupational Therapy Screen dated 10/14/24 revealed recommendation to Nursing for feeding was extensive assist with minimal help. During an interview on 12/2/24 between 12:12 PM-12:28 PM Resident #65's family member stated they felt the resident had lost weight. Resident #65's family member stated the resident needs assistance to eat due to confusion and impaired vision. They stated they weren't sure that the resident was receiving the required help and they had expressed this before to nursing. During an interview on 12/5/24 at 1:44 PM, Licensed Practical Nurse #4 stated they should be made aware of weight loss so they can monitor for adequate meal intake. They stated if weight loss was indicated on the 24-hour nurse report they would ask the Certified Nurse Aides what the resident consumed so it could be documented in the progress notes. Licensed Practical Nurse #4 stated the Certified Nurse Aides are responsible for documenting acceptance percentages of meals in the electronic medical record. Licensed Practical Nurse #4 stated they were not aware that Resident #65 had a weight loss. During an interview on 12/6/24 at 10:18 AM, Unit 500 Manager, Licensed Practical Nurse #2 stated the Dietitian enters weights in the electronic medical record, tracks resident's weights and alerts the Unit Managers of weight changes. They stated they were not aware Resident #65 had a weight loss and should have been notified so nursing follow up could be completed. They stated if | Plan of Correction: ApprovedJanuary 13, 2025 1. Resident #65 was reviewed by Dietitian for weight loss and conducted detailed nutritional assessment. Physician was updated on any change in weight. Any deficient findings were corrected immediately. The Occupational Therapy department conducted a review of the resident #65's plan of care and observed resident in unit dining including using adaptive equipment as per plan of care. Any Deficient practices were corrected immediately. The MD conducted full review of the patient to review for weight loss. The Unit manager and/or designee will review meal consumption and ensure accuracy on daily basis. Any deficient practices were corrected immediately. The Director of Nursing reviewed the resident #65 meal consumption record. Any Deficient findings were corrected immediately. All staff members who take care of Resident #65 was reeducated on residents plan of care related to meal intake and documentation on food consumption by RN Educator. It is the Dietitians responsibility to alert Nursing to update Physician of any weight loss and document in medical record. 2. All residents with significant weight loss are at risk for deficient practice of resident not being reviewed by IDT and MD for weight loss and lack of nourishment and meal acceptance by nursing staff. 3. Policy and procedure for meal and nourishment was reviewed by Director of Nursing and no changes were made. 4. All nursing staff were trained by RN Educator on meal and nourishment intakes. 5. All residents meal intakes with significant weight loss were audited by Dietitian for lack of documentation, Dietitian reported any weight loss to nursing manager to update physicians of weight loss. Any deficient findings were immediately addressed. 6. All resident meal consumption records will be audited by Diet Tech / Nursing Supervisor daily for 3 months and weekly for 2 months for deficient practice of lack of documentation for meal consumption. Any deficient findings will be corrected immediately and brought to QAPI for further review. Diet tech/Dietitian and designee will audit meal pass weekly for meal acceptance. Any deficient practice will be corrected. The Unit manager/desginee will audit meal consumption daily for meal observation versus documentation accuracy. Any Deficient practices will be corrected immediately and brought to QAPI for further review. Person Responsible: Dietitian |
Scope: N/A
Severity: N/A
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey completed on 12/6/24, the facility did not maintain Public Health Law 2803- 12. Specifically, the facility's Pandemic Emergency Plan (PEP) was not made available to the public on one of one facility website. The finding is: The New York State (NYS) Department of Health (DOH) Dear Administrator Letter (DAL) Nursing Home (NH) 20-09 dated 8/20/20 documented that each residential health care facility, by (MONTH) 15, 2020, shall prepare and make available to the public on the facility's website, and immediately upon request, a Pandemic Emergency Plan (PEP). During an interview on 12/5/24 at 1:43 PM, the Administrator stated the facility had a Pandemic Emergency Plan (PEP), and it was not available to the public on the facility's website. Review of the facility's website with the Administrator revealed the Pandemic Emergency Plan (PEP) was not on the website. New York State Public Health Law PHL 2803-12(a) | Plan of Correction: ApprovedDecember 31, 2024 1. Facility posted Pandemic Emergency Plan on website. 2. All residents are at risk for not having accessibility of the PEP plan available to them per policy and procedure for PEP. 3. PEP was reviewed by Administrator and changes were made to PEP prior to posting to website. 4. Admissions staff will be educated on process of posting up to date PEP by Administrator 5. The QAPI reviewed PEP prior to posting to website. The PEP will be brought to QAPI quarterly and website will be checked quarterly by Administrator to ensure compliance. Person Responsible: Administrator |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview and record review conducted during the Recertification survey completed on 12/6/24, the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance and had repeated deficiencies from the previous Recertification Survey 4/21/23 and Post Survey Revisit 7/12/ 23. In addition to identified systematic problems regarding grievances and functional/usable bathtubs. The findings are: Repeated Citations Refer to the following citations cited 4/21/23: F 584 Safe/Clean/Comfortable/Home Like Environment F 656 Develop/Implement Comprehensive Care Plan F 677 ADL (activities of daily living) Care Provided for Dependent Residents F 812 Food Procurement, Store/Prepare/Serve Sanitary F 880 Infection Prevention and Control F867 Quality Assurance and Performance Improvement Activities (7/12/23). Additionally, Refer to F 585 Resident Rights/Grievances Refer to F 561 Resident Rights/Self-determination. Review of the policy and procedure titled Quality Assurance/Performance Improvement revised 8/16, documented the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify area of service that are non-complaint, or with potential for improvement. The facility will ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization. The policy documented that the facility would have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its residents. Review of an undated facility document titled Quality Assurance Improvement Plan, provided by the Administrator during the entrance conference process documented that a dashboard for individual performance improvement projects were used to communicate progress and outcomes of individual QAPI (Quality Assurance Improvement Plan) projects. The QAPI (Quality Assurance Improvement Plan) lead is responsible for maintaining documentation of the minutes of all meetings. The plan documented that the QAPI (Quality Assurance Improvement) committee monitors progress to ensure that interventions or actions were implemented and effective in making and sustaining improvements. Once the performance improvement program goals have been met, it will be placed on a permanent tracking log for ongoing measurement to assure the performance improvement project doesn't get forgotten. Review of Recertification Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 4/21/23 revealed the facility was cited for the following: -F 656 the lack of development of comprehensive care plans for residents. The facilities corrective action plan included that the Assistant Director of Nursing would report monthly to the QAPI committee to determine if any further process changes or approaches were needed. This would happen for three months or longer depending on compliance outcomes. -F 677 the lack of chin hair removal and long fingernails. The facilities corrective action plan included the floor charge nurse along with the Assistant Director of Nursing would report their finding for three months and corrective action will be taken as necessary by the QAPI committee. -F 812 foods unlabeled/outdated in the refrigerators. The facilities corrective action plan included the Food Service Director along with the QAPI committee will submit weekly audit findings for three months or until problems were resolved. -F 584 the facility did not ensure that housekeeping and maintenance services were adequate to maintain a sanitary, orderly, and comfortable interior. The facilities corrective action plan included the audit results will be reported to the Quality Assurance and Performance Improvement committee for monthly for three months and the frequency of on-going audits will be determined based on the audit results. - F 880 issues involved transmission-based precautions and adequate hand hygiene. The facilities corrective action plan included audit results would be reported to the Quality Assurance and Performance Improvement committee monthly for three months and frequency of on-going audits will be determined based on the audit results. Review of Post Recertification Survey Revisit Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 7/12/23 revealed the facility was cited for the following (includes but not limited to): -F 812 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service. System implemented to ensure continued compliance included: the administrator will meet with the Director of Food Service and Director of Maintenance daily to review any kitchen/food service-related repairs and assign priority tasks. Audits will be performed by the Director of Food service daily for 1 month then weekly for 2 months. The Consultant will also conduct random onsite audits of the above areas for three months and report findings to the QA&A Committee. Frequency of on-going audits will be determined by the Committee based on audit results. -F 867 the Quality Assurance and Performance Improvement Committee the facility did not institute and follow corrective actions that were to put in place to ensure that the following deficiencies would not reoccur. An audit tool was to be developed to track completion of all audits; audits will be submitted to the administrator/designee for review weekly for 12 months to ensure compliance; Audit results will be reported to the QA&A Committee monthly. Frequency of on-going audits will be determined by the Committee based on the results; the Consultant will also conduct random onsite audits of the cited areas for three months and attend the meeting monthly for 3 months. Review of the Quality Assurance and Performance Improvement Meeting Minutes dated 10/25/23 documented that all staff were educated and aware of the importance of a clean and sanitized kitchen and weekly plan of correction audits were ongoing. The meeting minutes documented that infection control, quality assurance and discharge records were reported upon at the meeting. The minutes did not include if the plan was effective. Review of the Quality Assurance/Performance Improvement Meeting Agenda date 10/16/24 documented that infection prevention and control, dietary, environmental services, plant operations and medical record review were reported upon at the meeting. The minutes did not include if the plan was effective. During the QAPI/Quality Assessment and Assurance (QAA) interview on 12/6/24 at 2:25 PM with the Administrator and Director of Nursing, the Administrator stated they could not provide any further documents (QAPI items- meeting agendas, minutes, meeting attendance records or PIP's (performance improvement projects) from the previous Administration other then what was presented (10/25/23, 1/24/24 and 2/28/24). They stated they became the Administrator of record in (MONTH) 2024 and since they started the committee had conducted a PIP (performance improvement project) on Enhanced Barrier Precautions. The Administrator stated there was continued noncompliance with infection control practices and their performance improvement project was ineffective. The Director of Nursing stated their PIP (performance improvement project) for nail care and facial hair removal remained ineffective as noncompliance continues. The Director of Nursing stated the facility no longer had a Nurse Educator or an Assistant Director of Nursing and there was great turnover of the staff. This made it hard to continue to audit and educate the new staff. The Director of Nursing s | Plan of Correction: ApprovedJanuary 3, 2025 1. Administrator and consultant reviewed all deficiencies cited including F584, F656, F677, F812, F880 and F 867. A plan of correction was completed and causative factors for repeated deficiency were discussed with QAPI members. 2. All residents are at risk for deficient practice of QAPI not identifying systematic issues. 3. Policy and procedure for QAPI was reviewed and updated with recommendations from consultant. 4. QAPI team was educated on new QAPI process by consultant. All staff members were educated by consultant on QAPI process and how to become involved in quality assurance at the facility. 5. The Consultant will conduct monthly audits for 3 months on the QAPI process to ensure facility is able to follow new process and implement change based on systematic review. Any deficient practices will be corrected. Person Responsible: Administrator |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a standard survey, completed on 12/6/24, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, 2 (Units 1 and 5) of 4 units reviewed for environment had issues with brown stained ceiling tiles in halls and resident rooms. Unit 5 the baseboards in the halls were dirty with visible dark debris, and the shower room had a strong fecal odor, soiled wet linens on the floor, and soiled shower curtain. The findings are: The undated document titled Quality Assurance Improvement Plan documented it was the purpose of the Quality Assurance/Performance Improvement committee to provide excellent quality resident/patient care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the patients cost effectively while maintaining good resident/patient outcomes and perceptions of patient care. During an interview on 12/6/24 at 3:58 PM, the Director of Nursing stated they did not have a policy and procedure on homelike environment. 1a. Observations on Unit 5 revealed on 12/2/24 at 11:29 AM, 12/4/22 at 9:54 AM, and 12/6/24 at 9:13 AM, Resident room [ROOM NUMBER] had four ceiling tiles with brown circular stains. 1b. Observation on 12/6/24 at 9:15 AM, Unit 1 hall there were multiple ceiling tiles with large brown circular stains, and the wallpaper was visible buckling near the ceiling. Resident room [ROOM NUMBER] had multiple ceiling tiles with large brown stains. During interviews on 12/6/24 at 9:34 AM and 3:48 PM, the Environmental Department Director stated they were aware the ceiling leaked on multiple units, depending on the weather, and they were responsible for changing ceiling tiles. They stated they weren't aware that Resident room [ROOM NUMBER] had stained, soiled ceiling tiles and they should have been notified so they could be changed. They stated the facility should be maintained to provide a homelike, safe environment for the residents, and having rain pour in through the ceiling was not homelike. Additionally, they stated the roof of the entire facility needed replacing. 2a. During an observation on 12/2/24 at 8:57 AM and 9:36 AM, the Resident Spa on Unit 5 had a strong fecal odor, soiled wet linens on the floor and a soiled wet washcloth hanging from the towel bar. The shower curtain was soiled with a brown substance; dark brown/black debris on the floor outside the bathroom stall, and the third shower stall had a clump of brown debris, on the floor, that appeared to be fecal matter. 2b. During further observations on 12/3/24 at 8:20 AM, 12/4/24 at 10:31 AM, and 12/6/24 at 8:47 AM, the Resident Spa on Unit 5; continued to have a strong fecal odor, soiled wet linens on the floor and a brown smeared substance on the shower curtain. During an observation and interview on 12/6/24 at 8:52 AM, in the Resident Spa on Unit 5, Certified Nurse Aide #5 stated the Aides were responsible for picking up the linens and bodily fluids after each shower. Housekeepers were responsible for sanitizing the shower once per shift. Certified Nurse Aide #5 stated the shower room smelled like feces and the wet soiled linens should not be left on the floor because it was an infection control issue. During an observation and interview on 12/6/24 at 9:05 AM, the Director of Housekeeping stated shower rooms should be sanitized by the housekeeper once per shift and they should be disinfecting the shower curtains or replacing them as needed. They stated the shower room smelled like feces. The Director of Housekeeping stated the Certified Nurse Aides were responsible for cleaning any bodily fluids and removing the soiled linens, but their housekeeping staff should have let them know if they noticed that it wasn't being done, and it should not have been left that way. 3a. During an observation on 12/4/24 at 10:23 AM, 12/6/24 at 9:08 AM, Unit 5 the baseboards along the floor in the hallways were dirty with dark debris present. During an interview on 12/6/24 at 9:08 AM, Unit 5 Secretary stated that it didn't always feel homelike on the unit, it depended on which housekeeper was working. They stated the baseboards on Unit 5 were not clean, they were dirty and needed to be cleaned or replaced. During an interview and observation on 12/6/24 at 9:13 AM, Certified Nurse Aide #7 stated Unit 5's environment was not clean. They stated floors were sticky and the baseboards were very grimy, and dirty. Certified Nurse Aide #7 stated the floors and baseboards were the first thing seen upon coming onto the unit and they should be cleaned for a homelike environment. Upon observing the ceiling tiles in occupied Resident room [ROOM NUMBER], Certified Nurse Aide #7 stated there were color changes to the ceiling tiles and it looked like mold was present. They stated when it rains outside, it rains in the building. During an interview and observation on Unit 5 on 12/6/24 at 9:29 AM, Licensed Practical Nurse #8 stated they have had family members voice concerns over the cleanliness of the facility. They stated the baseboards were dirty, and they should be cleaned or updated. Described the ceiling tiles in Resident room [ROOM NUMBER] as water stained, dry, brown in appearance with black sharpie colored or something present on tiles. They stated the residents live here and they shouldn't have to look at that, it's not homelike. During an interview on 12/6/24 at 9:56 AM, Licensed Practical Nurse #7 stated housekeeping doesn't clean like they were supposed to. They stated the cleanliness was nasty in here. They stated you can lose your shoe because the floors were so sticky and the baseboards were nasty with god knows, food, dirt. They stated the overall cleanliness and look of the building was not homelike. Additionally, they stated ceiling tiles shouldn't be soiled, it indicates a leak. Licensed Practical Nurse #7 stated when it rains water pours from the ceiling on Unit 5. Maintenance gets notified, they come and patch it up until the next time. During an interview on 12/6/24 at 10:35 AM, the Infection Preventionist stated it was an infection control problem to leave soiled/wet linens and feces on the shower floor, and feces on the shower curtain. It was important for those things to be cleaned and sanitized as soon as possible so staff don't track germs to other rooms and cross contaminate other residents. Bacteria could grow quickly in wet linens causing residents and staff to get sick. The infection Preventionist stated that wet ceiling tiles were unsafe because they could fall on a resident or drip dirty water onto them or their food. The mold that could grow from wet ceiling tiles is a risk to the air quality, they are unhealthy, unsanitary and don't look good. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated they expected their nursing staff to clean up after each shower given. If they noticed bodily fluids, they should clean it right away and have housekeeping sanitize the room. During an interview on 12/6/24 at 11:20 AM, the Administrator stated they just had a discussion with the department heads about clearly defined job duties regarding shower rooms. They determined the Certified Nurse Aides were responsible for cleaning up any bodily fluids and wet linens after every shower. Then the housekeeper should sanitize the shower room at least a couple times a day. They did not want the residents to smell feces in the shower room. The Administrator stated that when they notice the ceiling leaking, they immediately clean up the water and they change the ceiling tiles. The facility has recognized the leaking roof was a problem, and it needs to be replaced. They stated that a leaking roof and stained ceiling tiles did not promote a homelike environment. 10 NYCRR 415. 5(h)(1)(2) | Plan of Correction: ApprovedJanuary 6, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident room [ROOM NUMBER] had four ceiling tiles were replaced by maintenance.1b.Unit 1 hall ceiling tiles were replaced. Wallpaper was removed where damaged by maintenance.Resident room [ROOM NUMBER] ceiling tiles were replaced by maintenance. Resident spa on Unit 5 was sanitized by housekeeping. Unit 5 hallways were sanitized by housekeeping.Baseboards were clean by housekeeping. Hallway floors were stripped and waxed by Floor tech. The Roof will be reviewed in Spring 2025 for roof repairs. 2. All residents are at risk for deficient practice of facility not being homelike as evidenced by sticky unclean floors, soiled ceiling tiles, dirty showers. 3. An Audit of all shower rooms were conducted by EVS Director and all shower rooms were sanitized. An Audit was completed of all ceiling tiles in facility and any deficient practice was corrected. An Audit of all baseboards were completed and baseboards were cleaned by floor tech. 4. Administrator reviewed the policy and procedure on floor care, daily housekeeping care and ceiling tiles. New policies were created for facility. Administrator reviewed policy and procedure for ceiling tiles. no changes were made. The Outside consultant will educate all staff on reporting environmental concerns including soiled ceiling tiles, cleaning issues in shower and floors. 5. Administrator educated EVS Director on floor care and daily housekeeping. All Housekeepers were educated on floor care and daily housekeeping. Administrator reviewed P and P on ceiling tile replacement with Maintenance Director. 6. QA Members will conduct weekly rounds for 6 months on floor care, ceiling tiles, shower room cleaning. Any deficient practices will be corrected immediately and brought to QAPI for further review.Resident grievances will be reviewed monthly for environmental concerns. Any deficient practices will be corrected immediately. Person Responsible: EVS Director |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Standard survey completed on 12/6/24, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Resident #64) of one resident reviewed. Specifically, Resident #64 was not provided with a tub bath per their preference as the facility did not have a functioning tub. The finding is: The policy and procedure titled Comprehensive Care Planning & Baseline dated 6/2021, documented a care plan will be individualized for each resident using a person-centered approach. Your Rights as a Nursing Home Resident in New York State dated 2022 documented, you have the right to self-determination includes but not limited to; be offered choices and allowed to make decisions important to you and receive services with reasonable accommodations for individual needs and preferences. The policy and procedure titled Tub Maintenance undated documented, repairs if needed are completed. If repair cannot be made, then this is communicated to maintenance department who calls in outside service company to make repair. The Maintenance Director will obtain necessary quote(s)for repair and the Administrator will be notified of quote and any scheduled repairs. Resident #64 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/24/24, documented Resident #64 was moderately cognitively impaired. The Activity Interview for Daily and Activity Preferences form dated 7/23/24 for Resident #64 documented very Important to choose between a tub bath, shower, bed bath or sponge bath and preferred a tub bath. During an interview on 12/3/24 at 10:20 AM, Resident #64 stated they used to take tub baths at home and would prefer a tub bath, but the facility doesn't have a working tub, and stated they think it's been broken for a long time. During an interview on 12/4/24 at 10:09 AM, Resident #64's Primary Contact (family) stated Resident #64 always took baths at home and Resident #64 had informed them they would prefer a tub bath at the facility. During an interview on 12/4/24 at 10:51 AM, the Activities Department Director #1 stated they had interviewed Resident #64 upon readmission and completed the Activity Interview for Daily and Activity Preferences form based on the residents answers. They would expect the Nursing Department to meet the Resident's preferences and they stated they did not know the facility did not have a functioning tub. Observation on 12/3/24 at 10:12 AM Unit 6's bathtub had red bags covering it that were held in place by straps. The tub was unable to be utilized. Observations on 12/5/24 between 11:03 AM and 11:20 AM revealed the following: - Unit 2's bathtub had dark brown debris in the base of the tub with a chair and other equipment stored in the tub. - Unit 1 did not have a bathtub available. - Unit 5's bathtub had dried white and dark brown debris in the base of the tub. During an interview on 12/5/24 at 9:37 AM, Porter #1 stated they clean Unit 6 shower room and they believe the tub had not functioned for over two years. During an interview on 12/5/24 at 9:47, Certified Nurse Aide #3 stated Unit 6's tub had been broken for over a year and doesn't know if there were any functioning tubs in the facility. During an interview on 12/5/24 at 9:52 AM, Certified Nurse Aide #4 stated Resident #64 had not asked for a tub bath and they had not offered a tub bath because there were no functioning bath tubs in the facility. At 9:53 AM Certified Nurse Aide #4 asked Resident #64 what their preference was for bathing and Resident #64 stated they preferred a tub bath but know they can't have one because there were not any functioning tubs in the facility. During an interview on 12/5/24 at 1:11 PM, the Environmental Department Director stated there were no functioning tubs on the units in the shower rooms, but there were some tubs in the private rooms that work. They stated they do not know what was specifically wrong with each of the shower room tubs and had reported the concern to the previous Administrator. The Environmental Department Director stated the facility should have a functioning bath tub for resident's who prefer a bath and suggested Resident #64 may be able to use a private room tub for their preferences, if one was available. During a telephone interview on 12/5/24 at 1:46 PM, previous Unit Manager Licensed Practical Nurse #3 stated they were not aware Resident #64 preferred a bath, but they would not be able to meet the resident's preference because the facility doesn't have a functioning tub. During an interview on 12/5/24 at 3:38 PM, the Therapy Department Director stated Resident #64 does not have the physical mobility to utilize one of the private room tubs, because the tub was too low and would be a safety concern. They stated choosing a bath verses a shower was a resident's right of preference and the facility should have a functioning tub. During an interview on 12/5/24 at 4:51 PM, the Director of Nursing stated the facility did not have functioning bathtubs in the shower rooms and the bathtubs in the private rooms were too low and would pose as a safety hazard for Resident # 64. They stated the facility should have a functioning bathtub for any resident that had a preference to use it. They stated they believed the last functioning bathtub in the facility broke approximately 2 years ago. During an interview on 12/5/24 at 5:00 PM, the Administrator stated they have been the Administrator since (MONTH) 2024 and didn't know the facility didn't have a functioning bathtub and would have expected the Environment Department Director to have informed them. They stated it was important for all residents to have choices and bathing preferences and the facility was unable to accommodate Resident #64's preferences. 10 NYCRR 415. 5 (b)(3) | Plan of Correction: ApprovedJanuary 14, 2025 1. Facility made repairs to the tub. Facility obtaining qoutes to fix all tubs. Resident #64 received tub per preference. 2. All residents who prefer to have a tub is at risk for deficient practice of not receiving a tub bath. 3. All residents assessments for preference will be audited by MDS to see who prefers a bath. Any deficient practices will corrected immediately. 4. Policy and procedure for maintenance of the facility tubs were reviewed and updated. 5. Administrator educated Maintenance Director and maintenance Tech on tub policy. 6. Facility will audit all tubs monthly to ensure tubs are functioning and available for preferences of the resident. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, alcohol-based hand rub (ABHR) was not properly stored. Specifically, storage of alcohol-based hand rub (ABHR) in quantities greater than five gallons in a single smoke compartment, were stored in an location that was not protected as a hazardous area. The requirements of the 2012 edition of National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code were not met. This affected one of one Administration area located on the Second Floor. The finding is: Review of the policy and procedure titled Alcohol Based Hand Sanitizer and Solutions with a date of revision of 12/24, documented, to ensure resident safety and avoid over storage of potentially flammable material in excess. Storage of quantities greater than 18. 9 Liters (10 Gallons) of alcohol-based hand-rub solution in a single smoke compartment shall meet the requirements of National Fire Protection Association 30, Flammable and Combustible Liquids Code. Observation on 12/3/24 9:20 AM on the Second Floor in the Administration area revealed nine, one gallon containers of liquid hand sanitizer were stored in the storage closet located across from Storage room (216). Further observation revealed the door to the closet did not self-close and latch into its door frame and the door was not equipped with a self-closing device. Continued observation revealed the active ingredient in the one gallon hand sanitizer containers was 80 percent (%) Ethyl Alcohol. During an interview at the time of the observation the Maintenance Director stated they were not aware the containers of liquid hand sanitizer were stored in the storage closet, they knew the regulations regarding the storage of alcohol based hand sanitizer, and the hand sanitizer should not have been stored in the closet. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2. 6, 8. 7. 3, 8. 7. 3. 1(1) 2012 NFPA 30: 9. 6, 9. 6. 2, 9. 6. 2. 1, Table 9. 6. 2. 1, 9. 6. 2. 2 2012 NFPA 30: 9. 1, 9. 1. 1, 9. 1. 4, 9. 7, 9. 7. 1, 9. 7. 2, Table 9. 7. 2 | Plan of Correction: ApprovedJanuary 2, 2025 1. 2nd Floor Administration Area - The door to the storage closet was repaired by Maintenance Director with a self closing device. All liquid hand sanitizer was removed to more appropriate storage area by Maintenance Director with proper signage. 2. All residents are at risk for deficient practice of liquids in quantities greater than 5 gallons in a single smoke compartment not being stored in proper hazardous areas. 3. A full facility audit of all storage areas will be conducted by the Director of Maintenance to ensure that liquid alcohol-based hand rub or other flammable items were properly stored and proper signage was in place. 4. The policy ?ôAlcohol-Based Hand Sanitizer and Solutions with a date of revision of 12/24, was reviewed by the Consultant, no revision was necessary. 5. All facility staff will be in-serviced on proper storage of liquid alcohol-based hand rub and other flammable liquids by the Consultant,(NAME)J Pietrowski, MSN RN LNHA 6. A weekly audits will be completed by Maintenance Director/Tech to ensure alcohol-based hand rub and other flammable liquids are stored properly. Any deficient practice will be corrected and brought to QAPI for further review. Person Responsible: Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, a kitchen hood extinguishment system was not maintained. Specifically, the Main Kitchen's, kitchen hood extinguishment system was not inspected and tested at least every six months. This affected one of one Main Kitchen located on the First Floor. The finding is: Observation on 12/2/24 at 12:41 PM on the First Floor revealed the Main Kitchen was equipped with a kitchen hood extinguishment system. Review of a Suppression(NAME)Inspection and Testing Reports from the contractor that inspected, tested , and maintained the Main Kitchen's kitchen hood extinguishment system revealed the kitchen hood extinguishment system was inspected on 3/29/23 and 4/16/ 24. Review of a Kitchen Fire Protection System Inspection and Test Report revealed the kitchen hood extinguishment system was inspected on 10/31/ 24. During an interview on 12/6/24 at 9:57 AM the Maintenance Director stated the facility had no documentation that showed the Kitchen's, kitchen hood extinguishment system had been inspected between 3/29/23 and 4/16/24 and they did not believe the kitchen hood extinguishment system had been continually inspected at least every six months. Review of New York State Department of Health historical documentation of a contractor Pre-Engineered Inspection Report (kitchen hood inspection report) revealed the facility's Main Kitchen, kitchen hood extinguishment system had been inspected on 8/7/ 23. The facility's Main Kitchen, kitchen hood extinguishment system was inspected on 8/7/23 and was not inspected again until eight months later, on 4/16/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2. 5, 19. 3. 2. 5. 1, 9. 2. 3, 2. 1, 2. 2 2011 NFPA 96: 11. 2, 11. 2. 1, 11. 5 | Plan of Correction: ApprovedJanuary 2, 2025 1. Administrator and Maintenance Director review all inspections for Kitchen for previous 12 months. Most recent hood inspection completed on 10/31/ 2024. 2. All residents are at risk for deficient practice of timely hood inspections. 3. Administrator reviewed policy and procedure on kitchen hood inspection. No changes were made to the Kitchen(NAME)Inspection policy. 4. Administrator educated Maintenance Dir/Maintenance Tech on Kitchen(NAME)inspection policy. 5. Maintenance inspection log will be brought to QAPI monthly to ensure all inspections are completed per schedule. Any deficient practices will be corrected. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Survey completed on 12/6/24, corridor doors were not maintained. Specifically, corridor doors were obstructed from closing and did not latch into their door frames. This affected two (Unit 5 and Unit 6) of three resident units and one of one Basement. The findings are: 1a. Observation on 12/2/24 at 10:54 AM on the First Floor on Unit 6 revealed a folding walker was folded up and lying against the corridor door to Resident Room 631 obstructing the door from closing. 1b. Observations on 12/2/24 at 10:55 AM and on 12/3/24 at 10:06 AM on the First Floor on Unit 6 revealed a trash receptacle was stored in front of and directly against the corridor door of Resident Room 633 obstructing the door from closing. 1c. Observation on 12/2/24 at 11:28 AM on the First Floor on Unit 5 revealed a plastic door chock was wedged under the corridor door of Resident Room 519 obstructing the door from closing. Further observation revealed that when the Maintenance Director removed the door chock and attempted to close the door, the door did not latch into its door frame. 1d. Observation on 12/2/24 at 12:02 PM on the First Floor on Unit 5 revealed a chair was stored in front of and directly against the corridor door of Resident Room 532 obstructing the door from closing. 1e. Observations on 12/2/24 at 2:07 PM and on 12/3/24 at 8:59 AM in the Basement A Wing revealed a three foot tall circular floor fan was stored in front of and directly against the Server room corridor door (A5) obstructing the door from closing. Further observations revealed the room was full of electrical equipment for the facility's television system, telephone system, computer system, and camera system. Continued observations revealed the door was in a fully open position and the fan was on and running. During an interview on 12/2/24 at 2:07 PM the Maintenance Director stated the split air conditioning unit in the Server room broke a couple months ago and the fan was being used to keep equipment in the room cool. 1f. Observation on 12/2/24 at 2:53 PM in the Basement revealed the corridor door (B6) of the Employee Break did not latch into its door frame. Further observation revealed the door was hung up on its door frame. During an interview at the time of the observation the Maintenance Director stated they had requested an angle grinder from the owner of the facility to be able to work on and fix this metal door, but their request had not been approved. 1g. Observations on 12/3/24 at 10:07 AM and on 12/4/24 at 10:45 AM on the First Floor on Unit 6 revealed a three drawer precautions cabinet was stored in front of and directly against the corridor door of Resident Room 610 obstructing the door from closing. 1h. Observations on 12/4/24 at 10:47 AM on the First Floor on Unit 6 revealed a three drawer precautions cabinet was stored in front of and directly against the corridor door of Resident Room 617 obstructing the door from closing. 1i. Observations on 12/4/24 at 11:07 AM on the First Floor on Unit 5 revealed a three drawer precautions cabinet was stored in front of and directly against the corridor door of Resident Room 526 obstructing the door from closing. Review of Annual Facility Door Audit sheets revealed the facility's corridor doors had been checked on 9/19/24 through 9/20/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 6. 3, 19. 3. 6. 3. 5, 19. 3. 6. 3. 10 | Plan of Correction: ApprovedJanuary 2, 2025 1. 1st Floor - Unit 6 - Folding walker against corridor door to Resident Room 631 obstructing the door from closing was removed during survey. 1st Floor - Unit 6 - Trash receptacle against corridor door of Resident Room 633 obstructing the door from closing was removed during survey. 1st Floor - Unit 5 - Plastic Chock wedged under the corridor door of Resident Room 519 obstructing the door from closing. When chock removed, the door did not self-close or latch into its door frame. The door was repaired by Maintenance Director. 1st Floor - Unit 5 chair against the corridor door of Resident Room 532 obstructing the door from closing was removed during survey.Basement - A Wing - Floor Fan against Server Room Corridor door (A5) obstructing the door from closing was removed during survey. Basement - corridor door (B6) of the Employee Break room did not latch into its doorframe. The door was repaired by Maintenance Director. 1st Floor - Unit 6 - precaution cabinet stored in front and against the corridor door of Resident Room 610 obstructing the door from closing was removed during survey. 1st Floor - Unit 6 - precaution cabinet stored in front and against the corridor door of Resident Room 617 obstructing the door from closing was removed during survey.1st Floor - Unit 5 - precaution cabinet stored in front and against the corridor door of Resident Room 526 obstructing the door from closing was removed during survey. 2. All Residents are at risk for deficient practice of obstructed doors and doors not closing and latching in their frames. 3. A 100% audit of all Units/corridor doors was conducted on 12/26/2024 to ensure that all doors are unobstructed. Any deficient findings were corrected immediately. 4. A 100% audit of all doors/latches and doorframes was conducted on 12/26/2024 to identify any doors not properly functioning. Any deficient findings were corrected immediately. 5. Administrator reviewed policy and procedure on corridor doors. No changes were made to the policy. Administrator educated Maintenance Director and Maintenance Tech on the policy and procedure of obstructed doors and doors latching properly. 6. All staff will be in-serviced with a post-test for competency by the Consultant regarding properly functioning doors, notification to maintenance regarding improperly functioning doors, and deficient practice of obstructing doors. 7. The Director of Maintenance will conduct a monthly survey of all corridor doors and report findings to the QAPI Monthly Meeting. Person Responsible: Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, a door equipped with a delayed egress locking mechanism (a timed-release, magnetic locking mechanism) was not maintained. Specifically, a door equipped with a delayed egress locking mechanism did not have signage indicating how the door could be opened during a fire or other emergency. This affected one (Unit 1/ 2) of three resident units. The finding is: Observation on 12/2/24 at 10:12 AM on the First Floor on Unit 1/ 2 revealed Stairway Exit Door (4) near Resident rooms [ROOM NUMBERS] was equipped with a delayed egress locking mechanism and the door was not equipped with signage that stated, Push Unit Alarm Sounds Door Can be Opened in 15 Seconds. Further observation revealed an illuminated exit sign was installed from the corridor ceiling near the door. During an interview at the time of the observation the Maintenance Director stated the delayed egress mechanism, wander, elopement system had been installed on the door three months ago and the facility had documentation for the checks of the doors equipped with delayed egress locking mechanisms, magnetic locks, and roam alert mechanisms. Review of a Weekly Maglock/ Door Alarm Check sheets and Weekly Roam Alert Check sheets revealed doors equipped with delayed egress locking mechanisms, electromagnetic locking mechanisms, and Roam Alert mechanisms were checked on 11/28/ 24. Review of daily rounds sheets revealed the facility's exit doors were checked on 12/2/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2, 19. 2. 1, 19. 2. 2. 2. 4, 7. 2, 7. 2. 1. 6. 1, 7. 2. 1. 6. 1. 1 | Plan of Correction: ApprovedDecember 29, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Stairway exit door near resident rooms [ROOM NUMBERS] was equipped with proper signage Push Unit Alarm Sounds Door can be opened in 15 seconds. 2. All residents are at risk for deficient practice of not having proper signage for exit door with delayed egress signage explaining functionality of door. 3. All exit doors with delayed egress features will be audited to ensure proper signage by the Maintenance Director/Designee. 4. The Maintenance Tech/Maintenance Director was inserviced by the Administrator that monthly audits have to be completed per the audit tool called Monthly Emergency Exit Doors and Signs. The Maintenance Director/Tech will submit this audit monthly to the QAPI Committee. The QAPI Committee will determine additional process change needed based on findings. Person Responsible: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, extension cords and a power strip were not maintained. Specifically, extension cords and a power strip were being used to supply a permanent supply of power to various equipment. This affected one (Unit 6) of three resident units, one of one Chapel located on the First floor, and one of one Basement. The findings are: 1a. Observation on 12/2/24 at 12:20 PM on the First Floor revealed a power strip that was plugged into an extension cord was being used to supply a permanent source of power to a television in the Chapel. Further observation revealed the television was located near the altar in the Chapel. During an interview at the time of the observation the Maintenance Director stated they were not aware the television was plugged into a power strip that was plugged into an extension cord and that residents usually watched the television near the entrance to the Chapel or the televisions in their rooms or the lounges on the units. 1b. Observation on 12/2/24 at 2:33 PM in the Basement revealed an extension cord was being used to supply a permanent source of power to a computer in the Housekeeping and Laundry Director's office. During an interview at the time of the observation the Maintenance Director stated they were not aware the extension cord was being used in the office. The Maintenance Director further stated the Maintenance staff checked for extension cords and power strips and the facility had documentation for the checks. 1c. Observation on 12/4/24 at 10:51 AM on the First Floor on Unit 6 revealed two extension cords were being used to supply a permanent source of power to two televisions in Resident Room 627. During an interview at the time of the observation the Maintenance Director stated they were not aware the extension cords were being used in the room. During an interview on 12/5/24 at 10:51 AM the Maintenance Director stated the power strip audit also included checking for extension cords. Review of the Annual Audit of Power Strips/ Resident Rooms revealed the facility's resident rooms were audited for power strips on 10/2/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 99: 2. 1, 2. 2, 10. 2. 3, 10. 2. 3. 6, 10. 2. 4, 10. 2. 4. 2, 10. 2. 4. 2. 3, 10. 2. 3, 10. 2. 3. 1, 10. 2. 3. 1. 1, 10. 3 2011 NFPA 70: 110. 3(A)(1)(8), 400. 3, 400. 8(1), 590. 3 | Plan of Correction: ApprovedDecember 30, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Extension cord was being used to supply a permanent source of power to a television in the Chapel was removed by Maintenance Director.Extension cord was being used to supply a permanent source of power to a computer in the Housekeeping and Laundry Director's office was removed by Maintenance Director. Extension cords were being used to supply a permanent source of power to two televisions in Resident room [ROOM NUMBER] was removed by Maintenance Director. 2. All residents are at risk for deficient practice of using extension cords and power strips bring used as a supply of power to equipment. 3. An entire house audit will be conducted to check for use of extension cords. Any deficient practices will be corrected and brought to QAPI for further review. 4. All staff were educated by RN Educator regarding policy and procedure use of extension cords. All residents and families received written notice on use of extension cords by Administrator. 5. A monthly audit of extension cords will be conducted by Maintenance and any deficient practices will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, an emergency generator was not maintained. Specifically, the facility did not have documentation that verified the emergency generator was inspected weekly on a continual basis, the facility did not have documentation that the emergency generator was run under load for 30 minutes monthly on a continual basis, and the facility did not have documentation that the building's electrical system main and feeder circuit breakers had been inspected annually. This affected one (First Floor) of one resident use floor including three (Units 1/ 2, Unit 5, and Unit 6) of three resident units, one of one Second Floor Administration area, and one of one Basement. The findings are: Review of the policy and procedure titled Generator Maintenance - Emergency Power Use with a date of revision of 1/1/19 documented, weekly spot checks of the surrounding area and inside the generator to ensure tubing, connections and gauges are operational. It shall include load and testing of the generator to ensure operational status. Observation on 12/3/24 at 11:10 AM revealed the facility's emergency generator was located at the exterior of the building near the Chapel. 1a. During an interview on 12/5/24 at 10:56 AM the Maintenance Director stated the facility had no documentation that weekly inspections of the emergency generator were conducted prior to 4/23/ 24. The Maintenance Director further stated the facility had no documentation that the emergency generator was run under load for at least 30 minutes monthly prior to 3/12/ 24. The Maintenance Director also stated the facility had no documentation that an annual inspection of the building's electrical system main and feeder circuit breakers had been conducted in 2023 and 2024. Review of Weekly Generator Check lists revealed they contained no documentation for weekly inspections of the emergency generator prior to 4/23/ 24. Review of Monthly Generator Checklists revealed they contained no documentation that the emergency generator had been run under load for at least 30 minutes monthly prior to 3/12/ 24. Further review of the Monthly Generator Checklists revealed the facility had no documentation that a monthly load test was conducted in (MONTH) of 2024 and a load test was not conducted in (MONTH) of 2024. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 5, 19. 5. 1, 19. 5. 1. 1, 9. 1, 9. 1. 3, 9. 1. 3. 1 2010 NFPA 110: 2. 1, 2. 2, 4. 2, 4. 4, 4. 4. 1, 4. 4. 2, 8. 3, 8. 3. 3, 8. 3. 4, 8. 3. 4. 1, 8. 4, 8. 4. 1, 8. 4. 2, 8. 4. 6, 8. 4. 6. 1 2012 NFPA 99: 6. 5, 6. 5. 1, 6. 4. 1, 6. 4. 1. 1. 6. 1, 6. 5. 4, 6. 5. 4. 1. 1. 2, 6. 4. 4, 6. 4. 4. 1. 1. 3, 6. 4. 4. 1. 1. 4, 6. 5. 4. 1. 2, 6. 4. 4. 1. 2, 6. 4. 4. 1. 2. 1 | Plan of Correction: ApprovedDecember 30, 2024 1. Administrator and Maintenance Director reviewed past year worth of testing and lack of documentation including weekly inspections of the generator. Maintenance Director has been running generator tests per policy since he started. An Annual inspection of the buildings electrical system main and feeder circuit breakers was completed by outside vendor. 2. All residents are at risk for deficient practice of not having generator run on full load for 30 minutes monthly and annual inspection of buildings electrical system main and feeder circuit breakers. 3. Administrator educated Maintenance Director and Maintenance Tech on Generator policy and procedure. 4. A monthly audit of generator will be conducted by Maintenance Director and brought to QAPI for review. Any deficient practices will be corrected immediately. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 12/6/24, electrical junction boxes were not maintained. Specifically, the covers were missing from electrical junction boxes. This affected two (Unit 5, and Unit 6) of three resident units and one of one Basement. The findings are: 1a. Observation on 12/2/24 at 8:58 AM in the Basement revealed the covers were missing from two electrical junction boxes in storage room (A3). 1b. Observation on 12/3/24 at 1:21 PM on the First Floor above the Unit 6 corridor ceiling tile revealed the cover was missing from an electrical junction box near the Beauty Shop. 1c. Observation on 12/3/24 at 1:57 PM on the First Floor above the Unit 6 corridor ceiling tile revealed the cover was missing from an electrical junction box located above the smoke barrier doors near Resident Room 626. 1d. Observation on 12/3/24 at 2:09 PM on the First Floor above the Unit 5 corridor ceiling tile revealed the cover was missing from an electrical junction box located near the ceiling mounted illuminated exit sign at the entrance to Unit 5. 1e. Observation on 12/3/24 at 10:39 AM on the First Floor above the Unit 6 ceiling tile revealed the cover was missing from an electrical junction box located above the tub in the bathroom in Resident Room 606. During an interview on 12/5/24 at 10:50 AM the Maintenance Director stated the Maintenance staff checked electrical junction boxes to ensure they had covers when they were working above the ceiling tiles and the facility did not have documentation for the checks. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 5, 19. 5. 1, 19. 5. 1. 1, 9. 1, 9. 1. 2 2012 NFPA 99: 2. 1, 2. 2, 6. 1, 6. 1. 1, 1. 3, 1. 3. 2. 1, 6. 3. 2, 6. 3. 2. 1, 15. 5, 15. 5. 1. 2 2011 NFPA 70: 110. 3(A)(1)(8), 110. 12, 314. 25, 314. 72(C) | Plan of Correction: ApprovedDecember 30, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The two electrical junction boxes in storage room were fixed by Maintenance Director. Junction box near beauty shop was replaced by Maintenance Director. Electrical junction box located above smoke barrier near resident room [ROOM NUMBER] was replaced. Electrical junction box located near the ceiling mounted illuminated exit sign at the entrance to Unit 5 was replaced by Maintenance Director.Junction box located above the tub in the bathroom in Resident room [ROOM NUMBER] was replaced by Maintenance Director. 2. All residents are at risk for deficient practices of missing electrical junction boxes. 3. A full house audit of all junction boxes will be conducted by Maintenance. Any Deficient practices will be fixed and brought to QAPI for further review. 4. Administrator educated Maintenance Director/Tech on junction boxes. 5. All junction boxes will be audited quarterly to ensure junction boxes are in place and in good condition. Any Deficient practices will be fixed immediately and brought to QAPI for further review. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, the facility's fire and evacuation policies and procedures did not match the actual procedure used. This affected one (First Floor) of one resident use floor including three (Unit 1/ 2, Unit 5, and Unit 6) of three resident units, one of one Second Floor Administration area, and one of one Basement. The finding is: Review of Fire Plan Policy 2. 2, reviewed with the with the Disaster Manual and Disaster Plan with a reviewed date of 10/16/24, documented. Note: Indicate that all evacuated rooms have been cleared by closing the door and marking the door with the red circular magnet located on the inside of the door and placing it on the outside of the door next to the doorknob to indicate all-clear. Observations on 12/2/24 between 8:30 AM and 3:46 PM revealed orange plastic tags and yellow plastic tags in the fire extinguisher cabinets on Unit 1/ 2, Unit 5, and Unit 6. Observations on 12/2/24 from 9:34 AM through 9:47 AM on Unit 1/ 2 and on 12/4/24 from 10:06 AM through 11:08 AM on Unit 5 and Unit 6 revealed red circular magnets were not observed in resident rooms. During an interview on 12/5/24 at 1:33 PM the Administrator stated the Disaster Manual Disaster Plan, review date 10/16/24, was the facility's current Emergency Preparedness Plan and has been plan in effect since they started during August 2024. During an interview on 12/6/24 at 10:13 AM the Maintenance Director stated they are not responsible to provide any education during new employee general orientation. The Maintenance Director further stated the tags for marking rooms during a fire or evacuation were kept in the fire extinguisher cabinets throughout the building. The orange tags were used to identify the fire room and the yellow tags were used to identify evacuated rooms. The Maintenance Director also stated they were not aware of any red circular magnets in resident room or the use of the red magnets to indicate a room had been evacuated. During an interview on 12/6/24 at 10:45 AM the Infection Preventionist stated they had been helping with education at the facility's general orientations for new employees since the facility no longer had an educator, and they had helped with six general orientations. The Infection Preventionist further stated that they had not been provided any documentation for the marking of resident rooms during a fire or evacuation. They verbally educated staff that the tags for marking rooms during a fire or evacuation were kept in the fire extinguisher cabinets throughout the building and the orange tags were for marking the fire room and the yellow tags were for marking evacuated rooms. The Infection Preventionist also stated they were not aware of any red circular magnets inside of resident rooms or using the red magnets to indicate the room had been evacuated. Review of documentation provided by the Infection Preventionist from the packets provided to employees during General Orientation that dealt with fire and evacuation policies and procedures revealed they contained no documentation regarding marking fire rooms with an orange colored tag, marking an evacuated room with a yellow colored tag, location of the tags, or circular red colored magnets. Review of Fire Drill Reports dated 5/11/24 through 11/1/24 revealed the following was documented on the reports, Knowledge of Room Tags, Location and Use was checked as part of the Observations portion of the reports. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7. 1. 1, 19. 7. 2. 1. 2, 19. 7. 2. 2 | Plan of Correction: ApprovedDecember 31, 2024 1. A review of the fire/evacuation policy and procedure was conducted by Administrator on 12/31/ 2024. The Policy and procedure was updated for fire and evacuation during potential fire. 2. All residents are at risk for policies and procedures for fire evacuation not matching the actual procedures. 3. RN Educator will educate all staff new policy and procedure for fire and evacuation practices. 4. A mock drill was conducted on fire and evacuation procedures. The drill was discussed at QAPI and any deficient practices were reeducated. 5. The facility will audit all fire drills conducted monthly. Any deficient practices will be addressed and brought to QAPI for further review. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the Life Safety Code survey completed on 12/6/24, the facility did not have documentation that fire drills had been conducted at least quarterly on each shift. This affected one (First Floor) of one resident use floor including three (Unit 1/ 2, Unit 5, and Unit 6) of three resident units, one of one Second Floor Administration area, and one of one Basement. The finding is: Review of the policy and procedure titled Fire Drill with an original date of issue date of 1/15 documented, the facility shall hold drills for all units as prescribed by New York State law. Drills must be done quarterly across all shifts. During an interview on 12/5/24 at 10:38 AM the Maintenance Director stated Fire Drills were conducted on the First Shift from 7:00 AM to 3:00 PM, on the Second Shift form 3:00 PM to 11:00 PM, and on the Third Shift from 11:00 PM to 7:00 AM. The Maintenance Director further stated the previous Maintenance Director stated they had conducted a fire drill in (MONTH) of 2024 and the facility had no documentation that a Second Shift fire drill had been conducted in the Second Quarter of 2024. The Maintenance Director also stated the facility had no documentation for fire drills conducted prior to 5/10/ 24. Review of Fire Drill Reports revealed fire drills were conducted on the following dates and times in the Second Quarter (April, May, June) in 2024: - 5/10/24 at 1:30 PM - 6/28/24 at 11:10 PM Review of Fire Drill Reports revealed the facility conducted a fire drill on 5/11/24 at 1:30 PM. Continued review of the 5/10/24 Fire Drill Report revealed it had a note attached to it that read (NAME) said he did one in (MONTH) he never handed in paperwork said he had it in his car. Continued review of the Fire Drill Reports provided by the Maintenance Director revealed the facility had no documentation for fire drill that had been conducted prior to 5/10/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7. 1, 19. 7. 1. 6, 4. 7, 4. 7. 6 | Plan of Correction: ApprovedDecember 30, 2024 1. A review of all fire drills was completed by Maintenance Director and Administrator for past year. All deficient practices were discussed and lack of paperwork was noted to QAPI. 2. All residents are at risk for deficient practices of not completing fire drills on all 3 shifts quarterly. 3. Administrator educated Maintenance Director/Maintenance Tech on Fire drills and holding each drill per shift quarterly. 4. Monthly audit of all fire drills will be conducted and brought to QAPI for further review. Any Deficient practices will be corrected. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, oxygen cylinders were not properly maintained. Specifically, oxygen cylinders were stored less than five feet from combustible materials, the door to a room that oxygen cylinders were being stored in was not lockable, a room that oxygen cylinders were being stored in did not have signage indicating oxygen cylinders were being stored in the room, and oxygen cylinders were stored free standing and unsecured. This affected two (Unit 1/ 2 and Unit 5) of three resident units. The findings are: Review of the policy and procedure titled Oxygen Supplies and Concentrators Inventory with revision date of 12/24 revealed it contained no documentation regarding oxygen cylinders being stored less than five feet from combustible materials, doors to rooms that oxygen cylinders were being stored in being lockable, room that oxygen cylinders were being stored in having signage indicating that oxygen cylinders were being stored in the rooms, and oxygen cylinders not being stored free standing and unsecured. 1a. Observation on 12/2/24 at 10:04 AM on the First Floor on Unit 1/2 revealed two E sized oxygen cylinders, each of which was stored in a two wheeled cart, were stored in the Clean Utility room across from Resident Room 207. Further observation revealed the oxygen cylinders were stored four inches away from three cardboard boxes of disposable gowns and face shields. Continued observation revealed the room's door was not lockable and there was no signage posted that identified oxygen cylinders were being stored in the room. During an interview at the time of the observation the Maintenance Director stated the room's door was not lockable and there was no signage on the door or corridor walls by the door that indicated oxygen was being stored in the room. The Maintenance Director further stated the oxygen storage for Unit 1/ 2 was in the Oxygen Storage room on the Unit 1 corridor and the staff must have stored the cylinders in the Clean Utility room on the Unit 2 corridor instead of storing them in the oxygen storage room. 1b. Observation on 12/2/24 at 12:08 PM on the First Floor on Unit 5 revealed one E sized oxygen cylinder in a two wheeled cart was stored in the Oxygen Storage/ Clean Linen room three inches away from a five foot tall by four foot long by two foot wide open metal rack of sheets, pillowcases, cloth bed pads, towels, face cloths, and gowns. Further observation revealed an oxygen cylinder storage cabinet was stored in the room. During an interview at the time of the observation the Maintenance Director stated the staff knew oxygen cylinders had to be stored in the oxygen storage cabinet located in the room. 1c. Observation on 12/4/24 at 11:08 AM on the First Floor on Unit 5 revealed one C sized oxygen cylinder in a nylon carrying case and one E sized oxygen cylinder were stored free standing and unsecured between a wooden dresser and a wooden wardrobe in Resident Room 536. During an interview at the time of the observation the Maintenance Director stated they were not aware the oxygen cylinders were stored free standing and unsecured in the room. The Maintenance Director further stated the staff knew oxygen cylinders were not to be left free standing and unsecured and that oxygen cylinders had to be secured in a cart or rack. During an interview on 12/5/24 at 10:52 AM the Maintenance Director stated the Maintenance Staff conducted checks of the oxygen storage rooms first thing every morning during daily rounds and the facility had documentation for the checks. Review of Daily Task rounds checklist for the week of 12/2/24 revealed the facility's oxygen storage rooms were checked daily from 12/2/24 through 12/5/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2. 4 2012 NFPA 99: 11. 3, 11. 3. 2. 3, 11. 3. 2. 6, 11. 6. 2. 3, 11. 6. 2. 3 (1)(3)(11), 11. 3. 3, 11. 3. 3. 1, 11. 3. 3. 2, 11. 3. 4, 11. 3. 4. 1, 11. 3. 4. 2, 11. 6. 2 | Plan of Correction: ApprovedJanuary 9, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A full facility audit of all oxygen storage areas was conducted to ensure that oxygen cylinders were properly stored, and proper signage was in place.A full facility audit was conducted of all storage and utility rooms to ensure that oxygen cylinders were not improperly stored in these rooms and where oxygen storage cabinets exist, that proper signage was in place and that doors were lockable.A full facility audit of all resident rooms was conducted to ensure that all oxygen cylinders were properly stored, and proper signage was in place. Two E Oxygen Cylinders were placed back in the proper storage areas during survey. The cardboard boxes of disposable gowns and shields were removed from the area during survey. Signage for the door was placed on door and door was repaired allowing the door to latch. The oxygen cylinders on Unit 5 was placed back in the proper storage units during survey. Oxygen Cylinder located on unit 5 c sized cylinder was placed in the oxygen room during survey. The oxygen cylinder in resident room [ROOM NUMBER] was removed from room and placed in oxygen storage area during survey. 2. All residents are risk for oxygen cylinders being placed 5 feet from combustible materials, room where oxygen was stored is not lockable and no signage in room where oxygen is stored and oxygen cylinders free standing and unsecured. 3. The Policy Oxygen Supplies and Concentrators Inventory revised 12/24 to include the verbiage regarding oxygen cylinders being stored less than five feet from combustible materials, doors to rooms that oxygen cylinders were being stored in being lockable, room that oxygen cylinders were being stored in having signage indicating that oxygen cylinders were being stored in that room, and oxygen cylinders not being stored free standing and unsecured was reviewed by the Consultant, no revision was necessary. 4. All facility staff will be in-serviced on proper storage of medical gases by the Consultant,(NAME)J Pietrowski, MSN RN LNHA 5. 5 Audits will be conducted weekly on oxygen cylinders being placed within 5 feet from combustible materials, ensuring door to oxygen room is properly locked. Signage is available where oxygen is stored and oxygen in secured storage. Any deficient practices will be immediately corrected and brought to QAPI for further review. Person Responsible: Maintenance Director Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, hazardous areas were not maintained. Specifically, hazardous area doors did not self-close and latch into their door frames and were obstructed from closing. This affected two (Unit 1/ 2 and Unit 5) of three resident units, one of one Basement, and one of one Administration area located on the Second Floor. The findings are: 1a. Observation on 12/2/24 at 9:21 AM on the First Floor revealed the door to the Unit 1/2 Soiled Utility room near Resident room [ROOM NUMBER] did not self-close and latch into its doorframe. Further observation revealed the door's latch was hung-up inside the door. Continued observation revealed the room contained a three foot long by two foot wide by three foot tall soiled linen receptacle, a 32 gallon soiled linen receptacle and a 32 gallon trash receptacle. During an interview at the time of the observation the Maintenance Director stated the Maintenance staff inspected the facility's hazardous area doors and the facility had documentation for the inspections. 1b. Observation on 12/2/24 at 11:28 AM on the First Floor revealed the door to the Unit 5 Soiled Utility room near Resident room [ROOM NUMBER] did not self-close and latch into its doorframe. Further observation revealed folded paper towels had been taped over the latch plate on the door's frame, preventing the door from latching. Continued observation revealed the room contained a three foot long by two foot wide by three foot tall soiled linen receptacle, a 32 gallon soiled linen red bag receptacle, two 32 gallon trash receptacles, and two 32 gallon plastic bags full of trash. 1c. Observation on 12/2/24 at 11:52 AM on the First Floor revealed the Unit 5 apartment door was held in a fully open position by a five gallon bucket of light weight all-purpose joint compound. Further observation revealed that when the bucket of joint compound was removed so the door was allowed to close, the door did not self-close and latch into its doorframe. Continued observation revealed the apartment was greater than 50 square feet in size and was used to store 215 cases of vinyl gloves, 40 cases of face shields, seven cases of isolation masks, one case of N95 masks, and two wooden pallets containing one gallon plastic bottles of water. 1d. Observation on 12/2/24 at 1:50 PM in the Basement revealed the double doors that separated the La(NAME)storage room from the Basement center corridor did not self-close and latch into their door frame. Further observation revealed the arm of the self-closing device on the right door leaf was not attached to the door. Continued observation revealed the top latch of the left door leaf was inside the door. The observation also revealed the room was greater than 50 square feet in size and was being used to store 15 mattresses, 15 bed frames, and three wooden pallet containing cases of medical supplies and housekeeping supplies. 1e. Observation on 12/2/24 at 2:34 PM in the Basement revealed the A Wing Housekeeping Storage room door (A6) did not self-close and latch into its door frame. Further observation revealed the door was hung up on its door frame. Continued observation revealed the room was greater than 50 square feet in size and was used to store two, five gallon buckets of floor polish, six boxes of vinyl gloves, four cases of trash can liners, 13 cases of red medical waste bags, 11 cases of vinyl gloves, 19 cases of face shields, two cases of disposable briefs, 15 cases of gowns, and eight cases of face masks. 1f. Observation on 12/2/24 at 2:37 PM in the Basement revealed the A Wing Storage Room door (A2) did not self-close and latch into its door frame. Further observation revealed the arm of the door's self-closing device was not attached to the door. Continued observation revealed the room greater than 50 square feet in size and was used to store 112 cases of disposable briefs. During an interview at the time of the observation the Maintenance Director stated this storage room was the brief storage room. 1g. Observation on 12/2/24 at 2:50 PM in the Basement revealed the B Wing Housekeeping Supply Storage room doors (B5) and (B7) did not self-closed and latch into their door frames and both doors separated this Housekeeping Supply Storage from the B Wing corridor. Further observation revealed the arms on both the door's self-closing devices were not attached to the doors. Continued observation revealed the room greater than 50 square feet in size and was being used to store one wooden pallet of cases of face clothes, two wooden pallets of cases of disposable briefs, seven, five gallon buckets of liquid laundry detergent, six cases of heavy duty floor stripper, 15 cases of lotion soap, two wooden pallets of cases of vinyl gloves, one wooden pallet containing cases of medical cups and cases of slipper socks, four wooden pallets of clean linen, one wooden pallet of cases of quick dry underbed pads, one wooden pallet of cases of bleach wipes, and two, five foot tall by four foot long by two foot wide open metal racks full of clean linen. During an interview at the time of the observation the Maintenance Director stated a member of the staff must have removed the arms of the door closers from the doors to make it easier to move supplies into the room. 1h. Observation on 12/3/24 at 8:22 AM in the Basement revealed the C Wing Housekeeping Storage room door (C12) did not self-close and latch into its door frame. Further observation revealed the room was greater than 50 square feet in size and was used to store a five foot all by four foot long by two foot wide trash receptacle full of bags of trash. During an interview on 12/3/24 at 8:42 AM the Housekeeping and Laundry Director stated the Housekeeping Staff stored the trash receptacle in this room and then they would take it out to the dumpster when it was full. 1i. Observation on 12/3/24 at 8:31 AM in the Basement revealed the C Wing Boiler Room door (C10) did not self-close and latch into its door frame. Further observation revealed that when the door was opened and allowed to self-close it became hung up on the floor of the C Wing corridor. During an interview at the time of the observation the Maintenance Director stated they had requested an angle grinder from the owner of the facility to be able to work on and fix this metal door, but their request had not been approved. 1j. Observation on 12/3/24 at 8:50 AM in the Basement revealed Activities Storage room door (A1) did not self-close and latch into its door frame. Further observation revealed that when the door was opened and allowed to self-close it became hung up on the floor of the Basement's center corridor. Continued observation revealed the room was greater than 50 square feet in size and used to store 11 cardboard boxes and two plastic totes full of activities supplies and holiday decorations and two, five foot tall, by four foot long by two foot wide open medal racks full of activities supplies. 1k. Observation on 12/3/24 9:33 AM in the Second Floor Administration area revealed the Kitchenette door was in a fully open position, the door was equipped with a self-closing device, and the door did not self-close and latch into its door frame. Further observation revealed that when the door was allowed to self-close it became hung up on the floor of the Kitchenette. Continued observation revealed the Kitchenette was greater than 50 square feet in size and was used to store: one case of vinyl gloves, three cases of shipping boxes, six cases of COVID-19 test kits, one box of N-95 masks, one cardboard box full of foil broiler pans, one cardboard box full of papers, three, 32 gallon plastic bags full of papers, two, five gallon bags full of papers, and a paper shredder. During an interview at the time of the observation the Maintenance Director stated the papers in the cardboard box and the plastic bags were stored in the Kitchenette to be shredded. Review of Annual Facility Door Audit sheets revealed the facility's hazardous area doors had been checked from 9/19/24 through 9/20/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedJanuary 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. A 100% audit of all doors/latches and doorframes was conducted on 1/3/2025 to ensure proper functioning. The door to Unit 1/2 Soiled Utility Room (near Resident room [ROOM NUMBER]) latch on the inside the door was repaired by Maintenance Director.Unit 5 Soiled Utility Room (near Resident room [ROOM NUMBER]) was repaired by Maintenance Director.Folded paper towels that were taped over the latch plate preventing the door from latching were removed during survey 12/6/ 2024. Unit 5 apartment door was repaired by Maintenance Director.Basement - LaVerna was repaired by Maintenance Director. The arm of the self-closing device on the right leaf was re-attached to the door. Basement - A Wing Housekeeping Storage Room Door (A6) was repaired by Maintenance Director.Basement - A Wing Storage Room door (A2) was repaired by Maintenance Director. The door's self-closing device was re-attached to the door. Basement - B Wing Housekeeping Supply Storage Room Doors (B5) and (B7) was repaired by Maintenance Director. The arms on both door's self-closing devices were re-attached to the doors.Basement - C Wing Housekeeping Storage Room door(C12) was repaired by Maintenance Director.Basement - C Wing Boiler Room door (C10) was repaired by Maintenance Director. floor of the C Wing Corridor was grounded down so the door no longer got hung-up on it. Basement - Activities Storage Room door (A1) was repaired by Maintenance Director. The floor of the basement's center corridor was grounded down so the door no longer got hung-up on it.2nd Floor Administration area - kitchenette was repaired by Maintenance Director. The floor of the kitchenette was grounded down so that the door no longer got hung-up on it. 2. All residents are at risk for deficient practice of hazardous doors not closing and latching in the frame. 3. All hazardous doors were audited by Maintenance Director for deficient practice of doors not closing and latching in frame. Any deficient finding was immediately repaired. 4. Policy and Procedure for hazardous doors was reviewed by Administrator. No change was made to policy. 5. All staff were in-serviced by the Consultant regarding the regulation for properly functioning doors, notification to maintenance regarding improperly functioning doors, and deficient practice of obstructing doors. Administrator inserviced Maintenance Director/Tech on policy and procedure for Hazardous Doors. 6. Monthly Audits of door/latches and door frames will be conducted by the Director of Maintenance and reviewed by the Administrator at the monthly QAPI meeting. Any deficient findings will be corrected and brought to QAPI. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, the facility did not maintain illumination of means of egress. Specifically, continuous egress lighting capable of automatic operation without manual intervention was not provided on the exterior of the building at exit doors. This affected one (Unit 6) of three resident units and one of one Therapy room located between Unit 5 and Unit 6. The findings are: 1a. Observation on 12/2/24 at 10:43 AM on the exterior of the First Floor on Unit 6 revealed there was no light fixture installed above exit door (13), located near Resident Room 621. Further observation revealed a light fixture with two separate lights was installed on the side of the building 22 feet away from the door and only one of the lights was facing toward door (13). Continued observation of the interior of the building revealed there was an illuminated exit sign installed above exit door (13). During an interview at the time of the observation the Maintenance Director stated there was no light fixture installed on the exterior of the building above exit door (13). 1b. Observation on 12/2/24 at 11:21 AM on the exterior of the First Floor on the Unit 6 revealed there was no light fixture installed above exit door (10) that was located in the Resident Lounge. Further observation revealed a light fixture with two separate lights was installed on the side of the building 15 feet away from the door and only one of the lights was facing toward door (10). Continued observation on the interior of the building revealed there was an illuminated exit sign installed above exit door (10). During an interview at the time of the observation the Maintenance Director stated there was no light fixture installed on the exterior of the building above exit door (13). 1c. Observation on 12/2/24 at 12:11 PM on the exterior of the First Floor between Unit 5 and Unit 6 revealed there was no light fixture installed above exit door (6) that was located in the Therapy Room. Further observation revealed no light fixture was installed above exit door (6) on the exterior of the building. Continued observation on the interior of the building revealed there was an illuminated exit sign installed above exit door (6). During an interview at the time of the observation the Maintenance Director stated there was no light fixture installed on the exterior of the building above exit door (6). Review of Monthly Outdoor Light Check sheets revealed the last time the facility's outdoor lights were checked was on 11/22/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2. 8, 7. 8, 7. 8. 1, 7. 8. 1. 1, 7. 8. 1. 2, 7. 8. 1. 4 | Plan of Correction: ApprovedJanuary 1, 2025 1. Exterior of the First Floor on Unit 6 had light fixture installed with two light fixtures above exit door by Maintenance Director on 1/17/ 2025. Exterior of the First Floor on the Unit 6 had two light fixture installed above exit door located by Resident lounge by Maintenance Dir on 1/17/ 2025. Exterior of the First Floor between Unit 5 and Unit 6 had two light fixture installed by Maintenance Director on 1/17/ 2025. 2. All residents are at risk for deficient practice of not having proper illumination above means of egress. 3. Administrator reviewed policy and procedure for life safety illumination of egress doors and no change to the policy was institute. 4. Administrator educated Maintenance Director/Maintenance Tech on illumination above egress doors. 5. All egress doors were audited by Maintenance for proper illumination. Any deficient practices were corrected immediately and brought to QAPI for further review. Weekly audits will occur for 8 weeks then monthly for 6 months. Person Responsible: Maintenance Director |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 12/6/24, the facility did not comply with emergency preparedness requirements. Specifically, the facility's Disaster Manual Disaster Plan did not have documentation for the method for sharing information from the manual and plan, that the facility had determined was appropriate, with residents and their families or representatives. This affected one (First Floor) of one resident use floor, including three (Unit 1/ 2, Unit 5, and Unit 6) of three resident units, one (Second Floor) of one Administration area, and one of one Basement. The finding is: Review of the facility's Disaster Manual Disaster Plan, with a review date of 10/16/24, revealed it did not have documentation for the method for sharing information from the Disaster Manual Disaster Plan, that the facility had determined was appropriate, with residents and their families or representatives. During an interview on 12/5/24 at 1:33 PM the Administrator stated the Disaster Manual Disaster Plan, with a review date 10/16/24, was the facility's current Emergency Preparedness Plan. The Administrator further stated the Disaster Manual and Disaster Plan was the emergency preparedness plan that the facility had when they started in (MONTH) of 2024 and the Disaster Manual and Disaster Plan included the policies and procedures the facility was currently using. The Administrator also stated they were working on an updated Emergency Preparedness Plan that had not been implemented at the facility. 42 CFR 483. 73-Emergency Preparedness 42 CFR: 483. 73(c)(8) | Plan of Correction: ApprovedDecember 29, 2024 1. Administrator reviewed current EPP and updated EPP on items not included. The EPP and Pandemic Plan were updated to facilities website on 1/17/ 2025. 2. All Residents are at risk for deficient practice for not having updated EPP posted on the website. 3. All staff and residents were notified that the EPP is posted on website on 1/17/2025 by written correspondence by Administrator. 4. The EPP plan will be reviewed quarterly in the QAPI meeting to ensure updated EPP is available via website for staff, residents and family. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, facility doors were not maintained. Specifically, doors within a means of egress were equipped with a lock that required more than one releasing operation. This affected one (Unit 1/ 2) of three resident units and one of one Basement. The findings are: 1a. Observation on the First Floor on 12/2/24 at 9:34 AM revealed the door that separated the Unit 1/2 Resident Lounge from the Unit 1 corridor was equipped with a thumb turn lock in the doorknob on the egress side of the door that required two actions to open the door. The thumb lock had to be turned to the unlocked position and then the doorknob had to be turned to allow the door to be opened. During an interview at the time of the observation the Maintenance Director stated the Maintenance staff inspected the facility's corridor doors and the facility had documentation for the inspections. 1b. Observation on 12/2/24 at 1:56 PM in the Basement revealed the La(NAME)storage room door that separated the room form the Center stairway was equipped with a thumb turn lock in the doorknob on the egress side of the door that required two actions to open the door. The thumb lock had to be turned to the unlocked position and then the doorknob had to be turned to allow the door to be opened. Further observation revealed an illuminated exit sign was installed above the door. 1c. Observation 12/2/24 at 2:11 PM in the Basement revealed Therapy Storage room door (A5) that separated the storage room form the A Wing corridor was equipped with a thumb turn lock in the doorknob on the egress side of the door that required two actions to open the door. The thumb lock had to be turned to the unlocked position and then the doorknob had to be turned to allow the door to be opened. Further observation revealed an illuminated exit sign was installed from the ceiling of the room near the door. Review of Annual Facility Door Audit sheets revealed the facility's doors were checked on 9/19/24 through 9/20/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2, 19. 2. 1, 19. 2. 2. 2. 4, 7. 2. 1, 7. 2. 1. 5. 1, 7. 2. 1. 5. 3 | Plan of Correction: ApprovedDecember 31, 2024 1. All locks requiring more than one releasing operation were audited on 12/30/2024 by Maintenance Director. Door that separates first and second unit was audited and locking mechanism was replaced. The door in basement by La(NAME)Storage room was audited by Maintenance Director on 12/30/2024 and locking mechanism was replaced. The Door for therapy storage in basement was audited by Maintenance Director on 12/30/2024 and locking mechanism was replaced. 2. All residents are at risk for deficient practice of doors wihin a means of egress being equipped with locking mechanism with more than one releasing mechanism. 3. The policy and procedure for life safety doors with section on Doors within a means of egress was created on 12/30/2024 by Administrator. 4. An entire building wide audit will be conducted on all doors within a means of egress having lock with more than one releasing mechanism.All doors with deficient practice will be repaired. 5. The Maintenance Director/Tech will be educated on this issue by the Administrator on 1/10/ 2025. 6. The Maintenance Director will report completion of lock changes to the QAPI Committee to ensure compliance with K 200. An audit will be completed monthly by the Maintenance Director/Tech to ensure this issue is no longer present in the facility. The QAPI Committee will review completion and determine any further changes needed. Person Responsible: Maintenance Director |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 12/6/24, the facility did not comply with emergency preparedness requirements. Specifically, the facility's Disaster Manual Disaster Plan, Facility Assessment and facility-based and community-based risk assessment did not contain documentation regarding missing residents. This affected one (First Floor) of one resident use floor, including three (Unit 1/ 2, Unit 5, and Unit 6) of three resident units, one (Second Floor) of one Administration area, and one of one Basement. The finding is: Review of the facility's Disaster Manual Disaster Plan, with a review date of 10/16/24, the Facility Assessment and facility-based and community-based risk assessment with date of assessment or update of 8/24 did not contain documentation regarding missing residents. During an interview on 12/5/24 at 1:33 PM the Administrator stated the Disaster Manual Disaster Plan, with a review date 10/16/24, was the facility's current Emergency Preparedness Plan and the Facility Assessment and facility-based and community-based risk assessment with a date of assessment or update of 8/24 were also part of the facility's current Emergency Preparedness Plan. The Administrator further stated the Disaster Manual and Disaster Plan was the emergency preparedness plan that the facility had when they started in (MONTH) of 2024 and the Disaster Manual and Disaster Plan included the policies and procedures the facility was currently using. The Administrator also stated they were working on an updated Emergency Preparedness Plan that had not been implemented at the facility. 42 CFR 483. 73-Emergency Preparedness 42 CFR: 483. 73(a)(1)-(2) | Plan of Correction: ApprovedDecember 29, 2024 1. Administrator completed updated HVA and included elopement into assessment on 12/29/ 2024. 2. All Residents are at risk for deficient practice for not having HVA assessment including elopement risk as a risk in the EPP. 3. All staff were trained on the emergency preparedness plan which included elopement risk and steps to follow in case of risk by RN Educator. Education was completed for all staff on 1/24/ 2024. 4. The HVA will be reviewed quarterly in the QAPI meeting to ensure updated HVA is reviewed and updated on any new risks. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 12/6/24, the facility did not comply with emergency preparedness requirements. Specifically, the facility's Disaster Manual Disaster Plan did not include policies and procedures for how the facility would provide a means to shelter in place for residents, staff, and volunteers who remained in the facility. This affected one (First Floor) of one resident use floor, including three (Unit 1/ 2, Unit5, and Unit 6) of three resident units, one (Second Floor) of one Administration area, and one of one Basement. The finding is: Review of the facility's Disaster Manual Disaster Plan, with a review date of 10/16/24, revealed it did not include policies and procedures for how it would provide a means to shelter in place for residents, staff, and volunteers who remained in a facility. During an interview on 12/5/24 at 1:33 PM the Administrator stated the Disaster Manual Disaster Plan with a review date of 10/16/24, was the facility's current Emergency Preparedness Plan. The Administrator further stated the Disaster Manual and Disaster Plan was the emergency preparedness plan that the facility had when they started in (MONTH) of 2024 and the Disaster Manual and Disaster Plan included the policies and procedures the facility was currently using. The Administrator also stated they were working on an updated Emergency Preparedness Plan that had not been implemented at the facility. 42 CFR 483. 73-Emergency Preparedness 42 CFR: 483. 73(b)(4) | Plan of Correction: ApprovedDecember 29, 2024 1. Administrator reviewed the current Emergency Preparedness plan and updated EPP on 12/29/2024 to include policy and procedure for Sheltering in place. 2. All Residents are at risk for deficient practice for not having sheltering in place policy procedure addressed in the EPP. 3. All staff were trained on the emergency preparedness plan which policy and procedure on sheltering in place and steps to follow in case of emergency by RN Educator. Education was completed for all staff on 1/24/ 2024. 4. The HVA will be reviewed quarterly in the QAPI meeting to ensure updated EPP is reviewed and updated on any new changes. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 12/6/24, the facility did not comply with emergency preparedness requirements. Specifically, the facility's Disaster Manual Disaster Plan did not include policies and procedures for the use of volunteers and other staffing strategies in its manual and plan. This affected one (First Floor) of one resident use floor, including three (Unit 1/ 2, Unit 5, and Unit 6) of three resident units, one (Second Floor) of one Administration area, and one of one Basement. The finding is: Review of the facility's Disaster Manual Disaster Plan with a review date of 10/16/24, revealed it did not include policies and procedures for the use of volunteers and other staffing strategies in its manual and plan. During an interview on 12/5/24 at 1:33 PM the Administrator stated the Disaster Manual Disaster Plan, with a review date of 10/16/24, was the facility's current Emergency Preparedness Plan. The Administrator further stated the Disaster Manual and Disaster Plan was the emergency preparedness plan that the facility had when they started in (MONTH) of 2024 and the Disaster Manual and Disaster Plan included the policies and procedures the facility was currently using. The Administrator also stated they were working on an updated Emergency Preparedness Plan that had not been implemented at the facility. 42 CFR 483. 73-Emergency Preparedness 42 CFR: 483. 73(b)(6) | Plan of Correction: ApprovedDecember 29, 2024 1. Administrator completed review of the current EPP on 12/29/2024 and updated EPP to include policy and procedure for Volunteer and procedure for staffing procedures on 12/29/ 2024. 2. All Residents are at risk for deficient practice for not having policy procedure on volunteer and staffing procedures addressed in EPP. 3. All staff were trained on the emergency preparedness plan which included policy and procedure on volunteers and staffing procedure by RN Educator. Education was completed for all staff on 1/24/ 2024. 4. The EPP will be reviewed quarterly in the QAPI meeting to ensure updated EPP is reviewed and updated on all policies required to be included in EPP including Volunteers and staffing strategies. Any deficient practices will be corrected and further reviewed at QAPI Meeting. Person Responsible: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, portable fire extinguishers were not maintained. Specifically portable fire extinguishers were missing their safety seal/ tamper indicator, and were obstructed. This affected one (Unit 6) of three resident units and one of one Basement. The findings are: 1a. Observation on 12/2/24 at 11:20 AM on the First floor revealed safety seal/ tamper indicator was missing from the portable fire extinguisher located in the Unit 6 Resident Lounge. Further observation of the tag attached to the portable fire extinguisher revealed the last monthly inspection of the extinguisher was conducted on 11/4/ 24. During an interview at the time of the observation the Maintenance Director stated they were not aware the safety seal/ tamper indicator was missing from the extinguisher. 1b. Observation on 12/2/24 at 3:07 PM in the Basement revealed safety seal/ tamper indicator was missing from the portable fire extinguisher located in the B Wing Laundry room. Further observation revealed this was the portable fire extinguisher located closest to the dryers. Further observation of the tag attached to the portable fire extinguisher revealed the last monthly inspection of the extinguisher was conducted on 11/4/ 24. During an interview at the time of the observation the Maintenance Director stated they checked the safety seal/ tamper indicator during the monthly inspections of the facility's portable fire extinguishers. 2a. Observation on 12/2/24 at 2:42 PM in the Basement in the B Wing Central Supply/ Medical Supply room revealed five foot tall by four foot long by two foot wide open metal rack full of medical supplies was stored in front of and obstructing the portable fire extinguisher in the room. During an interview at the time of the observation the Maintenance Director stated a staff member had been organizing the room and they must have moved the rack in front of the fire extinguisher. Review of Fire Extinguisher Check sheets revealed the facility's portable fire extinguishers had been inspected monthly form (MONTH) through (MONTH) in 2024. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 5. 12, 9. 7. 4, 9. 7. 4. 1 2010 NFPA 10: 7. 1, 7. 1. 1, 7. 2. 2, 7. 2. 2. 1, 7. 2. 2. 2 2010 NFPA 10: 6. 1. 3, 6. 1. 3. 1, 6. 1. 3. 3, 6. 1. 3. 3. 1 | Plan of Correction: ApprovedDecember 30, 2024 1. Portable fire extinguisher located in the Unit 6 Resident Lounge tamper seal was replaced by Maintenance Director. Portable fire extinguisher located in the B Wing Laundry room had tamper seal replaced by Maintenance Director. Basement in the B Wing Central Supply/ Medical Supply room had items removed from obstruction of portable fire extinguisher by Maintenance Director. 2. All residents are at risk for deficient practice of fire extinguishers missing safety seal and obstruction of fire extinguishers. 3. A complete audit of all fire extinguisher was completed by Maintenance Director. Any deficient practices were fixed. 4. All staff were educated on keeping all fire extinguishers free of obstruction by RN Educator. Maintenance Director/Tech were educated by Administrator to ensure tamper seals are in place on portable fire extinguisher. 5. A monthly audit of all fire extinguishers to check for obstruction and tamper seals will be done for next 6 months. Any deficient practices will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, a portable electric heater was not properly maintained. Specifically, a portable electric space heater was plugged in and running, and the facility did not have documentation that showed the portable electric heater's heating element did not exceed 212 degrees Fahrenheit (?é??F). This affected one of one Basement. The finding is: Review of the undated policy and procedure titled Space Heaters documented, purpose, to establish guidelines for the safe use of space heaters in non-resident areas of the facility, ensuring compliance with fire safety regulations while maintaining a comfortable environment. Scope, this policy applies to all staff members using portable space heaters in non-resident areas including, offices, break rooms, and other administrative spaces. Policy Statement, the use of portable space heaters is permitted in non-resident use areas of the facility under strict conditions to ensure the safety of the facility, staff, and visitors. Space heaters must meet specific safety standards and be used only under supervision. Approval and Placement. Space heaters must be approved by the facility administrator or maintenance department before use. Prohibited use. Space heaters are not permitted in resident care areas, storage rooms, or areas with flammable gasses or liquids. Compliance. All staff are responsible for adhering to this policy. Non-compliance may result in disciplinary action and removal of the heater from the premises. Responsibilities. Staff members: ensure proper use and supervision of approved space heaters. Observation on 12/2/24 at 3:08 PM in the Basement in the B Wing Laundry room revealed a portable electric space heater was stored on one of the laundry linen folding tables. Further observation revealed the portable heater was plugged into a duplex electrical outlet, was on and running on the heater's Low setting. Further observation revealed five folded blankets and two folded pillowcases were stored on the table less than three feet from the front of the heater and 15 folded sheets were stored on the table less than three feet behind the heater. During an interview at the time of the observation the Maintenance Director stated they were not aware the portable electric heater was in the Laundry room and that a portable electric heaters were not allowed in the building. Review of the manufacturer's sticker attached to the heater revealed it read: Warning Risk of Fire - Keep combustible materials such as furniture, papers, clothes and curtains at least 3 feet ( 0. 9 meters) from the front of the heater and away from the sides and rear. During an interview on 12/6/24 at 12:32 PM the Maintenance Director stated the facility did not provide the portable electric heater that was found in the Basement Laundry room and the facility had no documentation that showed the portable electric heater's heating element did not exceed 212 degrees Fahrenheit (?é??F) (100 degrees Celsius) (?é??C). 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7. 8 | Plan of Correction: ApprovedDecember 30, 2024 1. Space Heater located in Basement was removed by Maintenance Director. Facility conducted audit of all rooms to check for space heaters. Any deficient findings were corrected immediately. 2. All residents are at risk for deficient practices of not having proper documentation showing portable electric heater did not exceed 212 degrees. 3. All staff were educated on policy and procedure regarding space heaters by RN Educator. 4. An audit will be conducted monthly by QA staff to ensure no space heaters are present. Any deficient practice will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, the facility's automatic sprinkler system was not maintained. Specifically, sprinkler piping and sprinkler piping hangers were exposed to external loads and the facility did not have documentation that verified that the automatic wet sprinkler system and the automatic dry sprinkler system had been inspected, tested , and maintained on a quarterly basis. This affected the First Floor including three (Unit 1/ 2, Unit 5, and Unit 6) of three resident units, one of one Administration area located on the Second Floor, and one of one Basement. The findings are: 1a. Observation on 12/3/24 at 1:15 PM on the First Floor above the Unit 6 corridor ceiling tile near the Beauty Shop revealed ceiling tiles were attached to and hung from sprinkler piping by metals wires in four locations. Further observation revealed electrical wires were attached to a sprinkler pipe with black colored tape in one location. Continued observation revealed a ceiling tile was attached to and hung from the hanger of a sprinkler pipe by metal wires in one location. During an interview at the time of the observation the Maintenance Director stated there had been no recent work above the ceiling tiles in this area of the facility. 1b. Observation on 12/3/24 at 1:31 PM on the First Floor above the Unit 6 corridor ceiling tile between Resident rooms [ROOM NUMBERS] revealed a light fixture was attached to and hung from sprinkler pipe by meatal wires in one location. During an interview at the time of the observation the Maintenance Director stated there had been no recent work above the ceiling tiles in this area of the facility. During an interview on 12/6/24 at 10:47 AM the Maintenance Director stated the Maintenance staff inspected sprinkler piping located above the ceiling tiles whenever they were working in the areas above the ceiling tiles and the facility had no documentation of inspections of the sprinkler piping located above the ceiling tiles. 2a. During an interview on 12/6/24 at 9:54 AM the Maintenance Director stated the facility had no documentation for quarterly sprinkler inspections and testing for the wet sprinkler system and the dry sprinkler system from the Third Quarter (July, August, September) of 2023, the Fourth Quarter (October, November, December) of 2023, and the First Quarter (January, February, March) of 2024. The Maintenance Director further stated quarterly sprinkler inspections and testing were not conducted on the wet sprinkler system and the dry sprinkler system in the Third Quarter of 2023, the Fourth Quarter of 2023, and the First Quarter of 2024. Review of Wet Sprinkler System Inspection Reports and Dry Sprinkle System reports from the contractor that inspected, tested , and maintained the facility's automatic sprinkler systems revealed they contained no documentation that inspecting and testing of the wet sprinkler system and the dry sprinkler had been conducted in the Third Quarter of 2023, the Fourth Quarter of 2023, and the First Quarter of 2024. Review of documentation provided by the Maintenance Director regarding the inspection, testing, and maintenance records of the facility's wet sprinkler system and dry sprinkler system from the contractor's Property Owner Portal (electronic documentation of inspection records from the contractor's website) revealed they contained no documentation that inspecting and testing of the wet sprinkler system and the dry sprinkler had been conducted in the Third Quarter of 2023, the Fourth Quarter of 2023, and the First Quarter of 2024. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2011 NFPA 101: 9. 7, 9. 7. 1, 9. 7. 1. 1, 9. 7. 5 2011 NFPA 25: 4. 1, 4. 1. 1, 4. 1. 1. 1. 1, 4. 3, 4. 3. 1, 4. 3. 2, 4. 3. 3 2011 NFPA 25: 5. 1, 5. 1. 1, 5. 1. 1. 1, 5. 1. 1. 2, Table 5. 1. 1. 2, 5. 2, 5. 2. 2. 2, 2010 NFPA 13: 6. 1, 6. 6, 9. 1, 9. 1. 1. 7 | Plan of Correction: ApprovedJanuary 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility is requesting temporary waiver for F353 in order to make the necessary physical corrections to come into compliance with life safety code for the load on the sprinkler head. a. The Assessment of the sprinkler head load throughout building will be conducted by maintenance by removing all ceiling tiles. This will be done by 1/31/ 2024. The sprinkler load will be assessed by maintenance weekly until all load items have been removed. b. Building materials needed to reviewed including removing wires from sprinkler load. This will include removing load from sprinkler pipe and placing on ceiling. Load will be reassessed weekly by maintenance until full removal of load from all sprinkler pipes. The material phase will be completed by [DATE]th. c. Safety plan will include area where maintenance is removing the load on the sprinkler and reinstalling in the ceiling. This will include safety precautions for all residents in work area. Residents will be removed from area while work is being performed. Unit 1/2 will be completed by [DATE]th. Unit 5 will be completed by (MONTH) 14st and unit 6 will be completed by (MONTH) 31st. d. All areas will be reviewed by maintenance staff for goal of 100% removal of wiring on sprinkler pipes and removing all load from sprinkler pipe. This will be completed on (MONTH) 31st. 2. The facility will need until (MONTH) 1, 2025 as the time needed to reinstall ceiling grid and remove it from the sprinkler head is extensive. The time needed is based on in house labor hours. The facility will institute a safety plan for the project while to ceiling is removed and reinstalled. 3. All wires attached to sprinkler pipe will be removed including first floor corridor unit 6. All ceiling tiles attached to sprinkler head were removed by Maintenance. Light fixture hung from Sprinkler head on First Floor above the Unit 6 corridor ceiling tile between Resident rooms [ROOM NUMBERS] were removed by Maintenance staff. The facility had sprinkler system testing completed by outside vendor. 4. All residents are at risk for deficient practice of obstruction of sprinkler head and testing not being completed per regulations. 5. A full audit of all sprinkler system will be completed to ensure nothing is hanging from the sprinkler system. Administrator and Maintenance reviewed all documentation not completed in past 12 months. 6. Administrator reviewed policy and procedure on sprinkler system including obstruction including external loads and testing required. Changes were made to policy. 7. Administrator trained Maintenance Director/Tech on sprinkler external loads and mandatory testing that needs to be completed. RN educator educated all staff on sprinkler head obstruction on 1/17/ 2025. 8. 5 weekly audits will be completed by Maintenance on sprinklers to ensure no obstruction or external loads are provided to sprinkler pipes. Any deficient practice will be done and brought to QAPI for further review. Monthly audit of all required testing will be completed monthly by Maintenance Director and brought to QAPI for further review. Any deficient practices will be corrected. Person Responsible: Maintenance Director |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 12/6/24, stairways were not maintained. Specifically, stairway doors did not self-close and latch into their door frames, and were obstructed from closing. This affected one of one Main Kitchen located on the First Floor and one of one Basement. The findings are: 1a. Observation on the First Floor on 12/2/24 at 12:57 PM revealed the Main Kitchen rear stairway exit door did not self-close and latch into its door frame. Further observation revealed the door's latch was missing.There was a three inch long by one and one half inch wide opening in the door where the door's latch should have been, and the metal around this opening was bent out away from the door. During an interview at the time of the observation the Food Service Director and the Maintenance Director stated someone had pried open and broke the door three months ago. 1b. Observation in the Basement on 12/2/24 at 2:23 PM revealed the A Wing stairway exit door (19) did not self-close and latch into its door frame. Further observation revealed the stairway led from the A Wing to exterior of the building. Continued observation revealed an illuminated exit sign was installed from the Basement ceiling near the door. During an interview at the time of the observation the Maintenance Director stated the Maintenance staff checked the facility's stairway doors and the facility had documentation of the checks. 1c. Observation in the Basement on 12/2/24 at 3:18 PM revealed the Laundry room rear stairway exit door (14) did not self-close and latch into its door frame. Further observation revealed the door was equipped with a door sweep on the bottom of the door and when the door was opened and allowed to self-close it became hung up on floor of stairway. During an interview at the time of the observation the Maintenance Director stated they were not sure if just the door sweep was obstructing the door from closing or if the door was also hung up on the floor of the stairway. Review of Annual Facility Door Audit sheets revealed the facility's stairway doors were checked from 9/19/24 through 9/20/ 24. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2. 2. 3, 7. 2. 2, 7. 2. 2. 1. 1, 7. 1, 7. 1. 3. 2. 1, 7. 1. 3. 2. 2 | Plan of Correction: ApprovedDecember 30, 2024 1. Main Kitchen rear stairway exit door had self closing mechanism latch replaced by Maintenance on 1/10/ 2025. Door was then tested to ensure it self closed and latched in the frame. Basement A Wing stairway exit door had self closing mechanism installed by Maintenance on 1/10/ 2025. Door was then tested to ensure it self closed and latched in the frameBasement door by Laundry room rear stairway exit door had self closing mechanism installed and door was repaired by Maintenance on 1/10/ 2025. Door was then tested to ensure it self closed and latched in the frame 2. All stairway doors and stairwell areas have potential to be affected by deficient practice of obstruction from closing and latch not working. 3. All facility doors will be inspected to ensure self-closers work properly, and needed repairs to ensure doors close per regulation and latch into frames. 4. The facilitys policy and Life Safety - Means of Egress/ Exits - Hazardous Area Enclosure - Doors with Self Closing Devices, Stairway and Smoke Proof Enclosures policies and audit tool were reviewed and revised to include inspection for penetrations, fire resistance labeling and monthly QA process. 5. Facility Administrator to educate Maintenance Director/Tech on policy and procedure for Means of Egress for self closing devices. 6. A door audit tool will be developed to inspect and identify issues with facility doors including properly working self-closers affixed fire resistance labeling, latching into frame, and without penetrations. All doors will be audited monthly for 12 months by administrator or designee. All stairwells will be inspected weekly for 1 month and then monthly for 2 months. Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results Person Responsible: Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 6, 2024
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 12/6/24, smoke barriers walls were not maintained. Specifically, smoke barrier walls were not complete from floor to roof deck, not designed to have at least a 30-minute fire resistance rating, and not designed to resist the passage of smoke, due to penetrations through the smoke barrier walls. This affected one (Unit 5) of three resident units. The findings are: Review of the Smoke Barrier Penetration Policy with an effective revision date of 6/2023 documented, to ensure compliance, the facility fire/ smoke barriers including walls and doors will be audited by visual inspection following any repair/ remodel and on a monthly basis to ensure proper sealing of all penetrations. Maintenance Mechanics will be educated on fire/ smoke rating barrier walls, floors, doors, and ceiling assemblies. Mechanics will be assigned monthly to complete inspection of each floor to ensure compliance. The Director of Plant Operations/ designee will inspect any areas that have been recently renovated or when any repairs to the building or any installation of equipment has been completed. 1a. Observation on 12/3/24 at 2:48 PM on the First Floor above the Unit 5 corridor ceiling tile revealed a two inch long by one inch wide penetration next to a steel support beam that was installed through the smoke barrier wall above the smoke barrier doors near Resident Room 519. 1b. Observation on 12/3/24 at 2:50 PM on the First Floor above the Unit 5 corridor ceiling tile revealed a four inch long by two inch wide area between the corrugated roof deck and the smoke barrier wall above the smoke barrier doors near Resident Room 522 was filled with mineral wool that was not sealed with a fire rated material. 1c. Observation on 12/4/24 at 11:05 AM on the First Floor on Unit 5 revealed a five inch long by three inch wide penetration near plumbing pipes that were installed through the smoke barrier wall below the sink in the bathroom of Resident Room 522. During an interview at the time of the observation the Maintenance Director stated they were not aware of the penetration in the smoke barrier wall below the sink. The Maintenance Director further stated there had been no recent plumbing work done in the bathroom in Resident Room 522. During an interview on 12/5/24 at 10:49 AM the Maintenance Director stated the Maintenance staff checked the facility's smoke barrier walls and the facility did not have any documentation for these checks of the smoke barrier walls. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7, 19. 3. 7. 3, 8. 5, 8. 5. 1, 8. 5. 2, 8. 5. 2. 1, 8. 5. 2. 2, 8. 5. 2. 3 | Plan of Correction: ApprovedDecember 30, 2024 1. The Unit 5 corridor ceiling penetration next to a steel support beam near Resident Room 519 was sealed by Maintenance.The Unit 5 corridor ceiling penetration located by the corrugated roof deck and the smoke barrier wall above the smoke barrier doors near Resident Room 522 t was sealed with a fire rated material by Maintenance Director.The First Floor on Unit 5 penetration near plumbing pipes that were installed through the smoke barrier wall below the sink in the bathroom of Resident Room 522 was sealed with fire rated material by Maintenance Director. 2. All residents are at risk for the deficient practice of smoke barrier walls not being maintained. 3. All smoke barrier walls will be audited for penetrations. Any deficient practice will be repaired. 4. Administrator educated Maintenance Director and Maintenance Tech on Smoke barrier walls and 30 minute resistance rating. 5. The facility will conduct quarterly audits on Smoke barrier walls. Any deficient practices will be repaired and brought to QAPI for further review. Person Responsible: Maintenance Director |