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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 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 01/02/2025 to 01/10/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #76) of 1 resident reviewed for Pressure Ulcer out of a sample of 27 residents. Specifically, Licensed Practical Nurse #2 failed to practice appropriate infection control and placing the barrier on a visibly soiled overbed table and did practice appropriate hand hygiene and glove changes during wound care. The findings are: The facility policy titled Wound Care effective date 07/2024 and last reviewed 08/08/2024 stated that the purpose is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors as well as to provide guidelines for the care of wounds to promote healing. The policy also stated under the heading Steps in the Procedure: 1. Use disposable cloth (paper cloth is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange supplies so they can be easily reached. Resident #76 was admitted with [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #76 had short and long-term memory problems, severely impaired cognitive skills for decision-making. The Annual Minimum Data Set assessment also documented that Resident #76 required dependent assistance for transfers, was always incontinent of bowel and bladder, and had two stage 4 pressure ulcers that were present upon admission. The Physician order [REDACTED]. Apply Calcium Alginate, cover with Opti foam dressing two times a day for Stage 4 pressure ulcer of left hip, and cleanse sacral wound with Dakin's (1/4/ strength) solution and pat dry. Apply calcium alginate and cover with Opti foam dressing two times a day for Stage 4 pressure ulcer of sacral area. The Advantage Surgical and Wound Care Progress Note dated 12/30/2024 documented Stage 4 measuring 7cm x 7cm x1cm with undermining at 6:00 ends at 9:00 distance 1.5cm Moderate sero-sanguineous drainage, no odor, 90% granulation 10% slough. Periwound skin does not exhibit signs of infection. The progress note also documented a Left Hip Stage 4 wound measuring 3.5 x 2 x 1 with undermining noted at 9:00 and ends at 12:00 maximum distance. On 01/07/25 at 10:36 AM, a wound care observation for Resident #76 was conducted with Licensed Practical Nurse #2 who was assisted by Certified Nurse Assistant #2. Licensed Practical Nurse #2 washed hands, donned a gown, mask, and gloves, then placed a sterile drape on a visibly soiled overbed table. Licensed Practical Nurse #2 did not clean the overbed table before placing a sterile drape on the visibly soiled overbed table. A white Styrofoam tray was then placed on top of the barrier, solutions were placed at side of barrier, an unwrapped scissor was used to open the Opti foam and Calcium alginate packaging and then used to cut the Calcium alginate film which was then placed on the tray along with a bulk pack of gauze pads. Licensed Practical Nurse #2 washed their hands, donned gloves and removed the soiled dressing from Resident #76's left hip. Licensed Practical Nurse #2 removed the soiled gloves and donned a clean pair of gloves without performing hand hygiene and then placed several gauze pads onto the Styrofoam tray and proceeded to moisten gauze with Dakins solution. Licensed Practical Nurse #2 then used a dabbing motion to clean wound before cleaning in a circular motion. Licensed Practical Nurse #2 patted the wound dry with gauze picked up from the tray, changed gloves without performing hand hygiene, applied the Calcium Alginate and bordered gauze, and then removed a pen from their pocket which they used to date the dressing, returned the pen to their pocket, removed gloves and washed hands. Licensed Practical Nurse #2 performed the exact same procedure when cleaning the wound to the sacrum, with the same breaches in infection control and hand hygiene observed. On 01/08/25 at 11:13 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they were a little bit under the weather and not as organized as they usually are. Licensed Practical Nurse #2 then described the procedure of wound care as follows: wash my hands, gather supplies, cover table with a clean towel drape, then place supplies on a clean surface, then wash hands. Put on Personal Protective Equipment, remove old dressing, wash my hands, then put on clean gloves, clean area with Dakin's, cover with Calcium alginate, then apply bordered gauze. Licensed Practical Nurse #2 further stated that they perform hand hygiene before they start the procedure, after removing the old dressing and after they have applied the new dressing. Licensed Practical Nurse #2 stated that when gloves are removed, hands should be washed then and also when the wound is cleaned and before the dressing is put on, but they did not always do this today while doing the wound care. Licensed Practical Nurse #2 also stated that they had instructed the Home Health Aide to clean the overbed table before the dressing change and assumed it had been done. Licensed Practical Nurse #2 stated that they were informed that the tray was provided for them to do wound care today, but usually they just use the drape sheet and place supplies directly on to it. Licensed Practical Nurse #2 stated they received training on wound care some time ago and that a refresher training from time to time would be good. On 01/10/25 at 11:12 AM, an interview with Registered Nurse Supervisor #1 who stated that if nurses observe complications or a change in the wound, they assess the wound and notify the doctor. Registered Nurse Supervisor #1 also stated that they do not do the actual wound care and does not make observations of what the Licensed nurses are doing during wound care as they are the only supervisor in the building. On 01/10/25 at 11:30 AM, an interview was conducted with the Assistant Director of Nursing, who is also the Infection Preventionist, stated that they are the wound care nurse and assess residents on admission who are at risk for developing wounds. The Infection Preventionist described the process for wound care as follows: set up side table which should be cleaned first, place sterile drape, then supplies and treatments are placed on drape. Gauze is separated for normal saline and for treatments, scissors are taken from the treatment cart in a sealed package, wash hands, don gloves and remove dressing have bag close for garbage, wash hands put new gloves on and do treatment, cleanse wound with normal saline from cleanest to dirty, apply treatment and cover. The Infection Preventionist also stated that hand hygiene is done before contact, and when gloves come in contact with contaminated areas. The Infection Preventionist further stated that periodically observations of wound care are done, but it is not something that is done routinely or documented. The Infection Preventionist stated that they do competencies on wound care. The Infection Preventionist stated that use of Styrofoam trays during wound care is not encouraged, and hand hygiene is to be performed whenever gloves are removed. On 01/10/25 at 11:49 AM, an interview was conducted with the Director of Nursing Services who stated that the Infection Preventionist is in charge of wound care and wound care competencies are done by the Assistant Director of Nursing or themselves or a Registered Nurse will do observations in between. The Director of Nursing Services also stated they were not if the observations were documented anywhere. 10 NYCRR 415.19(b)(4) | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. The resident was examined by a physician and monitored for 72 hours to identify any signs and symptoms of infection that could have developed from the deficient practice. 2. Medical examination and monitoring documentation are recorded in the residents?ÇÖ medical record. 3. Licensed Practical Nurse # 2 was re-educated on: a. The deficient practices identified by the DOH surveyor. b. Key points in F880 c. Current standards of professional wound care practice. 4. Registered Nurse #1 was educated on: a. The deficient practices identified by the DOH surveyor. b. Key points in F880 c. Current standards of professional wound care practice. d. Accountability and responsibility to randomly observe wound care tasks performed by LPNs. 5. The Assistant Director of Nursing was educated on: e. The deficient practices identified by the DOH surveyor. f. Key points in F880 g. Current standards of professional wound care practice. 6. The Director of Nursing was educated on: a. The deficient practices identified by the DOH surveyor. b. Key points in F880 c. Current standards of professional wound care practice. d. the responsibility and accountability of the Infection Preventionist e. her responsibility and accountability to know where wound care observations are documented. 7. Wound care competencies were performed with: a. Licensed Practical Nurse #2, and b. Registered Nurse #1 8. Attendance sheet, lesson plans, and competencies are filed for reference and validation. Element II 1. The QAPI Committee populated a list of residents who had a physician?ÇÖs order for wound care. 2. The list was used to identify the residents who received wound care from Licensed Practical Nurse #1 over the last 7 days. 3. Residents were evaluated and monitored to identify any signs and symptoms of infection that could have developed from any deficient practices that may have occurred during the task with License Practical Nurse #1. 4. Findings are documented as part of the facility?ÇÖs QAPI program. Element III 1. The QAPI committee reviewed the policy and procedure titled, ?Ç£Wound Care?Ç¥ and revised it to align with current standards of professional wound care practices and F880. 2. All licensed nurses were educated on a. the deficient practices identified by the DOH surveyor. f. the revised facility policy titled ?Ç£Wound Care?Ç¥. g. key elements in F880 h. Current standards of clinical practice for wound care. 3. All license nurses were provided with wound care competency. 4. Attendance records, lesson plans, and competencies are filed or reference and validation. Element IV 1. The QAPI Committee developed an audit tool with measurable goals to monitor license nurses during wound care tasks. 2. The Director of Nursing/designee will utilize the audit tool to randomly observe license RNs and LPNs) nurses during their performance of wound care. 3. Audits will be conducted weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the update ?ÇÿWound Care?ÇÖ policy and procedure and F880. 8. Audits with negative findings will have corrective actions including immediate correction of the deficient practice, individual competencies, re-education and progressive disciplines. 9. The Director of Nursing will summarize their audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our delivery of care services, wound care practices, and compliance with F880. 10. The Lesson Plan for this Plan of Correction and the policy titled ?ÇÿWound Care?ÇÖ will be included in the facility?ÇÖs Orientation Program for newly hired licensed nurses. 11. All licensed nurses will participate in a Wound Care Skills Workshop, annually and as needed to evaluate each nurse?ÇÖs competency with performing wound care. Element V: Responsible person: Director of Nursing or designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review and interviews conducted during a Recertification Survey from 01/02/2025 to 01/10/2025, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 3 (Residents #47, #51, and #99) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide appropriate notification at least two calendar days before Medicare covered services ended as required and did not provide the designated form for notification in the nursing home setting. The findings are: The facility policy titled Advanced Beneficiary Notice of Non-Coverage revised 07/2024, documented that it is the facility policy to provide advance notice to Medicare beneficiaries of expected non coverage of services(denial) under Medicare Part B. Effective (MONTH) 1,2012. CMS form R-131 will be utilized to provide timely advance notification to residents/ designated representatives. 1. Resident #47 was discharged from Medicare Part A services on 11/01/2024 with 1 day remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form ) was signed by Resident #47 and dated 11/01/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS- which was also signed and dated 11/01/2024. 2. Resident #51 was discharged from Medicare Part A services on 06/21/2024 with 1 day remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form ) was signed by Resident #51 and dated 06/21/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS- which was also signed and dated 06/21/2024. 3. Resident #99 was discharged from Medicare Part A services on 07/12/2024 with 4 days remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form ) was signed by the spouse of Resident #99 and dated 07/12/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS- which was also signed by the spouse of Resident #99 and dated 07/12/2024. Additional information on the Notice of Medicare Non-coverage Form (CMS Form ) documented that notification was provided to Resident #99's spouse but did not document when the notification was made. On 01/08/25 at 03:21 PM, an interview was conducted with the Director of Social Services who stated that they had been providing notices for the past year and the Rehabilitation department provides a schedule of who is coming off therapy and their last day of services. The Director of Social Services also stated that notices are reviewed with resident who will sign it, and if the resident is not able to sign it then it is mailed to the family with a request that they return signed copies. The Director of Social Services further stated that notices are given as soon they receive the information from the Rehabilitation department. The Director of Social Services stated that they were not sure of and could not remember the timeframe in which the notices should be given, whether the notices needed to be given three days or 1 week in advance and could not explain why the notices were not given within this timeframe if they thought this to be the correct timeframe. The Director of Social Services also stated that for Resident #99 the spouse was notified on 07/11/2024 and came in to sign the form on 07/12/2024. The Director of Social Services also stated that the Finance department provided them with the form, and they were not aware that an incorrect form was being used. On 01/08/25 at 04:40 PM, an interview was conducted with the Administrator who stated that they did not have much involvement with the Beneficiary notice process, The Administrator also stated that the process of providing notification involves several departments so the facility tries to give themselves extra time so they thought that their policy references that notices should be provided three days before discharge from skilled services and not two as required. The Administrator further stated they were not aware that notices were not being provided in a timely manner and the incorrect form was being used. 10 NYCRR 415.3(g)(2)(i) | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. Residents #47, #51, and #99 along with their designated representatives were provided notification using the appropriate form for the nursing home setting. 2. The date of the notifications was documented as required. 3. The Administrator and Director of Social Services were educated on d. Key points in F582 e. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form (CMS- ) f. Ensuring that the current CMS Form is provided to residents and their designated representatives. g. Maintaining current knowledge on CMS changes for Advanced Beneficiary Notices. 4. Attendance sheets and lesson plans will be filed for reference and validation. Element II. 1. The QAPI Committee developed a list of residents who received notification at the termination of Medicare Part A Benefits since the effective date of the new CMS Form. 2. All residents and/or their designated representatives were provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form (CMS- ) 3. The Director of Social Services/designee was tasked to ensure that residents already discharged from the facility receive the appropriate notice. 4. Results are documented for reference and validation. Element III 1. The QAPI Committee reviewed the policy titled ?Ç£Advanced Beneficiary Notice of Non-Coverage?Ç¥ and corrected the deviations from current standards of professional practice and federal regulations. 2. All Social Services staff, Finance Department, Director of Nursing, and MDS Coordinator staff were educated on: a. the deficient practice identified by the DOH. b. the facility?ÇÖs updated policy and procedure. c. the newly revised CMS forms (CMS- ) d. timely notification using the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form (CMS- ) e. key elements in F582. f. Facility?ÇÖs responsibility to ensure that the correct regulatory forms are disseminated to residents and their designated representatives. h. Maintaining current knowledge on CMS changes for Advanced Beneficiary Notices. 3. The lesson plan and attendance sheets are filed for reference and validation. Element IV 1. The QAPI Committee developed an audit tool which will be utilized to audit all residents/designated representative notifications at the termination of Medicare Part A benefits to ensure that the appropriate form is used. 2. The Director of Social Services/designee will perform audit weekly for four weeks, monthly for four months and then quarterly thereafter to sustain 100% compliance with F582. 3. Audits with negative findings will have immediate corrective actions. 4. The Director of Social Services/designee will summarize the audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our delivery of care services, and compliance with F582. Element V- Responsible Person: Director of Social Services or designee |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observations and interviews during the Recertification survey from 01/02/2025 to 01/10/25, the facility did not ensure that total number of nursing staff and actual nursing staffing hours are posted in a prominent place readily accessible to the residents and visitors. The findings are: The facility's policy titled Staffing Policy dated 03/02/2020 last reviewed 07/2024 stated that the facility will post daily for each shift number of personnel responsible for providing direct care for residents. The policy also stated that within two hours of the beginning of the shift, the number of licenses Nurses such as Licensed Practical Nurses, Registered Nurses and Certified Nursing Assistants directly responsible for resident care will be posted in a prominent location accessible to residents and visitors and a clear readable format. During the Recertification survey from 01/02/25 to 01/08/2025, staffing postings for nursing staff documenting projected hours for day, evening and night shifts were observed on a bulletin board on the left side of the hallway which was not accessible to all residents and visitors. The Staffing postings dated 09/01/2024 to 01/08/2025 documented projected hours for the day, evening and night shift for each day. On 01/08/25 at 11:05 AM, the Staffing Coordinator was interviewed and stated that in order to develop the staffing postings, they look at how many licensed and unlicensed nursing staff are needed per shift as per the Staffing Par level. The Staffing Coordinator also stated that staffing is posted every day at 7 AM for all three shifts. The Staffing Coordinator further stated they have been posting the staffing for all shifts every day at 7 AM for twenty years. On 01/08/25 at 11:27 AM, the Director of Nursing Services was interviewed and stated that the facility policy is to post staffing for all three shifts every morning on the bulletin board, which is located next to the time clock on the first floor. The Director of Nursing that they were not aware that the posting needed to reflect actual staffing and be visible to residents and visitors. On 01/08/25 at 03:24 PM, the Administrator was interviewed and stated that they were not aware that actual nursing staffing hours and actual number of nursing staff needed to be posted before every shift. The Administrator also stated that most of the time the projected staffing posted is accurate, and their policy is to post at the beginning of the day. 10 NYCRR 415.13 | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. Upon notification that the required posting was not in a prominent place readily accessible to our residents and visitors and that the actual staffing was not present the a. Administrator removed the posting on the bulletin board on the left side of the hallway. b. Director of Nursing and Administrator collaborated to revise the posted document to capture the actual staffing. 2. The revised document was subsequently posted in a prominent, readily accessible location on the 1st floor. 3. The Director of Nursing, Staffing Coordinator, and Administrator were re-educated on: a. The data requirements for posting at F732. i. Facility name. ii. The current date. iii. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: RNs, LPNs, and CNAs. iv. Resident census 4. Attendance sheets and lesson plans are filed for reference and validation. Element II 1. The facility acknowledges that all residents have the potential to be affect by the deficient practice. 2. The QAPI Committee reviewed the postings in the last 30 days and identified the consistent gap in practice. Element III 1. The QAPI committee reviewed the policy and procedure titled, ?Ç£Staffing Policy?Ç¥ and revised it to meet the requirements at F732. 2. The Administrator, Director of Nursing, and Staffing Coordinator educated on d. the facility?ÇÖs revised ?Ç£Staffing?Ç¥ policy. e. the key elements in F732 a. their responsibility and accountability to ensure accurate information and posting location for Nurse Staffing each day. 3. Attendance records and lesson plans are filed or reference and validation. Element IV 1. The QAPI Committee developed an audit tool with measurable goals to visually check the required posting for accuracy and location. 2. The Director of Nursing/designee will utilize the audit tool to check Nurse Staffing Postings for facility name, current date, total number and the actual hours worked by RNs, LPNs, and CNAs responsible for resident care per shift, resident census and posted location. 3. Audits will be conducted weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the updated ?ÇÿStaffing?ÇÖ policy and procedure and F732. 4. Audits with negative findings will have immediate corrective actions including correction of the information on the posting and location and re-education. 5. The Director of Nursing will summarize their audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our delivery of care services, and compliance with F732. Element V: Responsible person: Director of Nursing or designee |
Scope: N/A
Severity: N/A
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that the Department of Health Criminal History Record Check Form 102: Acknowledgement and Consent form for Fingerprinting and Disclosure of Criminal History Record Information was accurate before submitting a request for Criminal History Record Check. This was evident for 5 (Employee #1, #2, #3, #4, and #6) employees reviewed for compliance with Criminal History Record Check. Specifically, an outdated Department of Health Criminal History Record Check Form 102 dated 01/07 was used instead of the updated form dated 02/21. The findings are: The facility policy and procedure titled Criminal Background Check last reviewed 08/2024 stated that the prospective employee must complete and sign the DOH 102 form prior to being fingerprinted. 1. Employee #1 was hired as a Home Health Aide on 09/12/24. The Department of Health Criminal History Record Check Form 102 dated 01/07 was used instead of the updated form dated 02/21. 2. Employee #2 was hired as a Home Health Aide on 12/18/24. The Department of Health Criminal History Record Check Form 102 dated 01/07 was used instead of the updated form dated 02/21. 3. Employee #3 was hired as a Home Health Aide on 11/12/24. The Department of Health Criminal History Record Check Form 102 dated 01/07 was used instead of the updated form dated 02/21. 4. Employee #4 was hired as a Home Health Aide on 10/14/24. The Department of Health Criminal History Record Check Form 102 dated 01/07 was used instead of the updated form dated 02/21. 5. Employee #6 was hired as a Certified Nurse Assistant and received a Pending Denial Letter dated 12/23/2024. The Department of Health Criminal History Record Check Form 102 dated 01/07 was used instead of the updated form dated 02/21. On 01/08/25 at 04:20 PM, an interview was conducted with the Director of Human Resources who stated that they had a large number of consent forms that they downloaded and copied some time ago. The Director of Human Resources also stated that it has been a while since they went online to obtain a form, and they were not aware that the form had been updated. On 01/08/25 at 04:18 PM, an interview was conducted with the Chief Financial Officer who provides supervision to the Human Resources Director. The Chief Financial Officer stated that the Criminal History Record Check consent forms are obtained online, and they were not aware the forms were outdated. On 01/08/2025 at 04:40 PM, an interview was conducted with the Administrator who stated that they have minimal involvement in the background check process and usually gets involved when there are negative letters. The Administrator also stated that they were not aware of the 2021 Dear Administrator Letter and that the DOH Form 102 had been updated. | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. Upon notification of the deficient practice from the NYSDOH surveyor, the Director of Human Resources identified and obtained copies of the DOH Form 102 dated 02/21. 2. Employees still employed with the facility were asked to complete the updated form. a. Updated forms are filed in the employee?ÇÖs personal file for reference and validation. 3. The Director of Human Resources, Chief Financial Officer, and Administrator were educated on: a. the deficient practice identified by the DOH. b. The new DOH Form 102 dated 02/21, and c. Their accountability and responsibility to maintain current and accurate DOH forms for CHRC submission. Element II. 1. The facility acknowledges that all residents have the propensity to be affected by the deficient practice. 2. Updated forms may have new information required by the DOH which could have been missed. 3. The Director of Human Resources populated a list of employees hired in the last 60 days. 4. The list was used to audit each employee?ÇÖs personal file to ascertain whether or not the DOH Form 102 dated 01/07 was used for CHR submission. a. No additional deficiencies were identified. b. Results are documented in the form of a QAPI project. Element III 1. The QAPI Committee reviewed the ?Ç£Criminal Background Check?ÇÖ policy and procedure and updated it to include the verbiage ?Ç£prospective employee must complete and sign the ?Çÿcurrent?ÇÖ DOH 102 forms prior to being fingerprinted.?Ç¥ 2. The Director of Human Resources was educated on: a. the revised ?Ç£Criminal Background Check?ÇÖ policy and procedure. b. key elements in NYCRR Article 10, 402.5. 3. The lesson plan and attendance sheet are filed for reference and validation. Element IV 1. The QAPI Committee developed an audit tool which will be utilized to audit new employee personnel files to ensure that DOH Form 102 dated 02/21 is used for the CHRC process and to ensure compliance with F577. 2. The Director of Human Resources/designee will utilize the audit tool to review new employee files weekly for four weeks, monthly for four months and quarterly thereafter to sustain 100% compliance with NYCRR Article 10, 402.5. 3. Audits with negative findings will have immediate corrective actions which will include replacing them with the correct DOH 102 Form. 4. The Director of Human Resources/designee will summarize the audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our CHRC process, delivery of care services, and compliance with NYCRR Article 10, 402.5. Element V Responsible Person: Director of Human Resources or designee. |
Scope: N/A
Severity: N/A
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that the Department of Health Criminal History Record Check policy and procedure contained the required elements. The findings are: The facility policy titled Criminal Background Check with a revised date of 08/2024 did not include information regarding not charging employees for fingerprinting, timeliness of initial submissions, reporting of terminations, and how long documents would be retained. On 01/08/25 at 04:18 PM, the Director of Human Resources was interviewed and after review of the policy acknowledged that the policy did not contain information regarding not charging employees for fingerprinting, timeliness of initial submissions, reporting of terminations, and how long documents would be retained. The Human Resources Director stated that they were not involved in the creation of the policy and that this was done by Administration. On 01/08/2025 at 04:30 PM, the Chief Financial Officer and was interviewed and stated the creation of the Criminal Background Check Policy was in collaboration with the Administration and stated that although timeliness of submission and prohibition of charging employees was not included in the policy, the facility was following those elements. The Chief Financial Officer also stated that they were not aware that these elements needed to be included in the policy. On 01/08/2025 at 04:40 PM, the Administrator was interviewed and stated that they review the Criminal Record Check policy annually. The Administrator reviewed the policy and acknowledged that it did not contain information on not charging employees for fingerprinting, timeliness of initial submissions, reporting of terminations, and retention of documents. The Administrator also stated that they were not aware that the missing elements discussed needed to be included in the policy. | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. Upon notification of the deficient practice from the NYSDOH surveyor, the Administrator revised the ?Ç£Criminal Background Check?ÇÖ policy and procedure to include information regarding not charging employees for fingerprinting, timeliness of initial submissions, reporting of terminations, and how long documents would be retained. 2. The Administrator reviewed the guidance at NYCRR Article 10, 402.9 Responsibilities of Providers; Required Notifications and provided education for the Director of Human Resources and Chief Financial Officer. Element II. 5. The facility acknowledges that all residents have the propensity to be affected by the deficient practice. 6. The Director of Human Resources populated a list of employees hired in the last 60 days. 7. The list was used to. a. No additional deficiencies were identified. b. Results are documented in the form of a QAPI project. Element III 1. The QAPI Committee reviewed the revised ?Ç£Criminal Background Check?ÇÖ policy and procedure and identified no additional deviations from current standards of professional practice or NYCRR Article 10, 402.9 2. The Director of Human Resources and Chief Financial Officer were educated on: a. the revised ?Ç£Criminal Background Check?ÇÖ policy and procedure. b. key elements in NYCRR Article 10, 402.9 3. The lesson plan and attendance sheet are filed for reference and validation. Element IV 5. The QAPI Committee developed an audit tool which will be utilized to review any changes in regulatory CHRC guidance and the facility?ÇÖs Criminal Background Check policies for accuracy and alignment with regulatory guidance. 6. The Administrator/designee will utilize the audit tool to review policies monthly for four months and quarterly thereafter to sustain 100% compliance with NYCRR Article 10, 402.9. 7. Audits with negative findings will have immediate corrective actions which will include updating polies to align with changes in regulatory guidance. 8. The Administrator will summarize the audit findings and report any new regulatory guidance and updated policies to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our CHRC policies and process, and compliance with NYCRR Article 10, 402.9. Element V Responsible Person: Administrator or /designee |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that survey result reports for the 3 preceding years were readily available to residents and visitors upon request. Specifically, upon review of the survey binder, only survey results for the year 2023 were included in the survey binder. In addition, notice of the availability of the survey results reports was not posted in areas of the facility that are prominent and accessible to the public. The findings are: On 01/06/2025 at 10:05 AM, during the Resident Council meeting nine of nine residents verbalized that they did not know where the Department of Survey results were posted in the facility. Six of nine residents had a Brief Interview for Mental Status (BIMS) score as follows: The BIMS test presents a scoring scale that guides the interpretation: 0 to 7 points indicates severe cognitive impairment, 8 to 12 points indicates moderate cognitive impairment, 13 to 15 points indicates cognitive intactness. Resident 44 with BIMS score of 15/15 Resident 117 with BIMS score of 15/15 Resident 36 with BIMS score of 13/15 Resident 61 with BIMS score of 12/15 Resident 45 with BMS score of 12/15 Resident 32 with BMS score of 14/15 On 01/08/2025 at 09:20 AM, the survey binder was observed by the reception area and contained Recertification survey results for 09/18/2023 only. During multiple observations during the survey, notice of the availability of the survey results was not observed on Units 2, 3 and 4. On 01/08/25 at 10:41 AM, the Director of Activities was interviewed and stated that residents are reminded about the availability of survey results and are told where to find the survey binder by the security desk during Resident Council meetings every month. The Director of Activities also stated that they did not currently have postings about the availability of survey results on all of the units. On 01/08/25 at 03:15 PM, the Administrator was interviewed and stated that historically the survey binder has been maintained by the Security desk and there is a sign posted there. The Administrator also stated that they were not aware that notice of the availability of the survey results were supposed to be posted in prominent areas throughout the building. The facility Administrator further stated that they were not aware that the three preceding years surveys and complaint investigation results should be made available to the residents and public. 10 NYCRR 415.3(d)(1)(v) | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. Upon notification of the deficient practice from the NYSDOH surveyor, the Administrator immediately corrected the identified gap in practice. a. The survey binder with only the year 2023 was updated to include reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect respect to the facility. b. The notice of the availability of the survey results reports was posted at the Front Reception Desk and on all resident care units. 2. The six (6) residents (Residents #44, # 117, 36, 61, #45, and #32) were informed about the facility?ÇÖs: a. Reports with respect to surveys b. Recertifications c. Complaint investigations made during the 3 preceding years. d. Current P(NAME)s in effect e. Locations for the above postings. 3. The Administrator developed a binder which included: a. Facility complaint investigations made in the last 3 years. b. Current plans of correction c. Reports on surveys and certifications over the last 3 years. 4. A binder was placed on each resident care unit. 5. The binder previously located in the lobby was updated to include the missing items. 6. The Administrator and Director of Activities were re-educated on. a. Key points in F 577 b. Ensuring that the reports required for posting in F577 are completed. c. Performing random checks to ensure that the required information for posting is consistently maintained and current. 7. Signs were conspicuously posted in the lobby and on all resident care units regarding the location of the binder, binder color, and its contents. Element II. 1. A Resident Council Meeting was held on (MONTH) 14, 2025. 2. During this meeting, the residents who attended were informed about the facility?ÇÖs most recent survey and the location of the binders developed by the Administrator. 3. Resident Council Minutes and attendance sheets are filed for reference and validation. 4. A list of residents with a BIMS of >12 was populated from the facility?ÇÖs EMR. 5. The Director of Recreation/designee was tasked to ensure that the residents who did not attend the Resident Council Meeting who had a BIMS of >12 were informed about the facility?ÇÖs most recent survey and the location of the binders developed by the Administrator for their inspection/refusal as needed. a. Results are documented for reference and validation. Element III 1. The QAPI Committee developed a policy and procedure to address the facility?ÇÖs accountability and responsibility in F577. 2. All administrative staff were educated on: a. the deficient practice identified by the DOH. b. the new policy and procedure. c. key elements in F577. 3. The lesson plan and attendance sheets are filed for reference and validation. 4. Future resident council meetings will be utilized to remind residents of the location and contents of the binder. Element IV 1. The QAPI Committee developed an audit tool which will be utilized to visually review each binder, postings, and their location to ensure compliance with F577. 2. The Administrator/designee will utilize the audit tool to check postings, binders, and their location monthly for four months and quarterly thereafter to sustain 100% compliance with F577. 3. Audits with negative findings will have immediate corrective actions which will include replacing any missing documents or postings. 4. The Administrator/designee will summarize the audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our delivery of care services, resident outcomes, and compliance with F577. Element V 1. Responsible Person: Administrator or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of ceiling tiles and resident equipment and found to be unsanitary and in disrepair. This was evident for 1 of 3 resident units (Unit 3). The findings are: The facility policy titled Homelike Environment dated 10/02/24 state that residents are provided with a safe clean and comfortable and homelike environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. ceiling tiles along the unit corridors were noted in disrepair, not firmly affixed to the ceiling, cracked and stained. 2. Corridor borders were noted to not be firmly attached and layered with dirt and dust. 3. room [ROOM NUMBER] B had brownish water-stained ceiling tiles. 4. room [ROOM NUMBER] B had a broken wall bumper behind the head of the bed, the wall tile behind the room sink was layered with dirt and stains, and the sink was chipped. 5. room [ROOM NUMBER] A had a high back wheelchair which was heavily stained with dried encrusted food particles. 6. room [ROOM NUMBER] had a wheelchair with a dusty seat cushion and torn left arm rest. 7. room [ROOM NUMBER] had a high back wheel chair which was layered and encrusted with dirt and dried food particles. 8. In the Dining Room there was a dusty worn piano, stains on the walls, and bent, dusty window blinds. On 01/10/25 at 09:08 AM, Housekeeper #2 was interviewed and stated that they start their shift by first cleaning the dining room area before breakfast. Cleaning includes but not limited to dining room tables, chairs, floors and walls if needed. Housekeeper #2 also stated that rooms are also cleaned and disinfected, and they wipe down the walls if they are dirty. Housekeeper #2 further stated that heavy duty cleaning of rooms is also done which consists of cleaning the walls, bed frame, mattress, floors, from top to bottom. On 01/10/25 at 10:08 AM, the Director of Environmental Services was interviewed and stated that their role is to ensure the safety and wellness of all residents, staff and visitors by maintaining a clean and safe and homelike environment. The Director of Environmental Services also stated that they oversee the performance of their staff and make spot checks to ensure the work is carried out, and when they come across an issue they address the issue at that moment with the staff. The Director of Environmental Services further stated that the wheelchairs are challenging to get washed, however they notify the Director of Nursing of the wheelchairs that are to be power washed, and the night shift nurse will remove the wheelchair and place it outside the room door. Sometimes residents will refuse to have their wheelchairs removed from their room. The Director of Environmental Services stated that they do have an issue with the roof which does leak when it rains, which is way the ceiling tiles are stained, and they do try to replace them. On 01/10/25 at 11:06 AM, the Administrator was interviewed and stated that the cleanliness of the environment is important for the prevention of infection control issues and for the overall well-being of the resident and staff morale. The Administrator also stated that they expect to receive a large grant that is going to enable them to replace all the room furniture, the windows, the roof which leaks when it rains, the air conditioners, ceiling tiles and more. The Administrator further stated that they ordered furniture, but the wrong items were sent and they are in the process of correcting this with the company. 10 NYCRR 415.5(h)(2) | Plan of Correction: ApprovedFebruary 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element I 1. The areas on Unit 3 identified as not being maintained in a clean, orderly, functional and sanitary (homelike) environment were repaired and corrected. a. ceiling tiles along the corridors were firmly affixed, those cracked and stained were replaced. b. corridor borders were firmly reattached; dust and dirt removed. c. Rooms 319 B- brownish water-stained ceiling tiles were removed and replaced. d. room [ROOM NUMBER] B, the broken wall bumper behind the head of the bed was replaced, the wall tile behind the room sink was cleaned, and the chip on the sink was repaired. e. The wheelchairs in Rooms 309 A, 317, and 308 were washed and sanitized. i. Cushions and the arm rest was replaced for the wheelchair in room [ROOM NUMBER]. f. Dining Room-the dusty worn piano, stains on the walls, and dusty window blinds were cleaned. i. The bent window blinds were replaced. 2. Housekeeper #2 was discipline and re-educated on his responsibility and accountability to maintain a clean environment and report areas that he is unable to complete to the Director of Environmental Services. 3. The Director of Environmental Services was re-educated on his responsibility and accountability to perform random inspections of the units to ensure cleanliness and sanitation to maintain a homelike environment. 4. The nursing staff on unit 3 were re-educated on the facility?ÇÖs protocol to report wheelchairs in disrepair and observed areas in need of cleaning/sanitization. 5. Attendance sheets and lesson plans are filed for reference and validation. Element II 1. The Director of Environmental Services reviewed the Maintenance Books/Logs on each resident care unit. a. No additional deficiencies identified. 2. The Director of Environmental Services/designee checked all other resident rooms and resident care areas (hallways, dining rooms, bathrooms etc.) to identify areas not being maintained in a clean, orderly, functional and sanitary (homelike) environment. a. No additional deficiencies were identified. 3. The QAPI Committee populated a list of residents with wheelchairs. a. The list was used to inspect wheelchairs for disrepair and cleanliness. b. No additional deficiencies were identified. Element III 1. The QAPI committee reviewed the policy and procedure titled, ?Ç£Homelike Environment?Ç¥ and identified no deviations from current standards of practice and F584. 2. All Housekeeping, Maintenance, and Nursing Staff were educated on a. the facility?ÇÖs policy titled ?Ç£Homelike Environment?Ç¥. b. key elements in F584 c. responsibility and accountability to report observed unsanitary areas and disrepair equipment. 3. Attendance records and lesson plans are filed or reference and validation. Element IV 1. The QAPI Committee developed audit tools with measurable goals to: a. #1-Visually inspect resident room for cleanliness, orderly, functionality, and a sanitary (homelike) environment, and b. #2-Visually inspect wheelchairs for impairment and cleanliness 2. The Director of Environmental Services/designee will utilize Audit Tool #1to randomly check resident rooms and resident care areas for cleanliness, order, functionality, and a sanitary (homelike) environment. 3. The Director of Rehabilitation Services/designee will utilize Audit Tool #2 to check residents?ÇÖ wheelchairs for uncleanliness and disrepair. 4. Audits will be conducted weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the ?ÇÿHomelike Environment?ÇÖ policy and procedure and F584. 5. Audits with negative findings will have immediate corrective actions including correction of the deficiency, re-education and progressive discipline. 6. The Director of Environmental Services and Director of Rehabilitation Services will summarize their audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our delivery of care services, homelike environment, and compliance with F584. 7. The Lesson Plan for this Plan of Correction and the policy titled ?ÇÿHomelike Environment?Ç¥ will be included in the facility?ÇÖs Orientation Program for newly hired employees. Element V: Responsible person: Director of Environmental Services or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025 the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the staff bathroom and nursing station on 1 (Unit 3) of 3 Units. The finding is: The facility policy titled Homelike Environment dated 10/02/24 stated that residents are provided with a safe, sanitary and orderly environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. The Staff bathroom adjacent to the Tub Room had a loose and wobbly toilet seat. 2. in the Nurse's Station: a. the Plexi glass was covered with dust, dirt and streaks. b. two swivel chairs were layered with dirt and dust. c. the call bell console was layered with dust and dirt d. there was an accumulation of dirt and dust on the floors underneath the desk e. the computer screen monitors and phones were layered with dust. On 01/10/25 at 09:40 AM, Housekeeper #2 was interviewed and stated that only the floors in the Nurse's station are cleaned and not the station itself. Housekeeper #2 also stated that they do not want to move anything and that the nurse is usually sitting at the nurse station, and they believe that they wipe down their own equipment. Housekeeper #2 further stated that they mostly wipe down the outer counter top of the nurse station. On 01/10/25 at 10:08 AM, the Director of Environmental Services stated that they make rounds to ensure that staff are performing their duties. The Director of Environmental Services also stated that housekeeping staff is supposed to clean the nurse's station, and they can speak with the unit nurse about the areas that they could clean. The Director of Environmental Services further stated that the nurses also wipe their station to keep it free from dust. 10 NYCRR 415.29 | Plan of Correction: ApprovedFebruary 3, 2025 Element I 1. The areas on other environmental conditions on Unit 3 identified as not being safe, functional, sanitary, and comfortable for residents, staff and public were repaired and corrected. a. the loose wobbly toilet seat in the staff bathroom adjacent to the Tub Room was repaired. b. The Plexi glass at the Nurses Station was cleaned and sanitized. c. The two swivel chairs at the Nurses Station were removed and replaced. d. The Call (NAME) console at the Nurses Station was cleaned and sanitized. e. The floor and surrounding areas underneath the desk at the Nurses?ÇÖ Station were sanitized, swept, and mopped. f. The computer screen monitors and phones were cleaned and sanitized. 2. Housekeeper #2 was re-educated on his responsibility and accountability to: a. maintain clean environmental conditions that are safe, functional, sanitary and comfortable for residents, staff, and the public. b. Deficient practices identified by the DOH. 3. The Director of Environmental Services was re-educated on his responsibility and accountability to perform random inspections of the units to ensure safe, functional, sanitary and comfortable environment for residents, staff, and the public. 4. The nursing staff on Unit 3 were re-educated to notify the Director of Environmental Services when the Nursing Station needs cleaning and sanitization; and when impaired toilet seats are observed; resident safety and impaired equipment. 5. Attendance sheets and lesson plans are filed for reference and validation. Element II 1. The Director of Environmental Services performed an evaluation of all units to identify other areas that were not maintained in a safe, functional, sanitary, and comfortable manner for residents, staff and public. a. No additional deficiencies were identified. 1. The Director of Environmental Services performed an evaluation of all Tub Rooms to identify other wobbly toilet seats that were not maintained in a safe, functional, sanitary, and comfortable manner for residents, staff and public. a. No additional deficiencies were identified. Element III 1. The QAPI committee reviewed the policy and procedure titled, ?Ç£Homelike Environment?Ç¥ and updated it to include verbiage that addressed having a safe, functional, sanitary, and comfortable environment resident, staff and public and F921. 2. All staff were educated on the: a. deficient practice identified by the DOH. b. facility?ÇÖs updated policy titled ?Ç£Homelike Environment?Ç¥. c. key elements in F921. d. responsibility and accountability to report observed unsafe, impaired, unsanitary, and uncomfortable areas for residents, staff and public. 3. Attendance records and lesson plans are filed or reference and validation. Element IV 1. The QAPI Committee developed an audit tool with measurable goals to monitor the facility for a safe, functional, sanitary, and comfortable environment for residents, staff and public. 2. The Director of Environmental Services/designee will utilize the audit tool to check each Nurses station and Tub Rooms for a safe, functional, and sanitary environment. 3. Audits will be conducted weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the ?ÇÿHomelike Environment?ÇÖ policy and procedure and F921. 12. Audits with negative findings will have immediate corrective actions including correction of the deficiency, re-education and progressive discipline. 13. The Director of Environmental Services will summarize their audit findings and report them to the QAPI Committee quarterly for needed revisions to the action plan, improvement of our delivery of care services, providing a safe, sanitary and comfortable environment for residents, staff, and the public; and compliance with F584. 14. The Lesson Plan for this Plan of Correction and the updated policy titled ?ÇÿHomelike Environment?Ç¥ will be included in the facility?ÇÖs Orientation Program for newly hired employees. Element V: Responsible person: Director of Environmental Services or designee. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 11, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.1.6.1 limits the 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, staff interview and documentation review during the recertification survey, the facility did not ensure that the building housing the existing health care occupancy was of at least Type II (222) Fire Resistive, Noncombustible construction. The nursing home building is a four-story Type II (000) construction. The elevator room and mechanical rooms on the first floor have protected steel beams. However, on floors two through four, the steel beams and ceilings above the drop ceiling remain unprotected. The findings include: In an interview on [DATE] at approximately 10:30 AM, the Administrator stated that the facility had a time limited waiver which expired in (MONTH) of 2024. They further stated that due to the facility's non-profit status, obtaining funding to complete the required repairs took the duration of the waiver period. The facility has replaced the light fixtures throughout with compliant fire-rated fixtures, and has started to replace ceiling tiles in some areas of the building. The facility intends to request a waiver to allow them time to complete the project. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review during an offsite post survey revisit on [DATE], the facility did not ensure that the building construction type was at least Type II(222), fire resistive construction. At the time of the revisit an approved time limited waiver had not been received. The facility was cited for the following during the Life Safty Code survey on [DATE]: 2012 NFPA 101: 19.1.6.1 limits the 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, staff interview and documentation review during the recertification survey, the facility did not ensure that the building housing the existing health care occupancy was of at least Type II (222) Fire Resistive, Noncombustible construction. The nursing home building is a four-story Type II (000) construction. The elevator room and mechanical rooms on the first floor have protected steel beams. However, on floors two through four, the steel beams and ceilings above the drop ceiling remain unprotected. The findings include: In an interview on [DATE] at approximately 10:30 AM, the Administrator stated that the facility had a time limited waiver which expired in (MONTH) of 2024. They further stated that due to the facility's non-profit status, obtaining funding to complete the required repairs took the duration of the waiver period. The facility has replaced the light fixtures throughout with compliant fire-rated fixtures, and has started to replace ceiling tiles in some areas of the building. The facility intends to request a waiver to allow them time to complete the project. 2012 NFPA 101: 19.1.6.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMarch 18, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K161 I Immediate Corrective Action Brooklyn United Methodist Church Home is requesting a three (3) year waiver in order to complete the work already in progress to satisfy the K161 citation. Brooklyn United Methodist Church Home, a not-for-profit nursing facility needed to apply for a loan in order to remedy the K161 deficiency cited in 2022 and simultaneously also applied for a two (2) year time limited waiver, also in order to complete the work necessary to comply with K161. The loan process took more than 18 months for approval which negatively impacted the start of the project and the time limited waiver, which has since expired. Since the approval of the loan, Brooklyn United Methodist Church Home has fireproofed the steel beams in the electrical room, the mechanical room and the boiler room. In addition, Brooklyn United Methodist Church Home has replaced all the light fixtures in the facility with compliant fire rated fixtures. Also, it is important to note that all the grids in the facility are fire rated so as to accommodate the installation of fire rated ceiling tiles. Further, the facility has purchased fire rated ceiling tiles and has installed the fire rated ceiling tiles on two (2) quadrants of the fourth (4th) floor. As such, Brooklyn United Methodist Church Home with a time waiver extension of three (3) years would be able to complete the required fireproofing of the facility with fire rated ceiling tiles as follows: Year 1 ?Çô Complete the Fourth (4th) and Third (3rd) floors by the end of [DATE] Year 2 ?Çô Complete the Second (2nd) floor, and by the end of [DATE] Year 3 ?Çô Complete the First (1st) floor by the end of [DATE] II. Identification of Other Residents Brooklyn United Methodist Church Home acknowledges that the residents have the potential to be affected by this practice. The facility respectfully states that there is no additional risk to the residents as the facility is fully sprinklered throughout and smoke detectors installed that are supervised by an approved outside entity. III. Systemic Changes All staff will receive in-service education regarding the life safety issues related to this requirement. The facility will conduct an extra fire drill on each shift per quarter until the fireproof ceiling tile work is completed. Additional fire extinguishers will be maintained on each unit of the facility. The Administrator will work to secure a three (3) year waiver. IV. QA Monitoring The Administrator will monitor the status of the waiver request, and any progress made in the process of continuing the work to fireproof the facility with fire rated ceiling tiles. The Administrator will provide a written report monthly to the QA committee, and said reports will be reviewed quarterly by the QAPI committee at the quarterly QAPI meetings. In addition, Brooklyn United Methodist Church Home will be submitting at a minimum, quarterly progress report to LTCLSCwaivers@health.ny.gov based on the date approved. Responsible Party: Administrator or designee DATE:[DATE] |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2010 NFPA 9612.1.2.4 All deep-fat fryers shall be installed with at least a 406 mm (16 in.) space between the fryer and surface flames from adjacent cooking equipment. 12.1.2.5 Where a steel or tempered glass baffle plate is installed at a minimum 203 mm (8 in.) in height between the fryer and surface flames of the adjacent appliance, the requirement for a 406 mm (16 in.) space shall not apply. 12.1.2.5.1 If the fryer and the surface flames are at different horizontal planes, the minimum height of 203 mm (8 in.) shall be measured from the higher of the two. Based on observation and staff interview, the facility did not ensure that all cooking equipment was installed in accordance with NFPA 96. This occurred in the kitchen on the first floor. The findings include: During the life safety survey of 1/6/2025, at approximately 11:00 am , it was noted that in the kitchen on the first floor, a deep fryer was located within 16 of a cooking surface. There was no physical barrier between the fryer and the hot surface. At the time of these findings, the Facilities Director stated that a metal baffle would be installed . 2012 NFPA 101 2011 NFPA 96 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedJanuary 24, 2025 I. Immediate Corrective Action The maintenance staff permanently installed an 8?Ç¥ tall steel plate onto the deep-fat fryer separating it from the adjacent cooking equipment. II. Identification of Other Residents Once the 8?Ç¥ tall steel plate was installed onto the deep-fat fryer, the only deep-fat fryer in the facility was permanently separated from the adjacent cooking equipment. The facility respectfully states that no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director will provide in-service education to all maintenance staff and the Director of Food Service related to the requirements of 2010 NFPA 9612.1.2.5, specifically the significance of the separation of deep-fat fryers adjacent to other cooking equipment. Lesson plan and attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor for the proper separation of the deep-fat fryer and the adjacent cooking equipment. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details 2010 NFPA 9910.2.4 Adapters and Extension Cords. 10.2.4.1 Three-prong to two-prong adapters shall not be permitted. 10.2.4.2 Adapters and extension cords meeting the requirements of 10.2.4.2.1 through 10.2.4.2.3 shall be permitted. 10.2.4.2.1 All adapters shall be listed for the purpose. 10.2.4.2.2 Attachment plugs and fittings shall be listed for the purpose. 10.2.4.2.3 The cabling shall comply with 10.2.3. 2011 NFPA 70 10.5.2.3 Adapters and Extension Cords. 10.5.2.3.1 Adapters and extension cords meeting the requirements of 10.2.4 shall be permitted to be used. 10.5.2.3.2 Three-to-two-prong adapters shall not be permitted. 10.5.2.3.3 The wiring shall be tested for all of the following: (1) Physical integrity (2) Polarity (3) Continuity of grounding at the time of assembly and periodically Thereafter 2011 NFPA 70: 400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 2011 NFPA 70: 590.2 All Wiring Installations. (A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (B) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation. 590.3 Time Constraints. (A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes. (C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work. (D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Based on observation, record review and staff interview, the facility did not maintain a policy for the use of extension cords and power strips. Power strips were noted in use on the first and second floors of the building. The findings include: During the life safety survey on 1/6/25, between 9:00 AM and 12:00 PM, a power strips was noted to be in use at the second- floor nurses' station. The UL listing of this power cord could not be determined at the time of the finding. In addition, in the first floor conference room, powers strips were found with two large, wall-mounted monitors/screens plugged into them. The UL listing of these was not visible. During document review on 1/7/25, between 9:00 AM and 111:00 AM, no policy for the use of power strips was available for review. At the exit conference on 1/7/25 at approximately 1:10 am, the Administrator would create a policy for the use of power strips and extension cords, and make sure that all such devices in the facility were compliant. 2012 NFPA 101 2010 NFPA 70 10NYCRR 711.2 (a) | Plan of Correction: ApprovedJanuary 24, 2025 I. Immediate Corrective Action The maintenance department purchased and installed power strips having a visible ULL listing of UL1363A at the second (2nd) floor nurse station and the conference room. The Administrator Developed the policy and procedure for power strips utilized in the facility. II. Identification of other Residents The Environmental Service Director toured the entire facility and no other power strips were identified that did not have a visible or proper ULL listing of UL 1363A. The facility respectfully states that once the maintenance department installed the power strips with a visible and proper ULL listing of UL1363A, no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director reviewed and revised the Electrical Safety policy and procedure. All maintenance staff will receive in-service education and understand the life safety issues and the importance of ensuring compliance with the Electrical Safety Policy and Procedures with an emphasis on power strips and extension cord prohibitions. Lesson plan and attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that any and all power strips utilized in the facility will have a visible ULL listing and that the listing be UL 1363A. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, other than battery systems for emergency luminaires in accordance with 7.9.2.5, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems. 2010 NFPA 110 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months. 8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2). 8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. 8.4.9.3 The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested . 8.4.9.4 A power interruption to non-EPSS loads shall not be required. 8.4.9.5 The minimum load for this test shall be as specified in 8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3. 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPS.A supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 8.4.9.5.3 For spark-ignited EPSs, loading shall be the available EPSS load. 8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test. 8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. Based on staff interview and document review, the facility did not ensure that all required testing and inspection was conducted on the facility's emergency generators. The findings include: During a review of the emergency generator testing and inspection records on 1/7/25, between 12:00 pm and 1:00 pm, a record for the three-year, four-hour load test was not found. At the exit conference on 1/7/25, at approximately 1:35 pm, the Administrator stated that the vendor would be contracted to conduct this test. 2012 NFPA 101 2010 NFPA 110 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedJanuary 24, 2025 I. Immediate Corrective Action The Environmental Service Director obtained a proposal from the vendor, National Standby Repair, Inc. to conduct the 3-year 4-hour load test to be conducted. II. Identification of Other Residents Once the required load test is completed, the facility respectfully states that there is no additional risk to the residents, further there is a co-generation plant in place to provide continuous power to the facility. III. Systemic Changes The maintenance staff will receive additional education related to the life safety issues identified with inspections and testing of the Emergency Generator. Lesson Plan and attendance will be filed for validation. The 3-year, four (4) hour load test for the Emergency Generator will be added to the established Preventative Maintenance and Scheduling program and all inspection results will be recorded in the building records and logs. The Environmental Service Director will develop an audit tool to track compliance with this requirement. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that all inspection results for the Emergency Generator are recorded. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be reported to the Administrator by the Director of Environmental Service/designee with a correction plan if warranted. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party; Director of Environmental Service |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details 2012NFPA101: 19.3.2 Protection from Hazards 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic closing. 19.3.2.1.5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 (9.3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 (4.6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. Based on observation and staff interview, the facility did not ensure that all doors protecting hazard areas were equipped with self-closing or automatic closing doors. This occurred on the first floor of the building. The findings include: During the life safety survey on 1/6/25, between 9:00 AM and 12:00 PM, it was noted that doors to hazardous areas were lacking self-closers. This included the door to a large dining room on the first-floor, which was being used to house a shipment of furniture, and the laundry room in the first-floor exit passageway leading to the loading dock. At the time of these findings, the Director of Environmental Services stated that self-closers would be installed on these doors. 2012 NFPA 101 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedJanuary 24, 2025 I. Immediate Corrective Action The maintenance department installed self-closing hinges to the dining area doors located on the first (1st) floor, compliant with 19.3.2.1.3 N.B. ?Çô The dining room housed a delivery of furniture that has been returned to the company. The maintenance department also installed self-closing hinges to the laundry room door, compliant with 19.3.2.1.3. II. Identification of Other Residents The Environmental Service Director inspected all doors to hazardous areas in the facility and found same to be compliant. Once the dining room doors and the laundry room door had self-closing hinges installed, the facility respectfully states that no other residents were affected by this practice. III. Systemic Changes The Environmental Service Director will provide In-service education to all maintenance staff related to the requirements of Hazardous area protection. Lesson Plan and Attendance will be filed for validation. The Environmental Service Director will develop an audit tool to track compliance. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that all hazardous area doors are compliant with 19.3.5.9. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months, and quarterly thereafter. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible Party: Director of Environmental Service |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 19.2 Means of Egress Requirements. 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. 7.2.2.1 General. 7.2.2.1.1 Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of 7.2.2, unless otherwise specified in 7.2.2.1.2. 7.2.2.5.5.1 Exit Stair Treads. Exit stair treads shall incorporate a marking stripe that is applied as a paint/coating or be a material that is integral with the nosing of each step. The marking stripe shall be installed along the horizontal leading edge of the step and shall extend the full width of the step. The marking stripe shall also meet all of the following requirements: (1) The marking stripe shall be not more than 1?2 in. (13 mm) from the leading edge of each step and shall not overlap the leading edge of the step by more than 1?2 in. (13 mm) down the vertical face of the step. (2) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm) and a maximum width of 2 in. (51 mm). (3) The dimensions and placement of the marking stripe shall be uniform and consistent on each step throughout the exit enclosure. (4) Surface-applied marking stripes using adhesive-backed tapes shall not be used. 7.2.2.5.5.2 Exit Stair Landings. The leading edge of exit stair landings shall be marked with a solid and continuous marking stripe consistent with the dimensional requirements for stair treads and shall be the same length as, and consistent with, the stripes on the steps. 7.2.2.5.5.3 Exit Stair Handrails. All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements: (1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. 7.2.2.5.5.4 Perimeter Demarcation Marking. Stair landings, exit passageways, and other parts of the floor areas within the exit enclosure shall be provided with a solid and continuous perimeter demarcation marking stripe on the floor or on the walls or a combination of both. Based on observation and staff interview, the facility did not ensure that all egress stairs were maintained in accordance with 2012 NFPA 101. This occurred in both of the facility's stairwells. The findings include: During the life safety survey of 1/6/2025, between 9:00 am and 12:00 pm, it was noted that the handrails in the East and West stairs lacked the required contrasting colored marking stripe for the length of the stairwells. At the time of these findings, the Director of Environmental Services stated that the rails would be painted immediately. 2012 NFPA 101 2010 NFPA 80 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedJanuary 24, 2025 I. Immediate Corrective Action The maintenance staff has permanently marked the handrails with the required contrasting yellow colored marking stripe for the length of the handrails in the East and West stairwells. II. Identification of Other Residents The facility acknowledges that the residents have the potential to be affected by this practice. The facility respectfully states that once the handrails on both the East and West stairwells from the first (1st) to the fourth (4th) floors were permanently marked with contrasting yellow marks, no other residents were affected by this practice. III. Systemic Changes The Director of Environmental Services will in- service the maintenance staff related to this requirement, lesson plan and attendance shall be filed for validation. The Director of Environmental Service/designee will inspect the stairs monthly for proper markings. The Director of Environmental Service will develop an audit tool to track compliance. IV. QA Monitoring The Environmental Service Director shall utilize the audit tool to monitor that the exit stair landings are marked with a solid continuous marking stripe. The Environmental Service Director/designee shall conduct the audits monthly for six (6) months. Any negative findings will be corrected immediately by the maintenance department and reported to the Administrator. All audit findings will be reported and reviewed quarterly at the QAPI committee meeting. Responsible party: Director of Environmental Service |