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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey from 3/30/2025 to 4/4/2025, the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 1 of 4 residents (Resident #16) reviewed for Activities of Daily Living. Specifically, Resident #16, who required extensive assistance with personal hygiene and was dependent with showers/ bathing, was observed during multiple observations with long fingernails and a left-hand contracture (shortening and hardening of muscles often leading to deformity and rigidity of joints). Findings include: The facility policy titled Nail Care, revised (MONTH) 2023 documented provide nail care to all residents as part of routine activities of daily living. The undated facility policy titled AM Care, documented residents unable to care for themselves are provided total care. Resident #16 had [DIAGNOSES REDACTED]. The 1/20/2025 Annual Minimum Data Set (resident assessment) documented Resident #16 had impairment to one upper extremity, impairments to both lower extremities, and required dependent assistance with showers and bathing. The Activities of Daily Living Functioning Care Plan updated 1/22/2025 documented Resident #16 required extensive assistance with personal hygiene, was dependent with showers/ bathing, and had an intervention to trim nails weekly and as needed. The physician's orders [REDACTED]. During an observation on 03/30/25 at 11:28 AM, Resident #16's left hand was contracted in a fist. Resident #16 stated, I can't open it. No positioning device was observed in the resident's left hand. Resident #16's fingernails were observed to be long and stained on both hands, and their left-hand fingernails were slightly curling inside their fist. During an observation on 03/31/25 at 09:21 AM, Resident #16 was observed with fingernails to both hands long and stained, and their left hand appeared contracted in a fist with their long fingernails curling slightly inside their fist. During an interview on 04/02/25 at 4:49 PM, Certified Nurse Aide #5 stated they provided care to Resident #16 yesterday and did not notice the resident's long fingernails. When Certified Nurse Aide #5 viewed Resident #16's fingernails at the time of the interview, they stated they were long and should be clipped. During an interview and observation on 04/02/25 at 4:55 PM, Registered Nurse Unit Manager #6 stated Resident #16's left hand was contracted, and their fingernails were too long and must be cut. They stated that Resident #16's fingernails should be trimmed to avoid their long fingernails from digging into the palm of their left hand. 10 NYCRR 415. 12(a)(2) | Plan of Correction: ApprovedApril 25, 2025 I. IMMEDIATE CORRECTIVE ACTION - 1 Resident #16 accepted and received nail care on 4/2/25 from the licensed nurse. Resident # 16 was evaluated by OTR and placed on skilled OT 5x weekly for 1-2 weeks for contracture management of left hand. Nurse Practitioner assessed resident for skin integrity of affected hand with no negative findings. II. IDENTIFICATION OF OTHER RESIDENTS - 1. All residents have the potential to be affected. III. SYSTEMIC CHANGES - 1. Facility policy and procedures on Nail Care was reviewed and revised. The revisions included the specialized nail care of the resident with hand contractures. All nursing staff to be reeducated and competencied on revised policies and procedures. 2. An audit tool will be developed for resident nail care, including residents with contractures of the hand. 2. An audit focusing on nail care will be done weekly x 1 month and then monthly x 2 months by the unit managers. 3. A nail care audit was completed by licensed nurse for all residents. Two residents had preferences for their nails to not be trimmed, just manicured and their care plan was amended to include their choices. IV. QAPI MONITORING - Audits of nail care for all residents will be done weekly x 1 month and monthly x 2 months by unit managers. These audits will be completed by unit manager/designee with the results brought to QAPI Committee. Any staff deficit will be reeducated and remediated at the time of the audit. The QAPI Committee will determine the need for ongoing monitoring V. RESPONSIBLE PARTY - DNS |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during a recertification survey from 3/30/2025 to 4/4/2025, the facility did not ensure a person-centered comprehensive care plan was developed and/or implemented for 2 of 3 residents (#16 and #60) reviewed for Positioning and Mobility. Specifically, there was no documented evidence that a care plan was developed for Resident #16's left hand contracture (shortening and hardening of muscles often leading to deformity and rigidity of joints), or for Resident #60's positioning in their specialized wheelchair. Findings include: The facility policy, Comprehensive Care Plan Process, revised (MONTH) 2024 documented each resident's comprehensive care plan will be individualized, define the problems/needs/goals, and the summary of the team's approach and outcomes. 1. Resident #16 had [DIAGNOSES REDACTED]. The 1/20/2025 Annual Minimum Data Set (resident assessment) documented Resident #16 had upper extremity impairment on one side, lower extremity impairment on both sides and required dependent assistance with showers and bathing. The Activities of Daily Living Functioning Care Plan updated 1/22/2025 documented Resident #16 required extensive assistance with personal hygiene and was dependent with bed mobility and transfers and toileting and showers/ bathing. On 03/30/25 at 11:28 AM, Resident #16 was observed with their left hand contracted in a fist. Resident #16 stated, I can't open it. On 03/31/25 at 09:21 AM, Resident #16 was observed with their left hand in a fist. There was no documented evidence of a care plan for Resident #16's left hand contracture. During an interview on 04/02/25 at 04:49 PM, Certified Nurse Aide #5 stated Resident #16's left hand was always clenched and the nurse knew about it. They stated this was not a new issue. During an interview and observation of Resident #16's left hand on 4/02/25 at 4:55 PM Registered Nurse Unit Manager #6 stated Resident #16's left hand was contracted. Registered Nurse Unit Manager #6 stated there was no contracture care plan in place, and stated they should have written a contracture care plan. 2. Resident #60 had [DIAGNOSES REDACTED]. The 3/15/2025 Quarterly Minimum Data Set ( an assessment tool) documented Resident #60 had moderately impaired cognition and required substantial to maximal assistance with all activities of daily living. The 3/26/2020 Activities of Daily Living and Locomotion Care Plan documented Resident #60 was dependent with use of a tilt-in-space wheelchair, with no instructions on how to use the specialized wheelchair. There was no documented evidence that the Certified Nurse Aide Care Guide documented instructions related to the use of the resident's specialized tilt-in-space wheelchair. There was no documented evidence of a positioning care plan. During an observation on 03/30/25 at 10:33 AM in the hall, Resident #60 was in their wheelchair asleep, leaning to the left side, and their head was falling off the side of the wheelchair. Hyperflexion (stretched very far) of the neck was observed. During an observation on 03/30/25 at 11:50 AM, Resident #60 was seated upright in their tilt-in-space wheelchair, the resident was awake, their head was unsupported and leaning to the left. During an observation on 03/31/25 at 09:29 AM, Resident #60 was in their tilt- in- space wheelchair in their room asleep, their head was unsupported and leaning to the left. The resident's left foot was hanging off the wheelchair between the footrests. During an observation on 04/02/25 at 09:02 AM, the resident was observed in their tilt- in-space wheelchair sitting up straight and their feet were dangling in the air. No footrests were observed on the wheelchair. During an observation on 04/02/25 at 11:28 AM, the resident was observed out of bed in their tilt-in-space wheelchair, the footrests were in place but the resident's feet were not on foot rests and were dangling in the air. During an interview on 04/02/25 at 09:05 AM, Licensed Practical Nurse #8 stated Resident #60 should have footrests in place when they are in the wheelchair when it is reclined or if staff are pushing the wheelchair. They stated the directions on positioning should be defined in the resident's care plan. During an interview on 04/02/25 at 09:11 AM, Certified Nurse Aide #9 stated they should put the footrests on the wheelchair. They stated they were unaware of any specific positioning direction regarding the tilt-in space wheelchair. During an interview on 04/02/25 at 09:15 AM, Registered Nurse Unit Manager #3 stated they were unaware of the specific directions about use of the tilt-in-place wheelchair for Resident # 60. They stated when the resident is in the tilt-in-space wheelchair it should be reclined and footrests should be in place for positioning. During an interview on 04/02/25 at 09:56 AM, the Director of Rehabilitation stated Resident #60 was issued a tilt-in-space wheelchair with built in lateral supports. They stated Resident #60 slumps forward and to the left. They stated the tilt-in-space wheelchair tilt function should only be used when the resident's excessive leaning forward is noted. During feeding the resident should be upright. They stated footrests should only be put in place when the chair is tilted or during transport. The resident should be returned to bed when they are sleeping. They stated the direct care staff was educated, although no documented evidence of education was provided. They stated the Certified Nurse Aide Care Guide, and a Positioning Care Plan should provide instructions for the use of the tilt-in-space wheelchair for positioning. They stated it is the Nurse Manager's job to initiate the care plan and to include instructions for the use of the tilt-in-space wheelchair in the Certified Nurse Aide Care Guide. During an interview on 04/02/25 at 1:17 PM, the Director of Nursing stated when the resident's wheelchair is tilted, they should have footrests on, and when the resident is not tilted they should not have them, and stated this should have been in the care plan. During an interview on 04/03/25 at 1:14 PM, Registered Nurse Unit Manager #3 stated it is their responsibility to develop and update care plans for the residents on the unit. For Resident #60, directions on specific positioning recommendations should be in the care plan. They stated they do not know why it was not developed. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedApril 25, 2025 I. IMMEDIATE CORRECTIVE ACTION - 1. The CCPs for resident #16 and resident #60, were reviewed and revised as needed by the IDT. II. IDENTIFICATION OF OTHER RESIDENTS - 1. All residents who have contractures and/or specialized wheelchairs for positioning needs, have the potential to be affected. III. SYSTEMIC CHANGES - 1. The P&P's for contracture management and specialized wheelchairs will be reviewed/revised as necessary by the Director of Nursing (DON) and Director of Rehab (DOR). 2. The DOR and Nurse Managers will round on all residents to develop a list of residents who have contractures and require contracture management and a CCP; and for all residents who have a specialized wheelchair for proper positioning. The DOR and unit manager will develop a CCP for any resident with a contracture or specialized wheelchair. 3. The DOR will ensure that all new admissions are screened by rehabilitation for any contractures and for any positioning issues that may require a specialized wheelchair, and will develop a CCP for contracture management and/or specialized wheelchairs for positioning as applicable. 4. An education and competency will be created and presented by the DOR for all rehabilitation therapists, nurses, and cnas for contracture management and for specialized wheelchairs and positioning needs and, education for the process to request a rehab. screen for contracture issues and positioning needs. 5. An audit tool will be created for all residents who have contractures and for all residents who have specialized wheelchairs to ensure compliance with: individualized CCP, proper positioning, management of the individual's condition and contracture/positioning needs. IV. QAPI MONITORING - The above referenced audits will be done for all residents who have contracture management and or are positioned in a specialized wheelchairs, weekly x 4 and then monthly x 2 months, by the unit managers, and the results of these audits will be presented to the QAPI Committee monthly x 3 months. The QAPI Committee will determine the need for ongoing monitoring reporting. V. RESPONSIBLE PARTY - Director of Rehabilitation (DOR) |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during the recertification survey from 3/30/2024 to 04/04/2025, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, food items were not properly identified and dated in the kitchen refrigerators, freezers, food storage areas and unit pantry refrigerators. Staff in the kitchen were observed without hairnets worn properly and beard covers. Areas in the kitchen were found with broken tiles, damaged baseboards, and dirt/dust. Findings include: The facility policy Food Handling Program reviewed 07/20/2024 documented that during food preparation, proper levels of sanitation will be maintained in employee handwashing and the use of gloves and utensils. The initial inspection of the kitchen was conducted on 03/30/2024 at 9:30 AM with Food Service Worker #1 and the following was observed: - In the Walk- in Freezer foods were without identification labels and undated. The Food Service Worker identified the contents as three packages of croissants in bags, a bag of pulled chicken in a bag, a bag of meatballs, and a bag of gluten free chicken pieces. There was a tray of frozen water on the top shelf just below freezer mechanism, water droplets frozen all over the ceiling of the freezer, and food boxes touching the ceiling of the freezer. - In the Walk-in Refrigerator, food observed without identification labels (the contents identified with the assistance of Food Service Worker #1) and not dated included a tray of sauce, uncut turkey meat, two blocks of cheese, a half cabbage, a container of sauce, a tray of ham, and five 2-ounce cups of beet salad. Food found without identification labels, included a tray of eggplant, a tray of stuffed shells, a block of cheese, three 10-pound bags of stew meat defrosting, and a tray of mushrooms. Food that was opened and not dated included a gallon of bourbon style sauce, an 8-pound container of macaroni salad, and an 8-pound container of potato salad. - In the Reach- in Refrigerator there were four blocks of cheese dated but with no food identification label, 1 gallon of Italian Dressing with no opened date, 1 gallon mayonnaise with no opened date, 1/2 tomato with no food identification label and no date, a 4-pound container of grape jelly with no opened date, and a bag of whipped topping with no opened date. - Under the food tray plating countertop, food found opened and not dated included one 1/2-gallon of Red-Hot sauce, a 100-ounce container of barbeque sauce, a 2-liter bottle of orange soda, a gallon of Worcestershire sauce, a gallon of pancake and waffle syrup, a box of Creamy Wheat [MEDICATION NAME] farina, and a box of pasta. When interviewed on 03/30/2024 at 9:45 AM, Food Service Worker #1 identified the listed foods and did not know why the food was undated and unlabeled. During the initial kitchen inspection on 03/30/2024 at 10:01 AM, Food Service Worker #2 was observed with a beard but was not wearing a beard net and Food Service Worker #3 was observed with their hairnet positioned only over half of their hair, and Maintenance Worker #1 entered the kitchen food prep area without wearing a hairnet. When interviewed on 03/30/25 at 10:02 AM, Maintenance Worker #1 stated they never wore a hairnet when coming into the kitchen. During a kitchen observation on 3/30/25 at 10:22 AM, the Commercial Conveyor Toasting System conveyor was covered in thick food particle deposits; the kitchen area gas cooking top was dirty; and the exhaust fan near the cleaning area was covered in dust accumulation. The fan was blowing into the cleaning area covered in dust accumulation. The wall corners had tape peeling off, base boards were damaged/missing. There were broken tiles in front of the walk-in freezer, and dirty floor tiles under the cleaning sinks. There was an exposed hole in the wall under the sink. There were broken and dirty tiles in the ice machine room, and dirty walls near the walk-in freezer. During an observation on 03/30/25 at 12:55 PM, of the third-floor pantry, the ice machine had white stains on back wall and the base appears soiled. The refrigerator Temperature was 50 degrees Fahrenheit, there were open unlabeled bottles, and a take-out food container had a resident's name on it and was dated 3/19/ 2025. During an interview on 04/01/25 at 2:09 PM, the Food Service Director stated the unit refrigerator temperatures were checked daily by the dietary staff and if the temperatures were not in range, they contacted maintenance and outside contractors to repair. During an observation with the Food Service Director on 04/01/25 at 2:21 PM of the second-floor pantry, the ice machine was dirty and had hard water deposits on surfaces. The Food Service Director stated they had hard water in the area. In the refrigerator there were open bottles of apple juice, cranberry juice, ginger ale soda and Thick and Easy with no opened date. During an interview on 04/04/25 at 9:39 AM, the Food Service Director stated the kitchen had a daily and monthly cleaning schedule. They acknowledged that the food service workers did not wear beard nets and did not wear hairnets appropriately and stated they had been educated on use of gloves, beard nets, hairnets, and food handling. 10NYCRR 415. 14(h) | Plan of Correction: ApprovedMay 12, 2025 I. IMMEDIATE CORRECTIVE ACTION 1. Food Service employee discarded all food items both in the kitchen and in the unit pantries that were found to not be properly labeled, stored or dated (done 3/30/25). 2. On 3/31-4/3/2024 dietary staff were reeducated on proper hand hygiene, and the proper wearing of hair nets and beard guards. Hairnet dispenser was also installed outside of kitchen to provide all other departments access to this protective wear. Signage also placed to instruct employees of same. 3. Broken tiles were removed and replaced with sheet metal covering. Damaged and missing baseboards were replaced during survey. Exposed hole in the wall under the sink was also repaired during survey. II. IDENTIFICATION OF OTHERS AFFECTED 1. All residents have the potential to be affected. No residents were affected by this deficient practice. III. SYSTEMIC CHANGES 1. The Policy and Procedure for food inventory, procurement, labeling, dating and storage will be reviewed and revised as necessary by the Food Service Director (FSD). 2. The Policy and Procedure for infection control in the dietary department, hand hygiene, including hair and beard nets will be reviewed and revised by the FSD. 3. The FSD will provide education and competency to all food service employees on the above policies. 4. The FSD will develop an audit tool to monitor compliance with proper hair and beard net use, proper cleaning and reporting maintenance repairs, as well as proper storage, labeling, and dating of all food items. 5. The FSD will revise the kitchen opening and closing list to include checks of all food items for proper storage, labeling and dating. 6. A kitchen/department environmental audit will be completed by the FSD with all findings forwarded to facility administrator and Maintenance director for any needed repairs or replacement of items. The Food Service Director will revise and reeducate staff on dietary responsibility concerning daily and monthly cleaning schedule. IV. QAPI MONITORING 1. The FSD will complete 5 audits weekly ( as described above) x 4 weeks, then 3 audits weekly x 2 months via use of the audit tool and direct observation. Further education will be provided by the FSD as needed. 2. The FSD will present the findings of the audits to the monthly QAPI Committee monthly x3 months. The QAPI Committee will determine the need for ongoing monitoring based on data results. V. RESPONSIBLE PARTY: Food Service Director (FSD) |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted from 3/30/2025 to 04/04/2025, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections. Specifically, housekeeping staff did not wear the appropriate Personal Protective Equipment when going inside the room of a resident on Droplet Precautions. Findings include: On 3/30/2025 at 10:46 AM, an observation of room [ROOM NUMBER] was conducted. A Droplet Precaution sign was observed on the door, and personal protective equipment was hanging on door. On 03/31/25 at 01:51 PM during view of video footage with the facility Administrator, observed that on 3/30/25 at 11:18 am, Housekeeper #1 went into room [ROOM NUMBER] without a gown, came out wearing gloves, and pushed the housekeeper cart down the hall. On 04/01/25 at 9:24 AM, observed Housekeeper #2 place three (3) new bins in room [ROOM NUMBER] wearing a surgical mask, gloves, and gown. Observed N-95 masks at the door of room [ROOM NUMBER], and a Droplet Precaution sign indicating to wear an N-95 mask. On 04/01/25 at 9:26 AM during an interview, Housekeeper #2 acknowledged they should wear an N-95 mask when going into a room with a Droplet Precautions sign posted on the door. Housekeeper #2 acknowledged having worn a surgical mask while in the room, and acknowledged they should have worn an N-95 mask. They stated they forgot to change their mask. On 04/01/25 at 2:09 PM during an interview, Housekeeper #1 stated they should have taken off their gloves, disposed, and sanitized or washed their hands when they exited room [ROOM NUMBER] on Sunday 3/30/25 without doffing their gloves. On 04/01/25 at 2:15 PM during an interview, the Activities and Housekeeping Supervisor stated all housekeeping staff should put on and take off the proper personal protective equipment, and all were educated on all transmission-based precautions, how to read the precautions signs and which personal protective equipment to don and doff. They stated all staff should wear N-95 masks in rooms with Droplet Precautions, and take off their gloves and perform hand hygiene before exiting those rooms. They stated they were responsible for the housekeepers to utilize personal protective equipment appropriately. 10 NYCRR 415. 26 | Plan of Correction: ApprovedApril 25, 2025 I. IMMEDIATE CORRECTIVE ACTION: 1. The identified housekeepers were reeducated and received a competency regarding infection control practices related to Droplet Precautions and all transmission-based precautions. They were reeducated/re-competencied on the donning and doffing of all personal protective equipment. Proper hand hygiene education/competency was also provided to the identified housekeepers. II. IDENTIFICATION OF OTHERS AFFECTED: 1. All residents have the potential to be affected with this deficient practice. III. SYSTEMIC CHANGES: 1. The Director of Nursing will review and revise as necessary the facility Infection Prevention and Control Policy and Procedure for donning and doffing PPE. Droplet Precautions Policy and Procedure will also be reviewed and revised. 2. All employees will receive reeducation regarding infection control practices with droplet precautions and transmission based precautions. Education to include donning and doffing PPE. Hand Hygiene education with a focus on donning and doffing gloves will be emphasized. This education will be provided by IP/designee 3. An audit tool will be developed by the ICP to monitor infection control practices and compliance for adhering to required PPE, hand hygiene, and donning/doffing of PPE for transmission based precautions. IV. QAPI MONITORING 1. The IP/designee will audit 6 employees weekly, across different disciplines and shifts, for infection control practices. 2. The IP will report audit findings to the QAPI Committee monthly for 3 months after which time the committee will determine the frequency of ongoing monitoring. V. RESPONSIBLE PARTY: IP |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the recertification survey from 3/30/2025 to 4/04/2025, the facility did not ensure the Quality Assurance & Performance Improvement and Quality Assessment & Assurance committees consisted at a minimum of the Medical Director, or their designee, and the Infection Control Practitioner attendance quarterly meetings. Specifically, the Medical Director or designee had not participated in Quality Assurance & Performance Improvement meetings for three out of the four meetings and the Infection Control Practitioner did not participate in two out of four Quarterly meetings as required. The findings are: The facility Quality Assurance and Performance Improvement Policy, last revised on (MONTH) 6, 2025, documented the Quality Assessment and Assurance Committee comprised of the Administrator, Director of Nursing Services, Medical Director, Clinical Coordinators, Unit Managers, Governing Body, and all Department heads. A review of the Quarterly Meeting Attendance Sheets entitled Quality Assurance and Performance Improvement for 6/6/24, 9/6/24, 12/27/24 and 2/26/25 revealed the Medical Director did not sign the attendance sheets. A review of the Quarterly Meeting Attendance Sheets entitled Quality Assurance and Performance Improvement for 6/6/24, and 9/6/24, revealed the Infection Control Practitioner did not sign the attendance sheets. During an interview on 04/04/25 at 02:17 PM, the Administrator stated they held Quality Assurance Performance Improvement meetings every month. The Administrator stated they had problems with the previous Medical Director attending the Quality Assurance Performance Improvement meetings. They stated they hired a new Medical Director at the beginning of the year. They stated that the Infection Control Practitioner had not been attending the Quality Assurance Performance Improvement meetings. They stated they had hired a new Infection Control Practitioner, and they had attended the last 2 Quarterly meetings. 10 NYCRR 415. 15(a) | Plan of Correction: ApprovedApril 25, 2025 I. IMMEDIATE CORRECTIVE ACTION - 1. The P&P for QAPI was reviewed. 2. The ICP and Medical Director/designee, and other required committee members(DON, LNHA, Department Heads) were educated on required attendance at QAPI Meetings II. IDENTIFICATION OF OTHER RESIDENTS - 1. All residents have the potential to be affected. 2. No residents were found to be affected. III. SYSTEMIC CHANGES - 1. The P&P for QAPI and QAPI Committee Meetings /required members will be reviewed and revised as necessary. 2. Regularly scheduled QAPI Meetings will have, at a minimum, attendance by committee members: Director of Nursing, LNHA, Medical Director/designee, ICP, department heads/designee who will be active participants at the QAPI Meetings. 3. All QAPI Committee members will be re-educated by the LNHA on their roles as QAPI Committee members and their required attendance at QAPI Meetings. 4. An audit tool will be developed to check on attendance of required committee members at all QAPI Meetings. The LNHA will do this audit monthly x 6 months. IV. QAPI MONITORING - 1. The audit of QAPI Committee attendance and required attendees will be presented to the QAPI Committee monthly x 6 months. The QAPI Committee will determine the need for ongoing reporting. V. RESPONSIBLE PARTY - LNHA |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey from 3/30/2025 to 4/4/2025 the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 3 of 3 residents (#16, #60, and #37) reviewed for Positioning and Mobility. Specifically, Resident #16 was not provided a positioning device for their left-hand contracture (shortening and hardening of muscles often leading to deformity and rigidity of joints), Resident #60 was not positioned correctly in their wheelchair, and Resident #37 was not provided positioning devices they needed for comfort and positioning. Findings include: The facility policy, Contracture Prevention and Management documented departments will work in conjunction to apply preventive measures to prevent and manage contractures. Contractures can be prevented by the use of active and passive range of motion techniques as well as positioning devices, splints, and braces. 1. Resident #16 had [DIAGNOSES REDACTED]. The 1/20/2025 Annual Minimum Data Set (resident assessment) documented Resident #16 had an impairment to one upper extremity, impairments to both lower extremities, and required dependent assistance with showers and bathing. During an observation on 03/30/25 at 11:28 AM, Resident #16 was observed with their left hand contracted in a fist. Resident #16 stated, I can't open it. No positioning device was observed in the resident's left hand. Resident #16's left-hand fingernails were long and slightly curling inside their fist. During an observation on 03/31/25 at 9:21 AM, Resident #16 was observed with their left hand in a fist, and long fingernails curling slightly inside their fist. There was no documented evidence of a care plan for Resident #16's left hand contracture. There was no documented evidence of a physician's orders [REDACTED].#16's left hand contracture management. During an interview and observation on 04/02/25 at 04:55 PM Registered Nurse Unit Manager #6 stated Resident #16's left hand was contracted. Registered Nurse Unit Manager #6 stated they should have sent a rehabilitation screen request for the left-hand contracture. During an interview on 04/03/25 at 10:34 AM, the Director of Rehabilitation stated they received a screen request after the surveyor identified the left-hand concern with the Registered Nurse Unit Manager # 6. They stated they re-assessed Resident #16 this morning and recommended a device to maintain skin integrity of their left hand and will pick up the resident for Occupational Therapy to evaluate for an appropriate device. They stated nursing should have requested a screen for evaluation and treatment regarding concerns with Resident #16's contracted left hand. 2. Resident #60 had [DIAGNOSES REDACTED]. The 3/15/2025 Quarterly Minimum Data Set (an assessment tool) documented Resident #60 had moderately impaired cognition and required substantial to maximal assistance with all activities of daily living. The 3/26/2020 Activities of Daily Living and Locomotion Care Plan documented Resident #60 was dependent with use of tilt-in-space wheelchair, with no instructions on how to use the specialized wheelchair. There was no documented evidence that the Certified Nurse Aide Care Guide had instructions related to the use of the resident's tilt-in-space wheelchair. Documented Resident #60 was totally dependent with locomotion on and off the unit. During an observation on 03/30/25 at 10:33 AM in the hall, Resident #60 was in their wheelchair asleep, leaning to left side, and their head was falling off the side of the wheelchair. Hyperflexion (stretched very far) of the neck was observed. During an observation on 03/30/25 at 11:50 AM, Resident #60 was seated in their tilt-in-space wheelchair not tilted, the resident was awake, leaning to the left and head positioned to the left with no head or neck support. Their feet were observed on the footrest. During an observation on 03/30/25 at 11:58 AM, Resident #60 was observed sleeping in their wheelchair in the hall with their head positioned all the way to the left, with no support for their head. During an observation on 03/30/25 at 12:36 PM, Resident #60 was observed in the dining room in their wheelchair, leaning to the left side, no positioning device was observed. During an observation on 03/31/25 at 09:29 AM, Resident #60 was in their tilt- in- space wheelchair in their room asleep, their head was unsupported and leaning to the left. The resident's left foot was hanging off the wheelchair between the footrests. The resident was unable to place it back onto the footrest independently. During an observation on 04/02/25 at 09:02 AM, the resident was observed in their tilt- in-space wheelchair sitting up straight and their feet were dangling in the air. No footrests were observed on the wheelchair. During an observation on 04/02/25 at 11:28 AM, the resident was observed out of bed in their tilt-in-space wheelchair, the footrests were in place, but the resident's feet were not on footrests and they were dangling. During an observation on 04/02/25 at 12:27 PM, Resident #60 was observed in their wheelchair in the dining room, sleeping, the chair was tilted back. The nurse was observed placing the chair in the upright position, foot pedals remained in place, left foot was not on the footrest, dangling in the air. Resident's head was facing down. During an observation on 04/02/25 at 12:42 PM in the dining room, the resident was awake and alert feeding themselves The wheelchair was observed in the upright position, and the footrests were in place. During an interview on 04/02/25 at 09:05 AM, Licensed Practical Nurse #8 stated Resident #60 should have footrests in place when they are in the wheelchair when it is reclined or if staff are pushing the wheelchair. They stated the directions on positioning should be defined in the resident's care plan. During an interview on 04/02/25 at 09:11 AM, Certified Nurse Aide #9 stated when we get the resident up, we should put the footrests on the wheelchair. They were unaware of any specific positioning directions regarding the tilt-in space wheelchair. During an interview on 04/02/25 at 09:15 AM, Registered Nurse Unit Manager #3 stated they were unaware of the specific directions about use of the tilt-in-place wheelchair for Resident # 60. They stated when the resident is in the tilt-in-space wheelchair we should place footrests on the chair and recline it for positioning. During an interview on 04/02/25 at 09:56 AM, the Director of Rehabilitation stated Resident #60 was issued a tilt-in-space wheelchair with built in lateral supports. They stated Resident #60 slumps forward and to the left. They stated the tilt-in-space wheelchair tilt function should only be used when the resident's excessive leaning forward is noted. During feeding the resident should be upright. The footrests should only be put in place when the chair is tilted or during transport. The resident should be returned to bed when they are sleeping. They stated the direct care staff was educated, although no documented evidence of education was provided. They stated the Certified Nurse Aide Care Guide, and a Positioning Care Plan should provide instructions for the use of the tilt-in-space wheelchair for positioning. They stated it is the Nurse Manager's job to include instructions for the use of the tilt-in-space wheelchair in the Certified Nurse Aide Care Guide. During an interview on 04/02/25 at 1:17 PM, the Director of Nursing stated the Rehabilitation staff should have educated the nursing staff on the proper use of the tilt-in-space wheelchair. During an interview on 04/03/25 at 1:14 PM, Registered Nurse Unit Manager #3 stated it was Rehabilitation Director's responsibility to educate the nursing staff on how to utilize the Resident's tilt-in-space wheelchair per specific instructio | Plan of Correction: ApprovedMay 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. IMMEDIATE CORRECTIVE ACTION - 1. Resident #16 was immediately evaluated by OTR and Put on skilled restorative 5 days a week 1-2 week 2. Resident #60 was reevaluated by OTR in tilt-in- space chair and made recommendations for proper positioning and indication for use of footrest The staff were reeducated on plan of care and proper use of specialized chair. This information was placed in the Care plan which was reviewed and revised and instructions were placed in the cna care guide. 3. Resident #37 was re-evaluated for use of heel off loading devices in and oob in bed and her care plan and cna care guide was revised and updated. II. IDENTIFICATION OF OTHER RESIDENTS - 1. All residents have the potential to be affected. 2. All residents with specialty tilting chairs were audited and identified to ensure that no others were affected by deficient practice- none found 3. An audit was completed of all residents with contractures and risk for contractures to ensure that no other residents were affected by this deficient practice- none found 4. Residents currently using Pressure Ulcer Prevention Devices have been identified and to ensure that no other residents were affected by this deficient practice - none found III. SYSTEMIC CHANGES - 1. Policy and Procedure on contractures/positioning devices and range of motion techniques will be reviewed and revised. Education regarding Identification of Changes in Range of Motion to be provided to all nursing staff. These policies will be reeducated to nursing staff. Competencies regarding staff knowledge will be developed to ensure staff understanding. 2. Policy and Procedure on specialized wheelchairs will be reviewed and revised. Proper positioning and specific directions for use will be communicated in cna care guide. All Direct care staff will be reeducated. Competency regarding same will be created to staff comprehension of knowledge. 3. Policy and Procedure on Pressure Ulcer Prevention will be reviewed and revised to include clarification regarding use of heel boots and other heel off-loading devices. 4. A full house audit will be completed to include all residents who have contractures and use splint/positioning devices (orthotics). Results of audit findings will be reeducated to all nursing staff and placed in CNA care guide and care plans. 5. OTR will review all other residents who are positioned in all specialized tilting chairs and reeducation on use provided to all direct care staff and will be communicated in CNA care guide. 6. A full review of all residents who have physician orders [REDACTED]. IV. QAPI MONITORING - 1. Random Audits of Staff Knowledge Competency on Identification of changes in range of motion to be completed unannounced by DOR/designee. a. Weekly 5 unannounced audits for x one(1) month to be measured b. Monthly audits for 3 months V. RESPONSIBLE PARTY - Director of Rehab/DNS |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review conducted during the recertification survey from 3/30/2025-4/4/2025, the facility did not ensure that a Registered Nurse was on duty for at least 8 consecutive hours a day, 7 days a week for one of 26 weekend days reviewed from 10/5/2024 through 12/31/2024, and daily staffing reviewed from 3/1/2025 through 4/3/ 2025. Specifically, no Registered Nurse worked during the 24-hour period on 11/2/ 2024. Findings included: The Facility Assessment reviewed 1/15/2025 documented the Minimum Nursing Staffing Plan to include a Registered Nurse staffed on all shifts. During an interview and review of the Facility Assessment Minimum Nursing Staffing Plan on 4/4/25 at 9:01 AM, the Director of Human Resources/Covering Staffing Coordinator stated that no Registered Nurse worked on 11/2/ 2024. They stated they did not understand why that happened and stated they were aware of the regulation that a Registered Nurse must work at least 8 hours in every 24-hour period. During an interview on 04/04/25 at 11:24 AM, the Director of Nursing reviewed the staffing sheet for (MONTH) 2, 2024, and stated that no Registered Nurse worked on that date. They stated they were aware that a Registered Nurse must work at least 8 hours on every 24-hour period. 10NYCRR 415. 13(b)(1) | Plan of Correction: ApprovedApril 25, 2025 I. IMMEDIATE CORRECTIVE ACTION - 1. The prospective staffing schedule was reviewed by the staffing coordinator and DON to ensure RN coverage daily. 2. The Facility Assessment and Nursing Staffing Plan were reviewed to ensure inclusion of RN coverage, for a minimum of 8 hrs. daily, 7 days/week. II. IDENTIFICATION OF OTHER RESIDENTS - 1. All residents have the potential to be affected; no residents were found to be affected. III. SYSTEMIC CHANGES - 1. The P&P for Nursing Staffing will be reviewed and revised as necessary to include RN coverage for a minimum of 8 hrs./day/7 days a week. 2. The Staffing Coordinator and DON will review the RN staffing coverage, daily for the upcoming days to ensure the RN coverage policy standard is met. 3. The Staffing Coordinator and DON will establish a contingency plan for RN coverage to cover possible absences/call outs to ensure the minimum RN coverage is met daily. 4. The Staffing Coordinator and DON were re-educated on the policy for minimum RN coverage daily. IV. QAPI MONITORING - 1. The nurse staffing schedule will be checked weekly, for the coming week, by the HR Director and/or Director of Nursing; they will develop an audit tool and check nurse staffing prospectively to ensure the scheduling of an RN daily as per policy. 2. The HR Director and/or Director of Nursing will check the nurse staffing schedule weekly retrospectively to ensure that the policy for RN staffing daily was met. 3. The results of the above mentioned (checks/audits) will be presented to the QAPI Committee monthly x 3 months; the QAPI Committee will then determine the need for ongoing monitoring and reporting. V. RESPONSIBLE PARTY - Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 4, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey from 3/30/2025 to 4/04/2025, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 2 of 2 resident floors (2nd and 3rd Floors) during observation of the environment. Specifically, the 3rd Floor Unit had a broken handrail endcap, an ongoing foul, pervasive, strong odor of urine, a broken dresser and a ripped chair were observed in room [ROOM NUMBER], the shower room walls were stained, the community unit bathroom tiles were stained, floor molding was cracked, sheetrock had a gouge, the Community room floor had visible dust and debris, privacy curtains in resident rooms were visibly soiled, and some base board moldings were cracked and soiled with wax build up. The 2nd floor base board moldings were cracked and soiled with wax build up. The findings are: An undated Housekeeping Policy and Procedure documented the purpose to have a detailed room cleaning. An undated Housekeeping Schedule provided included the scheduled cleaning of resident rooms as well as public areas within the building. Preventative Maintenance and Inspection Policy and Procedure last reviewed 5/23 documented provide a safe environment for residents, staff, and visitors, a preventative maintenance program has been implemented. During an observation on 03/30/25 at 9:35 AM on Unit 3 East floors were soiled, and there was an ongoing strong odor of urine. A broken dresser and a chair with a ripped seat and backrest were observed and the baseboard was cracked in room # 324. Baseboards and floors along the hallway were dirty and had wax build-up. The handrail by the nurse's station had a missing endcap. During an observation on 03/31/25 at 08:52 AM on Unit 3 East, there was an ongoing urine odor, broken molding, dirty baseboards, and broken molding. During observations on 3/31/2025 at 10:38 AM and 4/1/2025 at 1:04PM, the Community bathroom by the Unit 3 East nurse's station was observed to have chipped and broken molding tiles, brown stains along the top of the molding tiles, a dent in the wall, and tan discoloration on the wall between the toilet and sink. During an observation on 04/02/25 at 09:13 AM, there was a strong urine odor on Unit 3 East. During an observation on 04/02/25 at 12:45 PM in the Unit 3 East community room, there was loose debris and dust along the baseboard near the suction cart. During an observation on 04/02/25 at 04:49 PM on Unit 2 West, the hallway baseboard moldings were cracked and stained. During an observation on 04/04/25 at 09:21 AM on Unit 3 East, rooms #325, #326, and #330 had soiled privacy curtains. During an interview on 03/31/25 at 10:20 AM Resident #13 stated that the 3 East Community bathroom by the nurses station was never clean enough. During an interview on 04/03/25 at 08:48 AM the Director of Housekeeping stated they were aware base board moldings needed to be replaced on all the units as they appeared dirty. They stated there was no way to clean the buildup of dirt under the wax. They stated scheduled terminal individual room cleaning did not exist because they did not have enough staff. They stated housekeepers are supposed to check the privacy curtains daily when completing room cleanings. They stated staff is assigned to clean the community room daily and should include moving the furniture away from the wall to sweep and mop. They stated they were aware of the urine smell on the unit, some of the air fresheners were removed related to the unit being painted. They stated since there was no 11-7 housekeeping person, utility room garbage cans should be removed from the units by 7:30 AM. They stated that may have contributed to the odor. During an interview on 04/03/25 at 09:36 AM the Director of Maintenance stated during rounds they had not seen a broken handrail endcap. They stated they would have fixed the handrail end cap if they had been made aware of it. They stated since they did not enter all resident rooms daily, staff would need to report broken furniture to maintenance. They stated going in the resident rooms was not routine unless a specific issue was reported. They stated when rounding, the maintenance staff were probably not looking closely enough. They stated terminal cleanings were only done when residents were discharged . They stated nursing and housekeeping should check items in the rooms. They stated they were uncertain if housekeeping staff had been trained on reporting and checking the environment. They stated Environmental Services should conduct regular audits in and out of rooms. 10 NYCRR 415. 5(h-i)(1-3) | Plan of Correction: ApprovedApril 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. IMMEDIATE CORRECTIVE ACTION - 1. Furniture that was found to be in disrepair in room [ROOM NUMBER] was immediately removed and replaced with new furniture. A full house audit of condition of furniture was initiated with any furniture in disrepair removed. 2. The 3 East floors were cleaned and the odor of urine was eliminated. 3. The end cap handrail on 3 east was repaired. 4. Unit baseboards and moldings were cleaned, with plans to replace baseboard molding as necessary. 5. The identified dust and debris on the 3 east baseboard molding in the community room, was cleaned. 6. The 2 west identified baseboard moldings were cleaned with plans developed to replace broken and stained molding. 7. The soiled privacy curtains in rooms #325; #326; #330 on 3 east were removed and replaced. A schedule for detailed room cleanings, including cubicle curtains was created. II. IDENTIFICATION OF OTHER RESIDENTS - 1. All residents have the potential to be affected by the identified deficient environmental practices. III. SYSTEMIC CHANGES - 1. An outside environmental/housekeeping consultant was brought in to assist with identifying and correcting areas of concern. This consultant will assist with revising and implementing all cleaning schedules, and audit processes for both shifts. Technical training/education and competency will be conducted by the housekeeping/environmental services consultant for both line staff and the housekeeping director. In-service sessions will be both individual and classroom. Policies and procedures will be reviewed and revised as needed to ensure full compliance, as they relate to infection control practices and life safety procedures as they pertain to housekeeping services. 2. Policy and Procedure for detailed room cleaning was reviewed and revised by Facility Administrator and Outside consultant. The housekeeping staff will be educated and competencied on detailed room cleaning and privacy curtains by the Director of Housekeeping /designee. 3. Policy and Procedure for environmental audit was reviewed and revised by Facility Administrator and Outside consultant. This audit to be completed by Director of Housekeeping/Maintenance weekly. 4. A baseboard/molding/handrail audit was added to the Preventative Maintenance Program. Replacement molding and end caps will be ordered and installed as needed. 5. Implementation of daily cleaning assignment sheets, requiring assigned staff members to document, checking off completed rooms, throughout the day and the conclusion of scheduled shift, the housekeeping director or designee reviews assignment sheet, assuring tasks are completed, incomplete assignments or poor cleaning procedures are to be addressed and corrected immediately. 6. The housekeeping director will assess prioritizing rooms requiring immediate assignment. IV. QAPI MONITORING - 1. A staff competency on detailed room cleaning was reviewed and revised as necessary to determine staff knowledge. All housekeeping and maintenance staff will have competency completed; negative findings will have immediate onsite education. Findings will be brought to QAPI/safety committee monthly x 3. The QAPI committee will then determine the need for ongoing monitoring. 2. Housekeeping/maintenance director will complete 10 random/weekly environmental audits to ensure a safe, clean, comfortable, homelike environment. Results of these audits will be presented weekly to the facility administrator. Any safety concerns will be immediately addressed. Corrective Actions will be monitored on a weekly basis for 3 months by the facility administrator with the results being presented to the QAPI Committee monthly x 3 months, The QAPI committee will determine the need for ongoing monitoring V. RESPONSIBLE PARTY - Director of Housekeeping |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 1. 6. 1 limits existing health care occupancies to the building construction types shown in Table 19. 1. 6. 1 Construction Type Limitations. Table 19. 1. 6. 1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation and staff interview, the facility did not ensure that all structural components were maintained to meet the requirements for a construction Type II (222) building. This occurred on the first floor. The findings include: During the life safety survey on 3/31/2025, at approximately 10:30 am, unprotected steel beams were noted in the following areas: 1) The 1st floor landing of the East stair. 2) The garage attached to the building, accessible from the first floor. At the time of these findings, the Director of Maintenance stated that these deficiencies would be corrected. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 17, 2025 K 161- Automatic Sprinkler Protection I. IMMEDIATE CORRECTIVE ACTION: A licensed Contractor was hired to encapsulate the exposed, unprotected steel beams with the approved 2-hour NFPA material. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout the facility, all beams were assessed. None were found deficient at this time. III. SYSTEMIC CHANGES: A Monthly Compliance Audit of affected/corrected beams will begin May 2025. These monthly audits will continue for a period of 3 months with results reported by the Director of Maintenance to the facility QAPI Committee. Any negative findings will be immediately reported to the Director of Maintenance and corrected. IV. QAPI MONITORING The findings of the above noted compliance audit will be reported to the facility Quality Assurance and Performance Improvement Committee monthly for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and any interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion Date: 05/30/2025 Responsible Party: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 3. 6. 3. 1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 13?4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes. 19. 3. 6. 4 Transfer Grilles. 19. 3. 6. 4. 1 Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in corridor walls or doors. Based on observation and staff interview, the facility did not ensure that all corridor doors were designed to resist the passage of smoke. This occurred on the first and third floors of the facility. The findings include: During the life safety survey on 3/31/2025, at approximately 9:30 am, the following were noted: 1) The doors to the clinical social worker's office and the medical equipment storage closet were equipped with transfer grills at the bottom of the doors. 2) The large storage room on the first floor near the garage entrance was lacking a door. At the time of these findings, the Director of Maintenance stated that these deficiencies would be corrected. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 17, 2025 K 353 Corridor- Doors I. IMMEDIATE CORRECTIVE ACTION: A. Maintenance Director applied protective metal plate over top of transfer grille. It was applied on the interior portion of the affected doors. This metal plate will protect the corridor from smoke transfer. B. General Contractor was contacted to replace fire protection door on the first floor near the garage entrance. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout the facility, all corridor doors were assessed. No others were found deficient. III. SYSTEMIC CHANGES: A monthly compliance audit will include all corridor doors within the facility. This will ensure that doors are present and designed to resist passage of smoke. These monthly audits will continue for a period of 3 months with results reported by the Director of Maintenance to the facility QAPI Committee. Any negative findings will be immediately reported to the Director of Maintenance and corrected IV. QAPI MONITORING: The findings of the above noted compliance audits will be reported to the facility Quality Assurance and Performance Improvement Committee for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion Date: 5/30/2025 Responsible Party: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 14. 2 Internal Inspection of Piping. 2011 NFPA 25: 14. 2. 1 Except as discussed in 14. 2. 1. 1 and 14. 2. 1. 4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. Based on observation, document review and staff interview, the facility did not ensure that all required testing, inspection and maintenance was conducted on the facility's automatic sprinkler system. The findings include: During the life safety document review on 3/31/2025, at approximately 12:30 pm, it was noted that there was no record of the 5-year internal pipe inspection of the sprinkler system. At the exit conference on 3/31/2025 at approximately 1:30 pm, the facility's Administrator stated that the sprinkler vendor would be brought in to conduct this inspection. 2011 NFPA 25 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedApril 17, 2025 K 353- Sprinkler System- Maintenance and Testing I. IMMEDIATE CORRECTIVE ACTION The 5-year internal pipe inspection of the sprinkler system was immediately scheduled with our vendor Sprinkler Company. The Maintenance Staff were educated to ensure that all required testing, inspection and maintenance was conducted on the facility's automatic sprinkler system. II. IDENTIFICATION OF OTHERS AFFECTED: All residents have the potential to be affected. In order to ensure full compliance of this standard throughout this facility, the Director of Maintenance will review any additional required Automatic Sprinkler Testing to ensure it too meets all aspects of the NFPA Standard. All other Maintenance and Testing current and up to date. III. SYSTEMIC CHANGES: A monthly compliance audit will be completed to ensure that all required Sprinkler Maintenance and Testing are done. This audit will begin (MONTH) 2025 and continue for a period of 12 months. Any negative findings will be immediately reported to facility administrator and corrected. IV. QAPI MONITORING: The findings of the audit will be reported to the facility Quality Assurance and Performance Improvement Committee for 3 months by the Director of Maintenance. Any trends or concerns that may be identified will be discussed by the committee and any necessary interventions will be implemented. The QAPI Committee will determine the need for ongoing reporting. Completion date :05/30/2025 Responsible Party: Director of Maintenance |