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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: N/A
Severity: N/A
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
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 recertification post survey review conducted 1/4/23-1/6/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #501) reviewed. Specifically, staff did not utilize appropriate personal protective equipment (PPE) while caring for Resident #501 who was on transmission based precautions for influenza (flu). Findings include: The facility policy Influenza-Vaccination/Control revised 4/2019 documented the facility followed current guidelines and recommendations for the prevention and control of seasonal influenza. Staff would adhere to Droplet Precautions including gowns, gloves, and hand hygiene. Droplet Precautions would be implemented for residents with suspected or confirmed influenza for 7 days after onset or until 24 hours after resolution or respiratory symptoms. In some cases, Droplet Precautions may be applied for longer periods. The facility policy Isolation Precautions revised 12/2019, documented: - droplet transmission occurred when droplets traveled 3-10 feet by air when a resident coughed, sneezed, or talked; - contact transmission occurred through direct contact with the organism and then contact with another person or surface; - appropriate signage would be placed on the resident's doorway identifying the type of infection and type of precautions required; - wear a gown if body/clothing contact was likely; - wash hands before entering room, after removing PPE, and after removing gloves; - wear eye protection if within 3 feet of a resident on droplet precautions; and - wear appropriate mask prior to entering room (mask for droplet precautions and/or N95 mask depending on the disease specific recommendations). Resident #501 had [DIAGNOSES REDACTED]. The 12/13/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 1 with most activities of daily living (ADLs) and received oxygen therapy. The MDS did not document if the resident received the influenza vaccine for the current flu season. The 11/18/22 comprehensive care plan (CCP) documented the resident had an alteration in respiratory system and was at risk for cross contamination to potential COVID-19 exposure. Interventions included nebulizer (aerosol medication machine) treatments as ordered, provide supplemental oxygen as ordered, observe for poor airway clearance and gas exchange, and vital signs as ordered. The CCP did not include influenza [DIAGNOSES REDACTED]. The 12/30/22 test for flu by nasopharyngeal polymerase chain reaction (PCR, a highly accurate test to determine presence of flu and type of strain) documented the resident was positive for Flu A. The 12/31/22 at 12:16 PM registered nurse (RN) #16 progress note documented the resident's flu swab resulted positive for flu A. Nurse practitioner (NP) #28 was made aware and ordered Xofluza ([MEDICAL CONDITION] medication) and take vital signs every 4 hours. The resident was placed on isolation. During an observation on 1/4/23 at 12:07 PM, Resident #501's room had a sign on the doorway documenting the resident was on droplet/contact precautions. The sign documented staff were to put on a N95 mask, gown, gloves, and eye protection at the door prior to entering the room. There was only 1 resident assigned to that room. The room door had a PPE caddy hanging from the door and the door was open about 12 inches. Assistant Director of Nursing (ADON) #15 stated the resident was on droplet precautions due to having the flu. During an observation on 1/4/23 at 3:34 PM, licensed practical nurse (LPN) #18 entered Resident #501's room with gloves and a surgical mask on. The LPN did not don a gown or eye protection prior to entering the room. The resident was not wearing a mask. The LPN talked to the resident briefly, exited the room, went to a medication cart by the nursing station, went back into the room without donning a gown or eye protection, closed the door most of way, came back to the door 10 seconds later, grabbed a gown from the door caddy and began donning the gown in the entryway to room. The LPN then closed the door to the room. When interviewed on 1/4/23 at 3:45 PM, LPN #18 stated staff needed to put on a gown, gloves, and mask prior to entering Resident #501's room. The LPN was unsure why the resident was on precautions. The LPN stated infection control education was recently done. The LPN stated they did not put on a gown initially as they only entered to ask the resident a question. The LPN stated they did not don a gown the second time entering the room as the LPN's hands were full. They donned a gown when they had to provide care to the resident. When interviewed on 1/4/23 at 4:45 PM, certified nurse aide (CNA) #19 stated staff were to wear a surgical mask throughout the building, don gloves prior to providing hands on care, don a gown if there was a PPE caddy on the outside of the resident's door, and a N95 mask if they were in that same caddy. All staff were to wear eye protection for anyone on droplet precautions. All PPE was to be put on in the hallway prior to entering the room. Staff recently received PPE education. The CNA did not think PPE needed to be worn if just delivering or picking up a meal tray in the room. During an observation on 1/4/23 at 4:54 PM, CNA #19 delivered a meal tray to Resident #501's room wearing only a surgical mask for PPE. The CNA set the meal tray on an overbed tray table, asked if the resident wanted something else, exited the room, sanitized their hands, and went to pass a meal tray to another resident. CNA #19 was not observed changing masks after exiting Resident #501's room and before entering another resident room. During an observation on 1/5/23 at 10:08 AM, the door to Resident #501's room was open and the droplet/contact precautions sign on the door was in place. The resident was lying in bed in a hospital gown. Certified occupational therapy assistant (COTA) #20 was in the room at the bedside about 2 feet from the resident. The COTA had a N95 mask and gloves on and was not wearing a gown or eye protection. The resident did not have a mask on. There were no gowns or eye protection observed in the PPE caddy hanging from the room door. The COTA pulled the curtain in the room and began assisting the resident with care and dressing while standing about 2 feet or less from the resident. At 10:17 AM, the COTA moved the overbed table and walker in the resident's room, got a wheelchair from across the room and assisted the resident to self-transfer from the bed to the wheelchair. The resident was observed coughing twice. Once in the wheelchair, the resident removed an oxygen nasal cannula from their face, handed it to the COTA, and the COTA placed it on the bedside stand. At 10:23 AM, the COTA wheeled the resident to the bathroom and closed the door about ?é¾ of the way. Through the partially opened bathroom door the COTA was observed assisting the resident. The resident continued to occasionally cough and did not have a mask on. At 10:41 AM, the COTA assisted the resident out of the bathroom via a wheelchair. The COTA then entered the bathroom, removed the N95 mask and gloves and washed their hands. The COTA exited the room and donned a surgical mask from the PPE caddy. When interviewed on 1/5/23 at 10:43 AM, COTA #20 stated they had facility orientation around 8/2022 and had not received infection control education recently. The COTA stated the resident was on droplet precautions as they recently had the flu. The COTA stated a nurse informed them the resident no longer had the flu but could not remember which nurse had told them. The COTA stated they did not don a gown prior to entering the room as there were none in the caddy. There was a sign on the doorway specifying what PPE was to be donned prior to entering the room and if the sign was on | Plan of Correction: ApprovedFebruary 9, 2023 I.Transmission based precautions discontinued 1/8/23 for resident # 501. No ill effects suffered. All identified staff educated on infection control with emphasis on required PPE for transmission based precautions. II.All residents have the potential to be affected. A Full house audit was conducted of all residents on Isolation precautions to ensure staff entering the resident room donned the required PPE. III. The policy on Influenza-Vaccination/Control reviewed. No revisions required. All staff educated on the requirement, importance, expectation and steps to providing a safe, sanitary and comfortable resident care environment to help prevent the development and transmission of communicable diseases and infection, including use of PPE. IV. Director of Nursing/Designee will conduct rounds to audit infection control practices on units. (5) staff per unit will be observed. The audit will be conducted daily x 14 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met. Audit findings will be presented to the QAPI committee monthly for review and recommendations. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
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 on-site post survey review (PSR) conducted 1/4/23-1/6/23, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 2 of 11 medication carts (2 North and 4 North) reviewed. Specifically, prescribed controlled drugs on the 2 North and 4 North units were stored in untethered (free-moving) medication carts and not returned to the double-locked medication room cabinets after the medication passes were completed as required. Findings include: The facility policy Medication Storage, revised 1/2019, documented the facility's medications were stored in a manner that maintained the integrity of the product, ensured the safety of the residents, and was in accordance with the Department of Health guidelines. Except for emergency drug kits, all medications would be stored in a locked cabinet, cart or medication room that was accessible only to authorized personnel, as defined by facility policy. Staff training on medication storage dated 11/30/22 signed by licensed practical nurse (LPN) #3 and an orientation checklist dated 12/22 signed by LPN #4 included education on understanding the importance and expectation that narcotic medication was stored according to regulations. No signature was documented for registered nurse (RN) # 2. During an interview on 1/4/23 at 1:22 PM, licensed practical nurse (LPN) #4 stated their medication pass was completed on 2 North. They stated their medication cart contained all the unit's controlled medications. LPN # 4 stated they were a new LPN as of December. The LPN stated they had an orientation checklist to complete that included medication administration and medication storage of controlled medications and they had a preceptor. They stated controlled medications were supposed to be locked in the medication room cabinet at the conclusion of a medication pass. LPN #4 stated they should have locked up their controlled medications in the medication room when they went to lunch. During an observation on 1/4/23 at 1:43 PM the 2 North medication cart was located against a wall in the hallway untethered and unattended. Upon return to the medication cart at 1:45 PM, LPN #4 opened the locked drawer of the medication cart. The drawer contained the entire inventory of controlled medications for the unit for all administration times and shifts. Controlled medications observed included: - [MEDICATION NAME] (pain relief) 50 milligrams (mg) - 14 tablets - Briviact (anti-[MEDICAL CONDITION]) 50 mg - 29 tablets - [MEDICATION NAME] IR (opioid pain relief) 5 mg - 203 tablets - [MEDICATION NAME] (anti-anxiety) 0. 5 mg- 65 tablets - [MEDICATION NAME] (opioid pain relief) 5/325 mg - 119 tablets - [MEDICATION NAME] (sedative, anti-[MEDICAL CONDITION]) 0. 5 mg- 59 tablets - [MEDICATION NAME] (opioid) 10 mg - 46 tablets - Xtampra ER (opioid pain relief) 9 mg - 17 capsules - [MEDICATION NAME] sulfate IR (opioid pain relief) 15 mg- 60 tablets - [MEDICATION NAME] ER (extended release opioid pain relief) 10 mg - 8 tablets - pregabalin (nerve pain medication) 75 mg - 59 capsules - [MEDICATION NAME] (sedative) 5 mg -16 tablets - [MEDICATION NAME] 10/325 mg- 53 tablets - [MEDICATION NAME]/apap ([MEDICATION NAME] with Tylenol) 7. 5/325 mg - 29 tablets During an observation on 1/4/23 at 2:15 PM on unit 4 North (4N), registered nurse (RN) #2 opened the medication room controlled drug storage cabinet and there were no controlled drugs inside. The low side medication cart contained all controlled medications for the residents who resided on that side of the hall. RN #2 stated there were no residents scheduled to receive controlled medications for that medication pass and the medication pass for the shift was completed. The RN stated all the low side controlled medications were in the medication cart, and they did not return them to the double-locked, affixed cabinet in the medication room. Controlled medications in the low side cart included: - [MEDICATION NAME] IR 5 mg - 109 tablets - pregabalin 100 mg- 7 capsules - [MEDICATION NAME] ER 10 mg- 11 tabs - [MEDICATION NAME]/apap 325mg- 40 tablets During an observation on 1/4/23 at 4:16 PM on unit 4 North, LPN #3 was the evening medication nurse and was passing medications. The medication cart for the low side was not in use and contained all the controlled medications for the low side rooms 421- 430. Controlled medications in the low side cart included: - [MEDICATION NAME] IR 5 mg- 109 tablets - pregabalin 100mg- 7 capsules - [MEDICATION NAME] ER 10 mg- 11 tablets - [MEDICATION NAME]/apap 5/325mg - 39. 5 tablets LPN #3 stated the controlled medications were in both medication carts for the entire unit (low side and high side) and they did not have any controlled medications locked in the medication room. They were passing medications for the high side of the hall at that time and were not passing medications for the low side. During an interview on 1/6/23 at 10:15 AM, the Director of Nursing (DON) stated all licensed nurses were educated on medication administration and storage. The Unit Managers who were both LPNs and RNs were responsible for rounding on the units to observe medication storage. It was not acceptable that controlled medications were in the medication carts after medication passes were completed, or medication carts containing controlled medications were left unattended. The controlled medications should be returned to the medication room cabinet when not in use. During an interview 1/6/23 at 11:09 AM with RN Unit Manager #13, they stated they were the Unit Manager for both 2 North and 2 South. They stated they were responsible for rounding on the units and had not done any auditing or rounding regarding controlled medications on the 2 North unit. They stated the risk of leaving a medication cart unattended with controlled medications would be that any person could take the medication cart out of the building. Controlled medications should be returned to the medication room when the medication passes were completed. During an interview on 1/6/23 at 11:30 AM with RN Unit Manager #14, they stated they were responsible for the oversight of the 4 North unit, including the medication carts. RN Unit Manager #14 stated the controlled medications should be returned to the narcotic cabinet in the medication room when the medication passes were complete. The medication nurses were ultimately responsible because they were the sole holders of the medication cart and medication storage room keys. During an interview on 1/6/23 at 2:00 PM with the DON, they stated they expected staff to be compliant with medication storage policy. The Assistant Directors of Nursing (ADONs) and RN Unit Managers did rounds three times per week and audits to ensure compliance with medication storage. Morning report included ongoing conversations regarding accessibility for the medication nurses with the keypads on the medication carts and storage rooms. They stated the only controlled medications that should be in the medication carts were for the current medication pass only. The rest of the controlled medications should be locked in the narcotic cabinets in the medication storage rooms. All nurses had been educated on this topic. 10NYCRR 483. 45(h)(2) | Plan of Correction: ApprovedJanuary 27, 2023 I.All narcotic medication removed from medication cart at the conclusion of the medication pass and placed under double lock in affixed cabinet located in the medication room. Licensed Nurses on identified units educated on the importance and expectation that Narcotic medication be stored in accordance with regulations II.All residents have the potential to be affected. Rounds conducted on all units to ensure prescribed controlled drugs were not stored in an untethered (free moving) medication cart when not in use and all narcotic medication is stored in a double locked cabinet III. Polices on Medication storage Medication: Narcotic Management reviewed. No revisions required All licensed nurses educated on the importance and expectation that Narcotic medication be stored in accordance with regulations and are not stored in an untethered (free moving) medication cart when not in use IV. DON/Designee will conduct an audit on all units to ensure Prescribed controlled drugs are not stored in an untethered (free moving) medication cart when not in use and all narcotic medication is stored in a double locked cabinet. The audit will be conducted daily x 14 days. Then 3x per week x 3 weeks. Then weekly x 12 weeks. The audit will continue weekly until substantial compliance has been met Audit findings will be reported to the QAPI committee monthly. Responsible Party: Director of Nursing |
Scope: N/A
Severity: N/A
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the onsite post survey review (PSR) conducted 1/4/23-1/6/23, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 3 meals observed. Specifically, Resident #267's lunch meal tray was not served to the resident until 41 minutes after the meal cart was delivered to the unit, resulting in unsafe and unappetizing food temperatures. Findings include: The facility policy Food Preparation and Service revised 4/2022 documented the longer foods remained in the danger zone, above 41 degrees Fahrenheit (F) to below 135 F the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained below 41 F or above 135 F. Potentially hazardous foods held in the danger zone may cause foodborne illness. The facility's 12/14/22 Directed Education for Frequency of Meals for Nursing Leadership and Nurse Managers documented attendees understood corrected mealtimes schedule and location to ensure residents were served promptly. The facility's undated Meal Cart Delivery Schedule documented Unit 4 North would receive their lunch cart delivery at 11:20 AM +/- 20 minutes. The facility's undated Meal Service Delivery and Test Tray Evaluation documented the temperature standard of food on the tray line in degrees Fahrenheit (F): - Hot entree 140 degrees F or above. - Hot starch 140 degrees F or above. - Hot vegetable 140 degrees F or above. - Cold dessert cool/ firm. - Cold fruit cool - Cold beverage less 41 degrees F or below. Resident #267 had [DIAGNOSES REDACTED]. The 10/28/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required set-up assistance at meals. The following observations were made on 1/4/23 on Unit 4 North: - At 11:31 AM, the meal cart was delivered from the kitchen to the unit near the nursing station. - At 11:41 AM, registered nurse (RN) #2 was standing at the medication cart located at the nursing station approximately 10-12 feet from the meal cart. RN #2 stated there were 4 staff members assigned to the unit, 2 certified nursing assistants (CNAs), 1 RN (themself) who was passing medications, and the RN Unit Manager. - At 11:48 AM, RN #2 was standing at the medication cart at the nursing station and the facility's Administrator was behind the nursing station conducting a walk through with another surveyor. The meal cart remained in the hallway, untouched. - At 11:50 AM, RN Unit Manager #7 walked by the meal cart near the nursing station and told RN #2 that they needed to go downstairs. RN Unit Manager #7 did not acknowledge that the meal cart was on the unit near the nursing station. - At 11:52 AM, (21 minutes after the meal cart arrived to the unit) CNA #5 passed the 1st meal tray. - At 12:11 PM, (40 minutes after the meal cart arrived to the unit) CNA #6 passed the last meal tray on the cart to Resident # 267. Resident #267 agreed to have their meal tray used as a test tray and a new meal tray was ordered for the resident. Food item temperatures from the tray were taken in the presence of the Assistant Director of Nursing (ADON). The ground braised beef was measured at 123 degrees Fahrenheit (F), peas were 115 degrees F, rice was 116 degrees F, peaches were 62 degrees F, and apple juice was 65 degrees F. - At 12:34 PM, Resident #267's replacement meal tray arrived at the unit and was brought to the resident. During an interview with CNA #5 on 1/4/23 at 2:27 PM, they stated the lunch meals would come to the unit between 11:00 AM and 11:40 AM. There were only 2 CNAs and 2 RNs assigned to the unit. They stated they were providing care for residents and when they were done with care, they started passing meal trays. They had received education about making sure the food consistency was correct and all items on the tray matched the meal ticket. They did not receive any education on how soon the meal trays should be passed once the cart arrived on the unit, but they stated 20 minutes was a long time for trays to sit and could lead to cold food. They also stated any nursing staff could pass trays if the CNAs were busy providing care. During an interview with CNA #6 on 1/4/23 at 2:30 PM, they stated the lunch meals would come to the unit between 11:00 AM and 11:40 AM. There were only 2 CNAs working on the unit and when they had finished providing care to the residents, they observed the meal cart on the unit, and CNA #5 had just started passing meal trays. They had received education within the last month to ensure all items matched the meal tickets and the resident received the correct food consistency. They stated all nursing staff could help pass trays. They were unaware how long the meal trays were on the unit before they were passed, but 20 minutes was a long time for the meal trays to sit and the food might get cold. On 1/5/23 at 9:23 AM, the Director of Nursing (DON) stated nursing leadership and Unit Managers received additional education on meal trays being served promptly after the meal cart arrived at the unit. On 1/5/23 at 10:02 AM, RN Unit Manager #7 stated they had received education, about a month ago, on the importance of passing meal trays timely. The lunch meal cart arrived on the unit between 11:00 AM and 12:00 PM. They stated once the meal cart arrived on the unit it was expected that staff start passing meal trays. They stated they were responsible for supervising that meal trays were distributed in a timely manner and the meal cart should not sit in the hallway unattended. They stated on 1/4/23 they were helping RN #2 complete their medication pass and was unaware what time the meal cart arrived at the unit or what time tray passing began. Any nursing staff could pass meal trays. They stated 20 minutes was a long time for the meal trays to sit prior to being passed. They stated if meal trays sat on the cart for a long period, it could affect the temperature of the food and residents might not want to eat cold food. During a follow up interview on 1/5/23 at 10:56 AM, the DON stated RN Unit Manager #7 attended and signed the facility's Directed Education for Frequency of Meals for Nursing Leadership and Nurse Managers on 12/15/ 22. That meant they understood the information explained and that they would implement the education they received on their unit. They stated 20 minutes was a long time for the meal trays to sit before being passed. If the meal trays were not passed timely, it could impact the temperature of the food and could also impact the resident's intakes due the palatability of food. During an interview with the Food Service Director on 1/5/23 at 11:14 AM, they stated served promptly meant that nursing staff should pass trays once the meal cart arrived at the unit. 20 minutes too long for the meal trays to sit on the meal cart. Food temperatures would drop and could result in cold food being served. They stated hot food should be served at 130 degrees F or higher on the units and cold food should be served 40 degrees or below on the units. They stated the test tray temperatures taken were not acceptable. During an interview on 1/5/23 at 1:45 PM, with the Regional registered dietitian (RD) #12 they stated all nursing leadership and Unit Managers received education regarding prompt meal tray delivery. Prompt delivery meant once the meal cart arrived at the unit, nursing staff should start passing the meal trays. The RD stated 20 minutes was a long time for a meal cart to sit prior to the trays being passed. It was the responsibility of the Unit Managers to make sure the meal trays were passed timely. If the meal trays were not passed timely, it could affect the temperature and palatability of the food and could affect the resident's intakes at meals. Ideally, hot food should be served at 140 degrees F and cold food should be served 41 degrees F or below. During an interview on 1/5/23 at 4:03 PM, the facility Administrator stated all of nursing | Plan of Correction: ApprovedJanuary 27, 2023 I. The Registered Dietitian met and assessed Resident #267 to review any concerns with delivery of meal, meal temperature and palatability, and if meal time delivery had any impact on nutritional intake and acceptance of meal. Nursing staff on unit Were educated on timely delivery of meals to each resident II. The facility recognizes that all residents can be potentially affected by this deficient practice. An audit /observation was conducted on all units to ensure tray service started upon delivery of meal truck. Meal temperatures will be monitored ongoing with regular test tray evaluations by dietary/clinical nutrition team or designee to ensure hot/cold temperatures are maintained. III. The following policies were reviewed and no revisions required: ?ôFood Preparation and Service?Ø. No revisions required. The DON or designee will educate all nursing staff on the importance of timely delivery of meals to residents to ensure meal temperatures are safe and palatable. Education will include review on meal time schedule and locations. IV. Nursing manager will monitor meal service, delivery and distribution to ensure residents are served promptly Once per week x4 weeks, and then monthly or until substantial compliance is met. Any issues will be addressed immediately The Food service director, Registered dietitian or Diet technician will conduct 6 test trays on different units per month x6mths or until substantial compliance is maintained The Director of Nursing or designee will report outcomes from audits with interventions to QAPI committee monthly. The need for continued reporting will be determined by the QAPI committee Responsible Party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the onsite post survey review (PSR) conducted 1/4/23-1/6/23, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 3 meals observed. Specifically, Resident #267's lunch meal tray was not served to the resident until 41 minutes after the meal cart was delivered to the unit, resulting in unsafe and unappetizing food temperatures. Findings include: The facility policy Food Preparation and Service revised 4/2022 documented the longer foods remained in the danger zone, above 41 degrees Fahrenheit (F) to below 135 F the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained below 41 F or above 135 F. Potentially hazardous foods held in the danger zone may cause foodborne illness. The facility's 12/14/22 Directed Education for Frequency of Meals for Nursing Leadership and Nurse Managers documented attendees understood corrected mealtimes schedule and location to ensure residents were served promptly. The facility's undated Meal Cart Delivery Schedule documented Unit 4 North would receive their lunch cart delivery at 11:20 AM +/- 20 minutes. The facility's undated Meal Service Delivery and Test Tray Evaluation documented the temperature standard of food on the tray line in degrees Fahrenheit (F): - Hot entree 140 degrees F or above. - Hot starch 140 degrees F or above. - Hot vegetable 140 degrees F or above. - Cold dessert cool/ firm. - Cold fruit cool - Cold beverage less 41 degrees F or below. Resident #267 had [DIAGNOSES REDACTED]. The 10/28/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required set-up assistance at meals. The following observations were made on 1/4/23 on Unit 4 North: - At 11:31 AM, the meal cart was delivered from the kitchen to the unit near the nursing station. - At 11:41 AM, registered nurse (RN) #2 was standing at the medication cart located at the nursing station approximately 10-12 feet from the meal cart. RN #2 stated there were 4 staff members assigned to the unit, 2 certified nursing assistants (CNAs), 1 RN (themself) who was passing medications, and the RN Unit Manager. - At 11:48 AM, RN #2 was standing at the medication cart at the nursing station and the facility's Administrator was behind the nursing station conducting a walk through with another surveyor. The meal cart remained in the hallway, untouched. - At 11:50 AM, RN Unit Manager #7 walked by the meal cart near the nursing station and told RN #2 that they needed to go downstairs. RN Unit Manager #7 did not acknowledge that the meal cart was on the unit near the nursing station. - At 11:52 AM, (21 minutes after the meal cart arrived to the unit) CNA #5 passed the 1st meal tray. - At 12:11 PM, (40 minutes after the meal cart arrived to the unit) CNA #6 passed the last meal tray on the cart to Resident # 267. Resident #267 agreed to have their meal tray used as a test tray and a new meal tray was ordered for the resident. Food item temperatures from the tray were taken in the presence of the Assistant Director of Nursing (ADON). The ground braised beef was measured at 123 degrees Fahrenheit (F), peas were 115 degrees F, rice was 116 degrees F, peaches were 62 degrees F, and apple juice was 65 degrees F. - At 12:34 PM, Resident #267's replacement meal tray arrived at the unit and was brought to the resident. During an interview with CNA #5 on 1/4/23 at 2:27 PM, they stated the lunch meals would come to the unit between 11:00 AM and 11:40 AM. There were only 2 CNAs and 2 RNs assigned to the unit. They stated they were providing care for residents and when they were done with care, they started passing meal trays. They had received education about making sure the food consistency was correct and all items on the tray matched the meal ticket. They did not receive any education on how soon the meal trays should be passed once the cart arrived on the unit, but they stated 20 minutes was a long time for trays to sit and could lead to cold food. They also stated any nursing staff could pass trays if the CNAs were busy providing care. During an interview with CNA #6 on 1/4/23 at 2:30 PM, they stated the lunch meals would come to the unit between 11:00 AM and 11:40 AM. There were only 2 CNAs working on the unit and when they had finished providing care to the residents, they observed the meal cart on the unit, and CNA #5 had just started passing meal trays. They had received education within the last month to ensure all items matched the meal tickets and the resident received the correct food consistency. They stated all nursing staff could help pass trays. They were unaware how long the meal trays were on the unit before they were passed, but 20 minutes was a long time for the meal trays to sit and the food might get cold. On 1/5/23 at 9:23 AM, the Director of Nursing (DON) stated nursing leadership and Unit Managers received additional education on meal trays being served promptly after the meal cart arrived at the unit. On 1/5/23 at 10:02 AM, RN Unit Manager #7 stated they had received education, about a month ago, on the importance of passing meal trays timely. The lunch meal cart arrived on the unit between 11:00 AM and 12:00 PM. They stated once the meal cart arrived on the unit it was expected that staff start passing meal trays. They stated they were responsible for supervising that meal trays were distributed in a timely manner and the meal cart should not sit in the hallway unattended. They stated on 1/4/23 they were helping RN #2 complete their medication pass and was unaware what time the meal cart arrived at the unit or what time tray passing began. Any nursing staff could pass meal trays. They stated 20 minutes was a long time for the meal trays to sit prior to being passed. They stated if meal trays sat on the cart for a long period, it could affect the temperature of the food and residents might not want to eat cold food. During a follow up interview on 1/5/23 at 10:56 AM, the DON stated RN Unit Manager #7 attended and signed the facility's Directed Education for Frequency of Meals for Nursing Leadership and Nurse Managers on 12/15/ 22. That meant they understood the information explained and that they would implement the education they received on their unit. They stated 20 minutes was a long time for the meal trays to sit before being passed. If the meal trays were not passed timely, it could impact the temperature of the food and could also impact the resident's intakes due the palatability of food. During an interview with the Food Service Director on 1/5/23 at 11:14 AM, they stated served promptly meant that nursing staff should pass trays once the meal cart arrived at the unit. 20 minutes too long for the meal trays to sit on the meal cart. Food temperatures would drop and could result in cold food being served. They stated hot food should be served at 130 degrees F or higher on the units and cold food should be served 40 degrees or below on the units. They stated the test tray temperatures taken were not acceptable. During an interview on 1/5/23 at 1:45 PM, with the Regional registered dietitian (RD) #12 they stated all nursing leadership and Unit Managers received education regarding prompt meal tray delivery. Prompt delivery meant once the meal cart arrived at the unit, nursing staff should start passing the meal trays. The RD stated 20 minutes was a long time for a meal cart to sit prior to the trays being passed. It was the responsibility of the Unit Managers to make sure the meal trays were passed timely. If the meal trays were not passed timely, it could affect the temperature and palatability of the food and could affect the resident's intakes at meals. Ideally, hot food should be served at 140 degrees F and cold food should be served 41 degrees F or below. During an interview on 1/5/23 at 4:03 PM, the facility Administrator stated all of nursing | Plan of Correction: ApprovedJanuary 27, 2023 I. The Registered Dietitian met and assessed Resident #267 to review any concerns with delivery of meal, meal temperature and palatability, and if meal time delivery had any impact on nutritional intake and acceptance of meal. Nursing staff on unit Were educated on timely delivery of meals to each resident II. The facility recognizes that all residents can be potentially affected by this deficient practice. An audit /observation was conducted on all units to ensure tray service started upon delivery of meal truck. Meal temperatures will be monitored ongoing with regular test tray evaluations by dietary/clinical nutrition team or designee to ensure hot/cold temperatures are maintained. III. The following policies were reviewed and no revisions required: ?ôFood Preparation and Service?Ø. No revisions required. The DON or designee will educate all nursing staff on the importance of timely delivery of meals to residents to ensure meal temperatures are safe and palatable. Education will include review on meal time schedule and locations. IV. Nursing manager will monitor meal service, delivery and distribution to ensure residents are served promptly Once per week x4 weeks, and then monthly or until substantial compliance is met. Any issues will be addressed immediately The Food service director, Registered dietitian or Diet technician will conduct 6 test trays on different units per month x6mths or until substantial compliance is maintained The Director of Nursing or designee will report outcomes from audits with interventions to QAPI committee monthly. The need for continued reporting will be determined by the QAPI committee Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: N/A
Severity: N/A
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 6, 2023
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure a corridor wall was smoke tight for 2 isolated areas (918 building first floor south nursing office, and 918 building third floor south nursing office). Specifically, a wall within the 918 building first floor south nursing office was a corridor wall and it had an unsealed data wire penetration, and a wall within the 918 building third floor south nursing office had a window built into it and there was data wires passing through it. Findings include: During an observation on 10/21/22 at 9:42 AM, the 918 building first floor south nursing office had an unsealed data wire passing through a corridor wall into the corridor behind the nursing station. During an observation on 10/27/22 at 11:58 AM, the 918 building third floor south nursing office had a few unsealed data wires passing through an open window within a corridor wall into the corridor behind the nursing station. During an interview on 10/31/22 at 3:30 PM, the Administrator stated that they were not aware of the unsealed data wires passing through the walls of the 918 building first floor south nursing office and the 918 building third floor south nursing office. They stated that they would have expected the data wires being passed through the wall to be sealed immediately after installation. 2012 NFPA 101 19. 3. 6. 2 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Unsealed data cables passing through wall from behind nursing station to be sealed using appropriate methods and materials. Wires passing through window on 3rd floor south nursing area were removed. 2. All residents could have been affected by the deficient practice- none were. The facility maintenance team or designee will perform an audit on corridor walls to ensure that there are no other areas of non-compliance. Negative findings will be immediately addressed. 3. Facility policy related to corridor walls has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all corridor walls remain penetration free and that they are reviewed regularly for issues. All issues are expected to be addressed upon finding. 4. The facility maintenance team or designee will conduct audits on at least five random areas of corridor walls monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code recertification survey conducted from 10/20/22-11/2/22, the facility failed to ensure electrical installations were maintained for 7 isolated locations (906 building [MEDICAL TREATMENT] storage room, 918 building third floor south nursing office, 918 building first floor nursing station, resident room [ROOM NUMBER], resident room A36, resident room [ROOM NUMBER], and resident room C29). Specifically, the 906 building [MEDICAL TREATMENT] storage room, the 918 building third floor south nursing office, the 918 building first floor nursing station, and resident room [ROOM NUMBER] had adapters plugged into another adapter (daisy-chained); resident room A36 and resident room [ROOM NUMBER] had patient care related electrical equipment (PCREE) and resident owned electrical equipment (non-PCREE) plugged into the same adapter; resident room A36, resident room [ROOM NUMBER], and resident room C29 had unapproved adapters/extension cords. Findings include: During an observation on 10/20/22 at 11:22 AM, the 906 building [MEDICAL TREATMENT] storage room had a 6 prong adapter plugged into a UPC adapter that was plugged into a 6 prong adapter that plugged into the wall (daisy-chained). A lift battery charger was plugged into the 6 prong adapter. During an observation on 10/20/22 at 2:40 PM, the 918 building third floor south nursing office had a 6 prong adapter plugged into a UPC adapter that was plugged into the wall (daisy-chained). Miscellaneous computer equipment was plugged into the 6 prong adapter. During an observation on 10/21/22 at 9:20 AM, the 918 building first floor nursing station had a 6 prong adapter that was plugged into a 6 prong adapter that was plugged into a 20 prong adapter that was plugged into the wall (daisy-chained). Miscellaneous computer equipment was plugged into the 6 prong adapter. During an observation on 10/21/22 at 10:48 AM, resident room [ROOM NUMBER] had a coffee maker that was plugged into an unapproved extension cord that plugged into a 6 prong adapter that was plugged into the wall (daisy-chained). During an interview on 10/26/22 at 11:32 AM, the Administrator stated that staff had been educated not to use extension cords or unapproved adapters after the last federal survey and during staff orientation. They stated that if staff had seen an unapproved adapter they should have reported it to the maintenance department, or just removed it themselves. The Administrator stated that in the last six months they had seen unapproved adapters in resident rooms, and those residents and families were educated on why those were not allowed. They stated that the daisy-chained adapters, the unapproved adapters, and the unapproved extension cords found during the tour of the facility were not acceptable. During an observation on 10/31/22 at 10:10 AM, resident room A36 had the following extension cord issues: - an electric bed was plugged into the same UL1363A 6 prong adapter as a fan, a phone charger, and a laptop. PCREE and non-PCREE electrical items were not allowed to be plugged into the same adapter. - a coffee pot and a coffee pot warmer were plugged into an unapproved 3 prong adapter. - a mini-fridge was plugged into an unapproved 3 prong adapter. During an observation on 10/31/22 at 10:20 AM, resident room [ROOM NUMBER] had the following adapter issues: - an electric bed and oxygen concentrator were plugged into the same UL1363A 6 prong adapter as a cell phone charger and a fan. PCREE and non-PCREE electrical items were not allowed to be plugged into the same adapter. - a box fan, a mini-fridge, a TV, and an alarm clock were plugged into an unapproved 4 prong adapter. During an observation on 11/1/22 at 4:50 PM, resident room C29 had the following extension cord issues: - a window side electrical bed was plugged into an unapproved UL1363 adapter. - a wall side electrical bed was plugged into an unapproved 16 foot extension cord. During an interview on 11/2/22 at 9:35 AM, HMO Coordinator #34 stated that they were not aware of the unapproved adapters in resident room C29, and that extension cords were not allowed in resident rooms. They stated that both of the resident electrical beds located in resident room C29 should have been directly plugged into the wall. 2012 NFPA 99: 10. 2. 4 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents and family members were reminded of the rules surrounding power cords in resident care areas via administrator letter. [MEDICAL TREATMENT] storage room unapproved adapter removed during survey. 3rd floor south nursing office unapproved adapter removed during survey. 1st floor nursing unapproved adapter removed during survey. room [ROOM NUMBER] unapproved adapter and coffee machine removed during survey. A36 unapproved extension cord removed. PCREE and non-PCREE devices plugged into the same adapter were remedied . Unapproved adapters were also removed. room [ROOM NUMBER] devices plugged into same adapter were adjusted. Unapproved adapter in the same area was removed. C29 unapproved adapter removed. Unapproved extension cord removed. 2. All residents could have been affected by the deficient practice- none were. An audit of the facility will be conducted to determine if there are other areas that are deficient. Negative findings to be immediately addressed. 3. Facility policy related to power cords reviewed with no recommended changes. Maintenance staff to be educated on the requirements surrounding power cords and the requirement that the facility be regularly inspected for non-compliant items. Residents, resident contacts, and all other facility staff will be reminded which items are disallowed in resident areas via letter. 4. An audit will be conducted on at least 10 random resident care areas for the presence of unapproved cords, adapters or the incorrect usage of approved cords or adapters by the maintenance department or designee monthly x 5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code recertification survey conducted from 10/20/22-11/2/22, the facility failed to ensure patient care related electrical equipment (PCREE) was maintained in accordance with National Fire Protection Agency (NFPA) 99 for 3 of 5 PCREE reviewed (resident room [ROOM NUMBER] electrical bed, 906 building A floor north day room CD player, and 906 building A floor north day room floor lamp). Specifically, the resident room [ROOM NUMBER] electrical bed was not maintained as per the user manual; and the 906 building A floor north day room had a CD player and a floor lamp that lacked electrical inspection labels. Findings include: The facility Electrical Equipment policy, last revised 5/2019, stated that equipment would be maintained At least annually or sooner if recommended but the manufacturer all resident medical equipment will be inspected for safety and function. This policy was unclear and did not include the requirements for maintenance. 1. Electrical Beds A surveyor had requested an electrical bed user-service manual for any bed within the facility and was provided the manual for an electric bed located in resident room 134. The manual documented: - The maintenance required would be dictated by the bed's usage and care - a thorough inspection should be conducted monthly. During an interview on 11/1/22 at 3:15 PM, HMO Coordinator #34 stated that the electrical bed user service manual stated that the electrical bed in resident room [ROOM NUMBER] was required to be electrically inspected monthly, and that they could not find any documentation that an inspection had been completed since May 2022. During an interview on 11/2/22 at 10:20 AM, the Administrator stated that the electrical bed user service manual was just a recommendation, and that they felt the facility policy of annual electrical inspection for the beds was acceptable. They stated that the electrical bed manual monthly electrical inspection was to ensure maximum life of the product, and the manual did not require that monthly inspections be completed. 2. Other Facility Owned Equipment During an observation on 10/24/22 at 9:40 AM, the 906 building A Floor north day room had a CD player and a floor lamp that lacked electrical inspection labels. During an interview on 10/31/22 at 9:20 AM, the HMO Coordinator #34 stated that the CD player and the floor lamp, located within the 906 building A floor north day room, lacked inspection labels. They stated that there was no documentation to verify that either piece of equipment had been electrically inspected, and these items appeared to be facility used electrical equipment. 2012 NFPA 99: 10. 5. 3 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. CD player and lamp located in A floor day room were inspected and stickered appropriately. Resident bed in room [ROOM NUMBER] was inspected and stickered appropriately. 2. All residents could have been affected by the deficient practice- none were. Facility devices to be reviewed for correct frequency of inspections. Negative findings to be immediately addressed. 3. Facility policy related to equipment inspections reviewed and adjusted to clarify the requirements. Facility maintenance staff to be educated on the adjusted policy as well as the requirements related to electrical testing and maintenance. 4. An audit will be conducted on at least 10 random facility devices for appropriate frequency of inspections by the maintenance department or designee monthly x5 Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on record review and interview conducted during the Life Safety Code survey from 10/20/22-11/2/22, the facility failed to ensure that remote annunciator panels were properly installed as required in NFPA 99 for 1 of 2 emergency generators (906 building temporary diesel generator). Specifically, the 906 building temporary diesel generator was not wired to the 906 building B floor remote annunciator panel. Findings include: During an observation on 10/20/22 at 10:00 AM, there was no lights on the 906 building B floor remote annunciator panel, and it looked like there was no power going to this panel. During an interview on 10/25/22 at 3:35 PM, HMO Coordinator #34 stated that the 906 building temporary diesel generator was wired to the disconnected and non-functioning permanent 906 diesel generator, that was located on the 906 building S floor. They stated that a third party vendor would need to run an extended wire from the temporary generator to the 906 building B floor remote annunciator panel. During an interview on 10/26/22 at 3:05 PM, the Administrator was not aware that the 906 building temporary diesel generator was not connected to the 906 building B floor remote annunciator panel, and stated that the third party generator vendor had not made him aware of this. 2012 NFPA 99: 6. 4. 1. 1. 17 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. 906 generator annunciator panel located at the B unit nursing station to be hooked up to temporary generator. 2. All residents could have been affected by the deficient practice- none were. Generator annunciator panels to be inspected to determine if there are other deficiencies. Negative findings to be immediately addressed. 3. Facility policy related to electrical systems reviewed with no recommended changes. Maintenance staff to be educated on the requirements that facility generator annunciator panels be properly connected to the generators and that they are regularly reviewed for trouble- acting swiftly should issues be found. 4. An audit will be conducted on facility generator annunciators by the maintenance department or designee monthly x 5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on record review and interview during the Life Safety Code survey conducted on 10/20/22-11/2/22, the facility failed to ensure that the essential electric system was maintained for 1 isolated area (906 building C south floor between resident room C23 and resident room C28), and that 1 of 2 diesel emergency generators was not maintained in accordance with NFPA 110 (918 building temporary 300 KW diesel generator). Specifically, the red emergency outlets and the white outlets, located between the 906 building C south floor resident room C23 and resident room C28, had no power supplied to them; and an annual fuel test for the 918 building temporary 300 KW diesel generator had not been completed for 2020 and 2021. Findings include: 1. Electrical Outlets With No Power During an observation on 10/2522 at 10:30 AM, a surveyor plugged their work laptop into the red emergency outlet located on the wall between resident room C27 and resident room C28, and the laptop did not charge. During an observation on 10/26/22 at 4:10 PM, the red emergency outlet and the white outlet, located on the wall between resident room C27 and resident room C28, had no power. A staff owned cell phone charger, a facility owned hoyer lift battery charger, and facility owned portable fan were plugged into these outlets and they did not charge or turn on. During an observation on 10/26/22 at 4:20 PM, the red emergency outlet and the white outlet, located on the wall between resident room C23 and resident room C24, had no power. A staff owned cell phone charger, a facility owned hoyer lift battery charger, and facility owned portable fan were plugged into these outlets and they did not charge or turn on. During an interview on 10/27/22 at 10:00 AM, HMO Coordinator #34 stated that the breakers for the red emergency outlets and the white outlets, located between the C south resident room C23 and resident room C28, had been tripped, or shut off. They stated that the white outlets were on a separate electrical panel from the red emergency outlets. HMO Coordinator #34 stated that once the breakers within these two electrical panels had been reset, the electrical outlets had power, and this was verified and tested by a voltmeter. They stated that they had not received any work orders reporting the loss of power on the C south floor within the last month, and were not sure how long the breakers had been off. During an interview on 11/1/22 at 1:50 PM, the Administrator stated that they were not sure what electrical device had tripped the C floor breakers, or how long the power had been turned off to these electrical outlets. The Administrator stated that they were aware the red emergency electrical outlets and the white electrical outlets were on separate electrical panels. 2. Annual Generator Fuel Test Not Completed The third party vendor Fuel Sample Analysis for the 918 building's temporary 300 KW diesel generator stated that an annual diesel fuel test was completed on 11/4/ 19. The facility could not provide an annual fuel test for 2020 and 2021. During an interview on 10/31/22 at 2:25 PM, the Administrator stated that they were not aware that the last annual fuel test for the 918 building's temporary generator was completed in 2019, and that they were aware that diesel generators were required to have an annual fuel test. 2012 NFPA 101: 9. 1. 3. 1, 19. 5. 1 2012 NFPA 99: 6. 5. 1 2010 NFPA 110: 8. 3. 8 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Outlets located on C floor between rooms C23 and C28 were returned to normal operation via resetting of flipped breaker in nearby breaker panel during survey. Annual generator fuel test to be completed for both generators. 2. All residents could have been affected by the deficient practice- none were. Facility emergency outlets to be inspected determine if there are other deficiencies. Negative findings to be immediately addressed. 3. Facility policy related to essential electrical systems reviewed with no recommended changes. Maintenance staff to be educated on the requirements surrounding inspection frequency and requirements. 4. An audit will be conducted on at least 10 random emergency outlets by the maintenance department or designee monthly x 5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to maintain the fire alarm systems in accordance with the requirements of National Fire Protection Association (NFPA) 72 for 1 fire alarm system (918 building). Specifically, the 918 building had smoke detectors that were not annually inspected as required by NFPA 72. Findings include: The 918 building semi-annual third party inspection fire alarm inspections were completed on 1/13/2021, 6/30/2021 and 2/8/2022, and the second semi-annual inspection for 2022 had never been completed. The fire alarm inspections dated 6/30/2021 and 2/8/2022 had smoke detectors that were not tested . 100% of the smoke detectors within the the 918 building had not been annually tested as required by NFPA 72. Specifically: - there were 20 resident room smoke detectors that were not tested during the 6/30/2021 inspection, and these were skipped because there was no access due to patients changing/with doctor, etc. - there were 29 resident room smoke detectors that were not tested during the 2/8/2022 inspection, and these were skipped because no rooms in yellow or red status were tested . During an interview on 10/27/22 at 3:45 PM, HMO coordinator #34 stated that the fire alarm third party vendor had not addressed the smoke detectors that were skipped during the 6/30/22 and 2/8/22 918 building inspections. They stated that a third party vendor had came onsite on 10/26/22 to complete a semi-annual fire alarm inspection. HMO coordinator #34 stated that they were aware that the components of the fire alarm system had to be inspected annually. During an interview on 11/1/22 at 12:20 PM, the Administrator stated that they could not find which resident room smoke detectors were skipped during 2/8/22 third party vendor 918 building fire alarm inspection, and could not verify if some of these resident room were also skipped during the 6/30/21 third party vendor fire alarm inspection. They stated that they would have expected the third party fire alarm vendor to test all required devices annually and maintain the semi-annual inspection schedule. 2012 NFPA 101: 19. 3. 4. 1, 9. 6. 1. 5 2010 NFPA 72: 14. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility contracted a new vendor to complete required regular inspections on facility fire alarm system. Vendor to inspect all resident room devices in 918 building to ensure that all missed devices are inspected. Deficient items to be immediately addressed. 2. All residents could have been affected by this deficient practice- no residents were. Inspection reports will be reviewed for other potential areas of deficiency. Deficient findings to be immediately addressed. 3. Facility policy related to fire alarm testing has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all devices are appropriately inspected at the required interval and how to read the post-inspection report to ascertain this information. Further, they will be educated on the requirement that should inspections not be able to be conducted for specific areas at the time of an inspection visit that the inspector schedule a subsequent visit within the required timeframe to complete. 4. The facility maintenance team or designee will conduct audits on facility fire alarm inspections bi-yearly x 2. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure fire drills were completed as required for 1 of 3 night shift fire drills (third quarter of 2022). Specifically, a night shift fire drill was not competed for the third quarter of 2022. Findings include: The facility fire drill reports documented that a night shift fire drill was not completed for the third quarter of 2022. During an interview on 10/26/22 at 2:30 PM, the Administrator stated that there were two night shift fire drills completed for the second quarter of 2022; and that the last night shift fire drill for the second quarter, dated 6/21/22 should have counted as the missing night shift fire drill for the third quarter of 2022. 2012 NFPA 101: 19. 7. 1, 4. 7 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Facility to conduct night shift fire drill. 2. All residents could have been affected by the deficient practice- none were. Facility fire drill documentation to be reviewed to determine if there are other deficiencies in frequency. Negative findings to be immediately addressed. 3. Facility policy related to fire drills reviewed with no recommended changes. Administrator and maintenance staff to be educated on the requirements surrounding the frequency of fire drills. 4. An audit will be conducted on fire drill documentation to review appropriate frequency by the administrator or designee quarterly x 3. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility did not ensure oxygen tanks were stored properly for 3 of 7 resident floor oxygen storage rooms (918 building fourth floor oxygen storage room, 918 building second floor oxygen storage room, 918 building first floor oxygen storage room). Specifically, the 918 building fourth floor oxygen storage room door and door frame were painted over, the 918 building second floor oxygen storage room had an unsealed hole in a fire rated rated wall, and the 918 building first floor oxygen storage room had unapproved ceiling materials. Findings include: During an observation on 10/20/22 at 12:01 PM, the 918 building fourth floor oxygen storage room had 17 full oxygen tanks and the access door and door frame were painted over. During an observation on 10/20/22 at 6:15 PM, the 918 building second floor oxygen storage room had 19 full oxygen tanks and there was an unsealed 1/2 inch hole in one of the one-hour fire rated walls. During an observation on 10/21/22 at 9:45 AM, the 918 building first floor oxygen storage room had 14 full oxygen tanks, and there were two unapproved sections of ceiling material that were screwed into the ceiling, and one section of this material was 18 inch x 18 inch and the other was 18 inch x 10 inch. During an interview on 10/26/22 at 2:45 PM, the Administrator stated that they were not aware that oxygen storage rooms containing over 12 oxygen tanks were required to have one-hour fire rated walls and ceilings, and 45 minute fire rated doors. They stated that they were not aware that the 918 building fourth floor oxygen storage room door and door frame were painted over, that the 918 building second floor oxygen storage room had an unsealed hole in a fire rated rated wall, or that the 918 building first floor oxygen storage room had unapproved ceiling materials. The Administrator stated that the extra oxygen tanks from the resident floors would be moved to the larger oxygen storage room located in the 918 basement. 2012 NFPA 99: 11. 3. 2 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Oxygen rooms located on floors 1, 2, 3, 4, A, C, and D were adjusted to remove full cylinders exceeding the 12-bottle capacity that would then require the rooms to be specially designed for hazardous storage. 2. All residents could have been affected by the deficient practice- none were. Facility oxygen rooms to be reviewed to ensure that they are meeting storage requirements. Negative findings to be immediately addressed. 3. Facility policy related to oxygen storage reviewed and adjusted to clarify the requirements. Facility maintenance and central supply staff to be educated on the requirements related to oxygen storage. 4. An audit will be conducted on at least five random facility oxygen rooms for appropriate frequency of inspections by the maintenance department or designee monthly x 5. Results of the audit will be shared with the facility QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that hazardous areas were maintained for 11 isolated areas (resident room B10, resident room B11, 918 building fourth floor laundry shoot room, 918 building second floor laundry shoot room, 918 building third floor PPE closet, 918 building north elevator machine room, 918 building third floor medical storage room, 906 building S floor kitchen lounge, 918 laundry room, 906 building D floor clean utility room, and 906 building D floor soiled utility room). Specifically, resident room B10 and resident room B11 access doors and door frames lacked fire rated labels; the 918 building fourth floor laundry shoot room, the 918 building second floor laundry shoot room and the 918 building north elevator machine room access doors and door frames fire rated labels were painted over; the 918 building third floor PPE closet access door and door frame fire rated labels were painted over and the access door was not self closing; the 918 building third floor medical storage room and the 906 building S floor kitchen lounge access doors were not latching; and the 918 laundry room, the 906 building D floor clean utility room, and the 906 building D floor soiled utility room access doors had unsealed holes in them. Findings include: 1. Fire Rated Labeling During an observation on 10/20/22 at 11:10 AM, resident room B10 and resident room B11 had been converted to storage rooms, and both access doors lacked a fire rated label. During an observation on 10/20/22 at 12:40 PM, the 918 building fourth floor laundry shoot room access door and door frame fire rate label was painted over. During an observation on 10/20/22 at 5:15 PM, the 918 building second floor laundry shoot room access door and door frame fire rate labels were painted over. During an observation on 10/20/22 at 3:17 PM, the 918 building third floor PPE closet was approximately 48 square feet, and it contained 25 boxes of face shields and 5 boxes of masks. Due to the storage in this room it had been converted to a hazardous area and the access door and door frame fire rated labels were painted over. The access door to this room was not self closing, and one of these walls was shared by an adjoining tub room and this wall had only one layer of sheetrock. The walls within hazardous areas were required to have two layers of sheetrock. During an observation on 10/24/22 at 11:45 AM, the 918 building north elevator machine room had a section of wall with only one layer of one 3 foot by 18 inch section of sheetrock. The 918 building north elevator machine room access door and door frame fire rated labels were painted over. The walls within hazardous areas were required to have two layers of sheetrock. 2. Door Not Latching During an observation on 10/20/22 at 2:35 PM, the 918 building third floor medical storage room access door latch was taped open and would not latch. During an observation on 10/24/22 at 10:20 AM, the 906 building S floor kitchen lounge access doors did not latch and three attempts were made. This room was over 100 square feet and had the following items in the room: - a pallet with 7 boxes of dinner napkins; - 59 boxes of disposable trays; and - kitchen equipment, multiple empty boxes, and miscellaneous debris. 3. Unsealed Holes In Doors During an observation on 10/24/22 at 12:00 PM, the 918 laundry room clean side metal access door had five 1/16 inch() sized holes on both sides of the door. During an observation on 10/26/22 at 9:32 AM, the 906 building D floor clean utility room fire rated access door had six 3/16 holes at the top of it. During an observation on 10/26/22 at 9:34 AM, the 906 building D floor soiled utility room fire rated access door had six 3/16 holes at the top of it. During an interview on 10/31/22 at 2:50 PM, the Administrator stated they were not aware that the hazardous area access doors and door frames fire rated labels had been painted over, but was aware that the labels were required to legible. They stated that they were not aware that the wheelchair storage inside resident room B10 and resident room B11 had converted these rooms into hazardous areas, and would consider the 906 building S floor kitchen lounge a hazardous area. The Administrator stated that it was not acceptable for the ceilings and doors within hazardous areas to have unsealed holes, and that hazardous area doors were required to be self-closing. 2012 NFPA 101 19. 3. 2. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Resident room B10 and B11 will have storage items removed and placed in approved storage areas. 4th floor chute room door label with be adjusted so that the rating label is visible. 2nd floor chute room door will be adjusted so that the rating label is visible. 3rd floor PPE closet will have combustible storage removed and the door label adjusted so that the rating label is visible and a self-closing device installed on the door. 918 elevator room wall repairs will be adjusted so that it is completed using the correct methods and materials. The same elevator room door label will be adjusted so that the rating label is visible. 3rd floor medical storage room access door will be adjusted so that is properly latches. 906 employee lounge door will be adjusted so that it positively latches. Laundry room middle door will be adjusted so that the holes are properly sealed using approved methods and materials. D floor clean utility room access door will be adjusted so that the holes are properly sealed using approved methods and materials. D floor soiled utility room door will be adjusted so that the holes are sealed using approved methods and materials. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of rooms for hazardous material storage and their enclosures and access doors. Any adverse findings will be immediately addressed. 3. Policy related hazardous material areas enclosures has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that hazardous material area enclosures remain in good working order and that access doors function appropriately and are easily identified as being properly rated. They will further be educated on the importance of ensuring that appropriate methods and materials are used in their repair. 4. The facility maintenance team or designee will conduct audits on at least five random hazardous materials areas and their enclosures and access doors monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: N/A
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation, record review and interview during the Life Safety Code survey conducted on 10/20/22-11/2/22, the facility failed to ensure that one-hour fire rated doors were maintained for four isolated doors observed (kitchen dishwasher area access door, 918 building first floor two-hour fire barrier separation door, 906 building D floor fire barrier door and lobby fire barrier door), did not ensure that one-hour fire rated enclosures was maintained for one isolated enclosure (918 building emergency PPE storage room/ 918 building human resource office/918 building south stairwell), and did not ensure that two-hour fire rated building separation doors was maintained for one isolated door (918 building first floor two-hour fire barrier separation door). Specifically, the one-hour fire rated kitchen dishwasher area access door and the lobby fire barrier door would not latch, the one hour fire rated Unit 1 barrier door would not open, the one hour fire rated 918 building south stairwell enclosure had an emergency PPE storage room wall hatch that was open and an access door to the human resources office would not self close, and the two-hour fire rated 918 building Unit 1 separation barrier door would not latch. Findings include: The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This audit documented that all corridor doors were inspected. 1. Fire Doors During an observation on 10/20/22 at 10:15 AM and on 10/24/22 at 10:15 AM, the one-hour fire rated kitchen dishwasher area access door was part of a one-hour fire rated barrier and the door lacked a self closure device. Three attempts were made. During an observation on 10/21/22 at 10:35 AM, 1 of the one-hour fire rated 918 building first floor fire barrier double doors would not open and three attempts were made. Also, the fire rated label on the double doors and door frame were painted over. During an observation on 10/21/22 at 12:05 PM, 1 of the one-hour fire rated 906 building D floor fire barrier double doors would not latch and three attempts were made. Also, the miscellaneous hardware on this door was loose. During an observation on 10/27/22 at 9:34 AM, 1 of the one-hour fire rated lobby fire barrier double doors would not latch and three attempts were made. Also, the fire rated label on the double doors and door frame were painted over. During an interview on 11/1/22 at 3:00 PM, the Administrator stated that the facility one-hour fire rated barrier doors were last checked during the 6/22 corridor door audit. They stated that they were not aware that the 918 building first floor fire barrier door would not open, and was not aware that the lobby fire barrier door and the 906 building D floor fire barrier door would not latch. The Administrator stated that they were not aware that the kitchen dishwasher area access door lacked a self closure device, and that they were aware that fire rated doors were required to be self-closing. 2. Fire Rated Enclosures During an observation on 10/24/22 at 12:40 PM, the 918 building emergency PPE storage room shared a section of wall that was part of the 1 hour fire rated 918 building south stairwell enclosure and this wall contained a fire rated wall access hatch which was open. There was an adapter cord and two data wires passing through it, and there were two punch card computers plugged into the adapter. The cord and data wires prevented the self-closing device on the wall access hatch to close and latch. During an observation on 10/24/22 at 1:55 PM, the 918 building human resource office shared a section of wall that was part of a 1 hour fire rated 918 building south stairwell enclosure and one of two fire rated human resource office doors would not self-close as required. Both doors had self-closure devices and three attempts were made. During an interview on 11/1/22 at 3:00 PM, the Administrator stated that they were not aware that there were wires passing through the one-hour fire rated emergency PPE storage room wall access hatch, and that they were not sure how long that had been there. They stated that they were not aware that the human resource office door had a malfunctioning self-closure device. The Administrator stated that fire rated enclosure doors and wall hatches were required required to be self-closing. 3. Building Separation Barrier Doors During an observation on 10/27/22 at 11:05 AM, 1 of the two-hour fire rated 918 first floor building separation barrier double doors would not latch and three attempts were made. During an interview on 11/1/22 at 3:00 PM, the Administrator stated that the facility one-hour fire rated barrier doors were last checked during a 6/6/22 K363 Corridor Doors Facility Audit. They stated that they were not aware that the 918 building first floor fire barrier door would not latch, but were aware that fire rated doors were required to be self-closing. 2012 NFPA 101 19. 2. 1, 7. 2. 15. 2 2010 NFPA 80 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Kitchen dish room door will be adjusted so that it positively latches upon closure. 1S east fire door was repaired during survey. The paint over the label will be stripped so that it can be easily read. D floor fire barrier doors will be adjusted so that it positively latches upon closure. The hardware will be tightened. The lobby fire separation doors will be adjusted so that they positively latch upon closure. The painted over label will be stripped so that it is easily read. Cords passing through the wall access hatch outside the HR office area to be moved to a dedicated hole in the wall that is appropriately sealed per life safety requirements. HR office double door to be adjusted so that it closes automatically. 918 building separation barrier doors to be adjusted so that they positively latch upon closure. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of other means of egress to ensure that there are no similar issues. Negative findings will be immediately addressed. 3. Policy related to means of egress were reviewed with no recommended changes. The facility maintenance department will be educated on the importance of conducting regular audits of facility fire barriers, fire doors, smoke doors, and other means of egress areas and the importance of ensuring that they remain in compliance and in good working order. 4. The facility maintenance team or designee will conduct audits on at least five random means of egress areas for presence of non-working doors/obstructions as well as painted over rating labels monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that the two-hour fire rated building separation barriers were maintained for 1 of 2 barriers observed (906 building A floor bridge barrier). Specifically, the 906 building A floor bridge barrier had unsealed and improperly sealed penetrations. Findings include: The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This audit documented that all corridor doors were inspected, but did not address building separation barriers. During an observation on 10/28/22 at 12:45 PM, the two-hour fire rated 906 building A floor bridge barrier had the following: - there were multiple data wires passed through multiple holes on both sides of this barrier; - the gap between the top of the sheetrock and the metal ceiling deck was not sealed in the section of the barrier located over the two A unit bridge fire rated doors; - there was an unapproved material (red tape) used to seal the gaps between the two separate pieces of sheetrock within this barrier; and - there were gaps between the two separate pieces of sheetrock within this barrier that were not sealed. During an interview on 10/28/22 at 12:55 PM, HMO Coordinator #34 stated that they were not sure when the facility's two-hour fire rated barriers had last been inspected, and was not sure of the frequency of these inspections. They stated that they had assisted the surveyor with a ladder and a flashlight, and had never looked above the ceiling tiles to check the fire barriers prior to the observations made on 10/28/ 22. They stated that they assumed that data wires would have been sealed after the wires had been installed. During an interview on 10/31/22 at 11:10 AM, the Administrator stated that the two-hour fire rated building separation barriers were last inspected on a 6/6/22 K363 Corridor Doors Facility Audit, and had expected the 906 building A floor bridge barrier to have been properly sealed and smoke tight. 2012 NFPA 101 19. 1. 3. 5 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility maintenance team will inspect the 906 Building A floor bridge barrier area to plan for remediation. Once an appropriate repair is determined, they will fix the non-compliant penetrations so that the barrier maintains its required 2-hour rating. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of facility 2-hour barriers. Any adverse findings will be immediately addressed. 3. Policy related to facility fire barriers reviewed with no recommended changes. The facility maintenance department will be educated on the importance of conducting regular audits of facility fire barriers and the importance of ensuring that vendors that install wiring or otherwise need to penetrate fire barriers are appropriately sealing penetrations behind themselves so that the barriers remain sealed smoke-tight. 4. The facility maintenance team or designee will conduct audits on at least two random areas of 2-hour barriers for presence of penetrations monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure fire extinguishers were maintained for 10 of 10 floors (918 building fourth floor, 918 building third floor, 918 building second floor, 918 building first floor, 918 building basement, 906 building D floor, 906 building C floor, 906 building B floor, 906 building A floor, and 906 building S floor) in accordance with National Fire Protection Association (NFPA) 10, Standard for Portable Fire Extinguishers. Specifically, the annual fire extinguisher inspections were not completed for the above mentioned floors. Findings include: Review of the most recent third party fire extinguisher annual inspection documented that was completed on 7/1/ 2021. During observations on 10/20/22, between 11:40 AM and 12:00 PM, the following areas within the 918 building first floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - the DON nursing suite; and - the main lobby. During observations on 10/20/22, between 12:01 PM and 1:15 PM, the following areas within the 918 building fourth floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - hall near room [ROOM NUMBER]; - fourth floor pantry; and - hall near room 445. During an observation on 10/20/22 at 3:30 PM, the hall near room [ROOM NUMBER] had a fire extinguisher that was last annually inspected on July 2021. During observations on 10/20/22, between 5:10 PM and 6:14 PM, the following areas within the 918 building second floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - second floor pantry; - hall near room [ROOM NUMBER]; and - hall near room 238. During observations on 10/21/22, between 10:14 AM and 10:25 AM, the following areas within the 918 building first floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - hall near room [ROOM NUMBER]; - hall near room [ROOM NUMBER]; and - first floor pantry. During an observation on 10/21/22 at 11:10 AM, the 906 building penthouse had a fire extinguisher that was last annually inspected on July 2021. During observations on 10/21/22, between 11:28 AM and 11:59 AM, the following areas within the 906 building D floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - D floor pantry; and - hall near D 15. During observations on 10/21/22, between 12:40 PM and 12:48 PM, the following areas within the 906 building C floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - C floor pantry; and - hall near C 15. During an observation on 10/21/22 at 1:40 PM, the 906 building B floor occupational therapy storage room had a fire extinguisher that was last annually inspected on July 2021. During an observation on 10/21/22 at 2:56 PM, the hall near A11 had a fire extinguisher that was last annually inspected on July 2021. During observations on 10/24/22, between 9:50 AM and 10:10 AM, the following areas within the 906 building S floor had a fire extinguisher that was last annually inspected on (MONTH) 2021: - S floor general storage room; - S floor maintenance shop; and - S floor mechanical room. During an observation on 10/24/22 at 11:50 AM, the 918 building basement laundry room had a fire extinguisher that was last annually inspected on July 2021. During an observation on 10/24/22 at 1:55 PM, the 918 building basement human resources office had a fire extinguisher that was last annually inspected on July 2021. During an interview on 10/24/22 at 2:20 PM, the Administrator was not aware that the facility fire extinguishers had not been inspected annually as required, and stated that they were aware of this requirement. They stated that the facility had a fire extinguisher vendor to complete this fire extinguisher annual inspection. 2012 NFPA 101 19. 3. 5. 12, 9. 7. 4. 1 2010 NFPA 10 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. The facility contracted a new vendor to perform annual fire extinguisher inspects. All facility fire extinguishers were inspected by new vendor during survey. 2. All residents could have been affected by the deficient practice- none were. The facility maintenance team or designee will perform an audit on all fire extinguishers to ensure that they were addressed during the most recent vendor inspection. 3. Facility policy related to fire extinguishers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all fire extinguishers are inspected at the required intervals. They will further be educated on the requirement that they review inspection tags on all extinguishers during routine monthly inspections to ensure that they remain in compliance with annual testing requirements. 4. The facility maintenance team or designee will conduct audits on annual testing on at least 10 random facility fire extinguishers bi-yearly x 2. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation and interview conducted during the Life Safety Code survey on 10/20/22-11/2/22, the facility failed to ensure the building was properly maintained and protected throughout by an approved automatic sprinkler system for 1 isolated area (the laundry room). National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8. 3. 3. 2 states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8. 3. 3. 3. Specifically, there were 14 quick response sprinkler heads and 20 standard response sprinkler heads installed in the laundry room. Findings include: During an observation on 10/24/22 at 12:18 PM, there were 14 quick response sprinkler heads and 20 standard response sprinkler heads installed within the laundry room. During an interview on 10/26/22 at 10:55 AM, the Administrator stated that they were not aware of the mixed quick response sprinkler heads and the standard response sprinkler heads, and that they were not aware that a smoke zone/room could not contain both types of sprinkler heads. They stated that they expected the third party sprinkler vendor to identify this issue during the facility quarterly sprinkler inspections. NFPA 101: 19. 3. 5. 1, 9. 7. 1. 1 2010 NFPA 13: 8. 3. 3. 2 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Standard response sprinkler heads in the clean laundry room area to be swapped for quick response type sprinkler heads of the same temperature rating. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of rooms for incorrect mixing of sprinkler head types. 3. Facility policy related to fire sprinklers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all sprinkler areas that contain quick response heads have only quick response sprinkler heads within that smoke compartment. They will further be educated on the requirement to report findings of non-compliance immediately to facility management for follow up. 4. The facility maintenance team or designee will conduct audits on facility fire sprinkler system in at least 5 random areas bi-yearly x 2. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/02/22, the facility failed to ensure the automatic sprinkler system was maintained for 6 isolated rooms in 906 building (906 building occupational therapy storage room, 906 building south penthouse, 906 building penthouse level south stairwell, the 906 building north penthouse, 906 building D floor electrical room and 906 building S floor female locker room) and for 11 isolated rooms in 918 building (918 building third floor shower room across from room [ROOM NUMBER], 918 building third floor north social workers office, 918 building administrator office, 918 building second floor day room, 918 building first floor hallway near the soiled utility room, 918 building first floor soiled utility room, 918 building first floor staff bathroom, 918 building first floor shower room across from room [ROOM NUMBER], 918 laundry room, 918 building emergency PPE storage room, and 918 building human resources office). Specifically, the above mentioned rooms had missing ceiling tiles and unsealed data wire penetrations that could allow smoke and heat to rise past the sprinkler head, not allowing the sprinkler head to function as designed. Findings include: 906 Building: During an observation on 10/20/22 at 11:15 AM, the 906 building occupational therapy storage room had a 1 foot x 1 foot section of missing ceiling tile. During an observation on 10/21/22 at 11:10 AM, the 906 building south penthouse had a 2 foot x 6 inch section of missing ceiling tile, and a 4 foot x 4 foot missing section of ceiling tile. During an observation on 10/21/22 at 11:15 AM, the 906 building penthouse level south stairwell had a 2 foot x 4 foot section of missing ceiling tile. During an observation on 10/21/22 at 11:19 AM, the 906 building north penthouse had three 2 foot x 4 foot sections of missing ceiling tile. During an observation on 10/21/22 at 11:35 AM, the 906 building D floor electrical room had a 2 foot x 3 foot section of missing ceiling tile. During an observation on 10/24/22 at 9:57 AM, the 906 building S floor female locker room had a 1 foot x 1 foot section of missing ceiling tile. 918 Building: During an observation on 10/20/22 at 3:14 PM, the 918 building third floor shower room across from room [ROOM NUMBER] had a loose ceiling light enclosure in the shower room and this was not smoke tight. During an observation on 10/20/22 at 3:24 PM, the 918 building third floor north social workers office had an unsealed wire that passed through a hole in the corridor wall, passed over the solid ceiling tile, and into a corridor wall into resident room 326. During an observation on 10/20/22 at 4:50 PM, the 918 building administrator office ceiling had a 6 inch x 12 inch unsealed rectangular hole. During an observation on 10/20/22 at 5:00 PM, the 918 building second floor day room had a 4 foot x 6 foot section of missing ceiling tile. During an observation on 10/21/22 at 9:10 AM, the 918 building first floor hallway near the soiled utility room had an unsealed data wire passing through solid ceiling. During an observation on 10/21/22 at 9:15 AM, the 918 building first floor soiled utility room had an unsealed data wire passing through solid ceiling. During an observation on 10/21/22 at 9:40 AM, the 918 building first floor staff bathroom had a gap around the ceiling sprinkler head and this was not smoke tight. During an observation on 10/21/22 at 10:10 AM, the 918 building first floor shower room across from room [ROOM NUMBER] had a 4 inch x 4 inch ceiling hole. During an observation on 10/24/22 at 11:55 AM, the 918 laundry room cage area ceiling had a 1 1/2 inch hole. During an observation on 10/24/22 at 12:15 PM, the 918 building dirty side of the laundry room ceiling had a 5 foot x 10 foot section of missing ceiling tiles, and there was a 1 foot x 1 foot section of missing ceiling tile located over the handwashing sink. Also, there was an open ceiling hatch in this area. During an observation on 10/24/22 at 12:40 PM, the 918 building emergency PPE storage room ceiling had a 1 foot x 1 foot missing section of ceiling tile. During an observation on 10/24/22 at 1:55 PM, the 918 building human resources office ceiling had three 2 foot x 4 foot sections of missing ceiling tile. During an interview on 10/26/22 at 11:10 AM, the Administrator stated that in the last month there was a burst pipe over the 918 building second floor day room ceiling that affected this room and the 918 laundry room, that this was an active leak, and were not aware of the other missing ceiling tiles observed during survey. They stated that a fire or smoke event could happen at any time and the ceilings in the facility should always be smoke tight. The Administrator stated that in the last 6 months a third party vendor had installed wanderguard and door mag-locks, and the vendor should have sealed the vertical penetrations through the solid ceiling tiles after they were installed. They stated that the sprinkler heads installed within this facility could be negatively affected by unsealed holes in the ceiling. The Administrator stated that if an employee would see a hole in a ceiling that it should be reported to a supervisor and recorded in the work order log book located at each nursing station. 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 5 2011 NFPA 25 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Missing ceiling tile in OT storage room locate on the B floor to be replaced using appropriate methods and materials. 906 south penthouse missing ceiling tiles to be replaced using appropriate methods and materials. South penthouse stairwell missioned ceiling tile to be replaced using appropriate methods and materials. North penthouse missing ceiling sections to be replaced using appropriate methods and materials. D floor electrical room missing ceiling sections to be replaced using appropriate methods and materials. Loose light fixture in 3rd floor shower room across from room [ROOM NUMBER] to be adjusted using appropriate methods and materials so that it is smoke tight. 3rd floor social worker office unsealed wire into corridor and resident room [ROOM NUMBER] to be sealed using appropriate methods and materials. Administrator office hole in ceiling has been repaired using appropriate methods and materials. 2nd floor day room ceiling has been repaired using appropriate methods and materials. 2st floor hallway near the soiled utility room unsealed data wire to be filled using appropriate methods and materials. 1st floor staff bathroom gap around sprinkler head to be sealed using appropriate methods and materials. 1st floor shower room across from room [ROOM NUMBER] hole in ceiling to be repaired using appropriate methods and materials. Laundry room hole in ceiling to be repaired using appropriate methods and materials. Holes above washing machines and handwashing sink to be repaired using appropriate methods and materials. Ceiling roof hatch in same area to be closed. PPE storage room ceiling to be repaired using appropriate methods and materials. Human resources ceiling to be repaired using appropriate methods and materials. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of ceilings in sprinklered areas to ensure that they are intact and are not in a condition that would impact the efficacy of the facility sprinkler system. 3. Facility policy related to fire sprinklers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all sprinkler have a ceiling that is maintained in a way that it would not hinder the efficacy of the sprinkler system They will further be educated on the requirement to report findings of non-compliance immediately to facility management for follow up. 4. The facility maintenance team or designee will conduct audits on facility fire sprinkler areas for intact ceilings in at least five random areas monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the Life Safety Code recertification survey conducted 10/20/22-11/02/22, the facility failed to ensure 1 of 3 smoke barriers observed were constructed to a 1/2 hour fire resistance rating (smoke barrier located near room A14). Specifically, the smoke barrier located near room A14 had unsealed conduit penetrations. Findings include: The document Facility Audit-K363 Corridor Doors dated 6/6/22, documented that this was a whole-house audit on corridor doors for holes, non-latching, or gaps of more than 1 inch on the bottom. This audit documented that all corridor doors were inspected, but did not address building smoke barriers. During an observation on 10/28/22 at 12:25 PM, the smoke barrier located near room A14 had an unsealed data wire passing through both layers of sheetrock. Also, there were two data wires passing through the gap between the top of the sheetrock and the metal ceiling deck and the packing material that filled the space was loose. During an interview on 10/28/22 at 12:55 PM, HMO Coordinator #34 stated that they were not sure when the facility's smoke barriers had last been inspected, and was not sure of the frequency of these inspections. They stated that they had assisted the surveyor with a ladder and a flashlight, and had never looked above the ceiling tiles to check the smoke barriers prior to the observations made on 10/28/ 22. They assumed that data wires would be sealed after had been installed. During an interview on 10/31/22 at 11:10 AM, the Administrator stated that the smoke barriers were last inspected during the 6/6/22 K363 Corridor Doors Facility Audit, and had expected the smoke barrier located near room A14 to have been properly sealed and smoke tight. 2012 NFPA 101 19. 3. 7. 3 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 1. Penetrations in smoke barrier near A14 and loose packing between floor decking and the top of the smoke barrier to be repaired using appropriate methods and materials in a manner that ensures the area remains smoke tight. 2. All residents could have been affected by the deficient practice- none were. The facility maintenance team or designee will perform an audit on smoke barriers to ensure that there are no other areas of non-compliance. Negative findings will be immediately addressed. 3. Facility policy related to smoke barriers has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of ensuring that all smoke barriers remain penetration free and that they are reviewed regularly for issues. All issues are expected to be addressed upon finding. 4. The facility maintenance team or designee will conduct audits on at least five random areas of the facility smoke barriers monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2022
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code recertification survey conducted 10/20/22-11/2/22, the facility failed to ensure that the facility had no vertical penetrations for 3 isolated areas (resident room [ROOM NUMBER], 918 building north stairwell, and the 906 building A floor south nursing station), and did not ensure that proper ceiling material was in use for 7 isolated areas (918 building third floor restroom across from resident room [ROOM NUMBER], 918 building third floor restroom across from resident room [ROOM NUMBER], resident room [ROOM NUMBER], 918 building first floor oxygen storage room, 918 building fourth floor south hallway, 918 building third floor south hallway, 918 building second floor south hallway). Specifically, resident room [ROOM NUMBER] and in 906 building A floor south nursing station had vertical unsealed penetrations, the 918 building north stairwell had an unsealed wall pipe penetration; the ceiling material was not acceptable for 918 building third floor restroom across from resident room [ROOM NUMBER], 918 building third floor restroom across from resident room [ROOM NUMBER], resident room [ROOM NUMBER], 918 building first floor oxygen storage room, 918 building fourth floor south hallway, 918 building third floor south hallway, and the 918 building second floor south hallway. Findings include: 1. Vertical Penetrations During an observation on 10/20/22 at 12:16 PM, resident room [ROOM NUMBER] had an unsealed cable that passed through a hole through the concrete flooring into the floor below. During an observation on 10/20/22 at 2:05 PM, the penthouse level of the 918 building north stairwell had an unsealed 1 1/2 inch pipe going through an outside wall. During an observation on 10/21/22 at 2:50 PM, the 906 building A floor south nursing station had a two inch circular unsealed hole in the floor, and this hole went through the concrete flooring into the floor below. There were three data wires passing into the floor below. During an interview on 10/31/22 at 3:05 PM, the Administrator stated that in the last 7 1/2 months vendors have ran additional data wires through the ceiling and had expected those to be properly sealed after the wires had been installed. They stated that they were not aware of the floor penetration by resident room [ROOM NUMBER] and the 906 building A floor south nursing station. The Administrator stated that they did not feel that the penetration in the stairwell to the outside was an issue due to the fact that this penetration was through an outside wall. 2. Unapproved Ceiling Tiles During an observation on 10/20/22 at 3:35 PM, the 918 building third floor restroom across from resident room [ROOM NUMBER] had a section of damaged ceiling that was patched with a sheet of paper ( 8. 5 inch() x 11). During an observation on 10/20/22 at 3:41 PM, the 918 building third floor restroom across from resident room [ROOM NUMBER] had a 2 foot(') x 2' section of ceiling that was covered with an unapproved plastic material. During an observation on 10/20/22 at 3:45 PM, the resident room [ROOM NUMBER] had a 3' x 3' section of ceiling that was covered with an unapproved plastic material, and a 1' x 4' section of ceiling that was covered by an unapproved unknown material. During an observation on 10/21/22 at 9:45 AM, the 918 building first floor oxygen storage room had an 18 x 18 section of unapproved ceiling material, and a 18 x 10 section of approved sheetrock material that was screwed onto the ceiling over a hole (not smoke tight). During an observation on 10/27/22 at 11:45 AM, the 918 building fourth floor south hallway ceiling near the soiled utility room had an approximate 1' x 1' section of an unknown plastic material. This unknown plastic material was also found on a section of ceiling near the south pantry. During an observation on 10/27/22 at 11:51 AM, the 918 building third floor south hallway ceiling near the soiled utility room had an approximate 1' x 1' section of an unknown plastic material. This unknown plastic material was also found on a section of ceiling near the south pantry. During an observation on 10/27/22 at 12:20 PM, the 918 building second floor south hallway ceiling near the soiled utility room had an approximate 1' x 1' section of an unknown plastic material. This unknown plastic material was also found on a section of ceiling near the south pantry. During an interview on 10/31/22 at 1:50 PM, HMO Coordinator #34 stated that they were not aware of the unknown ceiling materials found during tour of the facility, and that they were not sure if those were approved ceiling materials. During an interview on 10/31/22 at 1:50 PM, the Administrator stated that the unapproved ceiling tile materials found during the tour of the facility was not allowed, and proper ceiling material should have been used. 2012 NFPA 101: 19. 3. 1, 8. 6 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedDecember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Unsealed cable passing through the floor in room [ROOM NUMBER] will be sealed with appropriate methods and material. 918 north penthouse unsealed pipe through outside wall will be sealed with appropriate methods and materials. A Floor nursing station hole was patched with fire-stop material. 3rd floor restroom across room [ROOM NUMBER] unapproved ceiling hatch to be remedied with appropriate methods and materials. Resident room [ROOM NUMBER] ceiling repairs with unknown and unapproved material will be remedied with approved methods and materials. 918 1st floor oxygen storage room ceiling unapproved material and repair will be remedied with approved materials and methods. 4th floor south hallway ceiling near soiled utility room with unknown material repair with be remedied with approved materials and methods. 3rd floor south hallway ceiling near soiled utility room and near soiled utility room unknown plastic material (access hatch) will be remedied with approved methods and material. 2nd floor south hallway ceiling near soiled utility room unknown plastic material (access hatch) will be remedied with approved methods and materials. 2. All residents could have been affected by this deficient practice- no residents were. The facility maintenance department or designee will conduct an audit of ceiling and floor penetrations and openings. Any adverse findings will be immediately addressed. 3. Policy related to vertical openings has been reviewed with no recommended changes. The facility maintenance department will be educated on the importance of conducting regular audits of ceilings and floors and the importance of ensuring that appropriate methods and materials are used in their repair. 4. The facility maintenance team or designee will conduct audits on at least five random ceiling or floor areas for vertical opening issues monthly x 5. Adverse findings will be immediately corrected. Results of the audits will be shared with the QAPI committee for the duration of the audit cycle for the committees determination of further actions, adjustment to corrective actions, and/or to determine the need for further audit continuance. The administrator is the responsible party. |