NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 9, 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 Standard survey completed on 4/9/25, the facility did not ensure that each resident who was unable to carry out activities of daily living received services to maintain grooming and personal hygiene for one (1) (Resident #26) of five (5) residents reviewed for activities of daily living. Specifically, Resident #26 was observed on multiple days with dark brown debris under their fingernails on both hands and the resident was observed eating with their hands. The finding is: The policy titled Resident hygiene dated 2/2022, documented the purpose of the facility was to maintain cleanliness and comfort. Residents received sponge baths with morning care and evening care in bed, bathroom, or at resident's bedside. Body parts were cleansed in twice daily sponge baths included face (including shave/removal of facial hair), hands and nails, axilla (arm pit), back, perineal area, and any other areas indicated. The facility provided document titled Certified Nurse Aide Job Description dated 1/2021, documented the Certified Nurse Aide provided nonprofessional services and aid to residents with their activities of daily living (ADL's) under the supervision of a Licensed Practical Nurse or a Registered Nurse. They were responsible for knowing and following resident's plan of care via verbal report, door cards and review of care plans. Assist and/or perform the activities of daily living for assigned residents including, but not limited to, giving baths, personal care, feeding, and perform other related duties as required by their supervisor. The finding is: Resident #26 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 2/4/25 documented Resident #26 was severely cognitively impaired, was understood, understands, and had no behaviors or refusals. The comprehensive care plan dated 10/28/24, documented Resident #26 received showers on Wednesday 7:00 AM to 3:00 PM and Saturday 3:00 PM to 11:00 PM, required a moderate assist of one staff member. The Visual Bedside/Kardex dated 4/8/25 documented Resident #26 required a moderate assist of one staff member for personal hygiene and eating. Review of Treatment Administrator Record dated 3/1/25 to 4/9/25 documented Resident #26 had an active order to receive nail care monthly on bath day or as needed every evening shift every four weeks on Monday. The (MONTH) and (MONTH) 2025 records were blank. Review of nursing progress notes dated 3/1/25 to 4/9/25 revealed no documented refusals of personal hygiene or nail care. Review of 24-Hour Report Log Sheets dated 3/31/25 to 4/6/25 revealed no documented evidence that Resident #26 refused nail care. During an observation on 4/3/25 at 10:37 AM, Resident #26 was sitting up in bed, both hands had dark brown debris under the fingernails. During an observation on 4/4/25 at 8:17 AM, Resident #26 was sitting up in their bed eating a sandwich with their hands, the dark brown debris remained under the fingernails on both hands. During an observation on 4/7/25 at 8:52 AM, Resident #26 was sitting up in their wheelchair, the dark brown debris remained under their fingernails on both hands. During an interview and observation of care on 4/7/25 at 1:34 PM, Certified Nurse Aide #4 transferred Resident #26 into bed and completed incontinent care with assistance from Certified Nurse Aide #5, Licensed Practical Nurse #3 Assistant Unit Manager was also present. After completion of care, Certified Nurse Aide #4 handed Resident #26 their call light and stated they were finished. Certified Nurse Aide #4 did not offer or provide any nail care to Resident # 26. Certified Nurse Aide #4 and Certified Nurse Aide #5 stated Resident #26 had some dark brown debris under their nails and could use some cleaning. They stated they should have offered Resident #26 nail care after they provided incontinent care. They stated Certified Nurse Aides were responsible for providing nail care every day, or any time it was noticed the resident required it. They stated it was important for infection control, because bacteria could get under their nails, especially if they ate with their hands. During an interview on 4/7/25 1:56 PM, Licensed Practical Nurse #3 Assistant Unit Manager stated Certified Nurse Aides were trained to provide nail care in the morning, during showers, or any time it was noticed it was needed. They stated Certified Nurse Aide #4 and #5 should have offered nail care to Resident #26 after completion of incontinent care, or whenever it was noticed. They stated it was important for infection control reasons, especially because bacteria could get into their mouth if the resident ate with their hands. They stated nurses were to monitor and follow through. During an interview on 4/7/25 at 2:30 PM, Licensed Practical Nurse #2 Unit Manager stated Certified Nurse Aides were responsible for performing nail care on residents any time it was noticed the resident required it. They stated nail care should have been offered and provided, if allowed, to Resident # 26. If the resident refused, they would have expected it to be documented in the nursing progress notes or on the 24-hour report sheet. Nurses were to monitor and ensure completion, and assist in providing care if able. During an interview on 4/9/25 at 10:26 AM, the Director of Nursing stated they expected staff to provide nail care to residents anytime it was noticed they required cleaning. Certified Nurse Aide #4 and #5 should have offered and provided nail care to Resident #26; residents should not be eating with dirty nails. They stated nail care was a part of daily hygiene and important for infection control reasons. Nurses were responsible for ensuring the appropriate care was completed During an interview on 4/9/25 at 11:01 AM, the Administrator stated they expected Certified Nurse Aides to offer nail care any time it is noticed the resident required it and document somewhere if the resident refused. They stated it was important to offer and provide nail care to dependent residents for dignity and infection control reasons. During an interview on 4/9/25 at 11:37 AM, Inservice Coordinator and Clinical Director of Education and Training stated Certified Nurse Aides were taught to offer and provide nail care with morning and evening care, during showers, and whenever it was noticed. Certified Nurse Aide #4 and #5 should have offered and provided nail care to Resident #26 when they provided hands on care to them. If was important for infection control purposes and just general patient care. Nurses were to monitor and ensure completion of all required activities of daily living. 10 NYCRR 415. 12 (a)(3) | Plan of Correction: ApprovedMay 1, 2025 Corrective Action for Resident Identified: Upon identification, staff immediately assisted the resident with hand hygiene and nail care. The residents care plan was reviewed and updated to ensure nail care is provided and documented as part of daily grooming tasks. The CNA assigned to the resident received immediate re-education regarding proper hygiene assistance and documentation practices. The facility will conduct an audit of all residents requiring assistance with ADLs, focusing specifically on grooming and nail care. Additionally, the Occupational Therapy department will identify residents who eat with their hands and their need for appropriate assistive devices. Dietitians will also be consulted to assess whether alternative food options are more suitable for the identified residents. The audit will include visual inspections, interviews, and documentation review. Systemic Changes to Prevent Recurrence - The facilitys Resident Hygiene Policy was reviewed and clearly defines staff responsibilities regarding nail care and hygiene for residents requiring ADL assistance. - All direct care staff will receive in-service education covering: Importance of maintaining personal hygiene for residents Proper nail care techniques Infection control concerns related to unclean hands and fingernails Preserving resident dignity during meal times and hand hygiene before and after meals. Monitoring and Quality Assurance - The Director of Nursing (DON) or designee will perform random weekly audits of 5 residents requiring ADL assistance for 8 weeks to ensure nail care and hygiene are being performed and documented. - Resident mealtimes will be observed daily by nurses to ensure residents are assisted with hand hygiene prior to eating. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. If compliance is maintained at 100% for 8 weeks, audits will transition to monthly for 3 additional months. Responsible Person: Director of Nursing or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Compliant investigation (#NY 229) during the Standard survey completed on 4/9/25, the facility did not ensure that all residents comprehensive person-centered care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (1) (Resident #8) of four (4) residents reviewed. Specifically, the resident was not provided with a maximal assist by two staff members for bed mobility as care planned. The finding is: The facility provided document titled Certified Nurse Aide Job Description dated 1/2021 the Certified Nurse Aide was responsible for knowing and following resident's plan of care via verbal report, door cards and review of care plans. Duties and responsibilities consisted of but were not limited to; assisting resident with exercise, ambulation, and range of motion directed by their total plan of care, always following all safety regulations and precautions, and following all laws, rules and regulations of the Federal and New York State (NYS) Health Codes in regard to the department and overall organization operation. Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/2/24 documented Resident #8 was cognitively intact, was understood, and understands. The comprehensive care plan dated 1/9/22 documented Resident #8 required assistance with activities of daily living with an intervention for toileting hygiene with a maximal assist of one staff member, to provide a bedpan upon request and provide peri care (incontinent care) after each incontinent episode. The Visual/Bedside Kardex (a guide used by staff to provide care) with an as of date of 9/12/24 documented Resident #8 required a maximal assist of two staff members for all bed mobility, including rolling in bed. The Facility Investigation form dated 9/12/24 documented during an investigation it was determined that Certified Nurse Aide #2 rolled Resident #8 and placed them on the bedpan by themselves. Resident #8 was care planned to require a maximal assist of two staff members for bed mobility and Certified Nurse Aide #2 completed the residents bed mobility alone. During an interview on 4/3/25 at 10:02 AM, Resident #8 stated Certified Nurse Aide #2 provided care to them alone on 9/12/ 24. They reported it to Registered Nurse # 1. During a telephone interview on 4/8/25 at 8:28 AM, Certified Nurse Aide #2 stated they were assigned to Resident #8 on the overnight shift (11:00 PM to 7:00 AM) of 9/11/24 to 9/12/24 and had completed care independently on Resident #8, including rolling the resident and placing them on the bed pan. Certified Nurse Aide #2 stated they were familiar with Resident #8 so they did not review their care plan prior to providing care that shift, they believed the resident was a one assist for bed mobility but could not remember. Additionally, they stated they didn't always review residents care plans prior to providing care unless it was reported there was a change in the resident, but they probably should have. During a telephone interview on 4/8/25 at 10:58 AM, Registered Nurse #1 stated it was reported to them that Certified Nurse Aide #2 rolled Resident #8 and placed them on the bed pan by themselves and the Resident had a complaint regarding the care. They stated they spoke with and performed an assessment on Resident #8 following the incident and there were no injuries sustained. It was reported and an investigation was started. During an interview on 4/8/25 at 12:59 PM, Licensed Practical Nurse #2 stated they would have expected Certified Nurse Aide #2 to review Resident #8's care plan prior to providing care to them and followed their plan of care according to what it stated. They stated Resident #8 was a two assist for bed mobility and Certified Nurse Aide #2 should have followed their plan of care and asked another staff member for assistance. It was important to follow residents plan of care to ensure their safety. During an interview on 4/9/25 at 9:15 AM, Licensed Practical Nurse #3 reviewed the investigation from 9/12/24 and stated Resident #8 was a two assist for bed mobility, rolling in bed, and Certified Nurse Aide #2 provided care by themselves on 9/12/24, which was a break in the resident's care plan. They stated they would have expected Certified Nurse Aide #2 to review Resident #8's care plan prior to providing care to them. They stated the care plan was a guide to help staff know how to take care of the residents and nursing staff caring for the resident were responsible for reviewing the care plan prior to providing any care. Licensed Practical Nurse #3 stated it was important for staff to review care plans prior to providing care to residents to ensure their safety. During an interview on 4/9/25 at 10:35 AM, the Director of Nursing stated they expected all staff to review care plans prior to providing care to residents and follow the care plans accordingly. Residents plans of care change all the time and it was important to review care plans frequently to ensure residents safety. They stated Certified Nurse Aide #2 should have reviewed Resident #8's care plan prior to providing care, they should not have provided care to Resident #8 by themselves, it was a break in care plan. During an interview on 4/9/25 at 11:06, the Administrator stated they would have expected Certified Nurse Aide #2 to have reviewed Resident #8's care plan, realized they required an assist of two staff members, and asked another staff member for assistance. They stated the staff member providing care was responsible for ensuring the residents plan of care was reviewed and followed, and nursing leadership should be monitoring and enforcing. The Administrator stated it was important for staff to review care plans prior to providing care because care plans can change often, to ensure residents safety. During an interview on 4/9/25 at 11:46 AM, the Inservice Coordinator, with the Clinical Director of Education and Training present, stated staff were trained to review the residents care plan prior to providing any care. 10 NYCRR 415. 11 (c)(1) | Plan of Correction: ApprovedMay 1, 2025 Corrective Action Taken for the Resident Identified The resident was assessed immediately by nursing staff, and no injury was sustained. The incident was self-reported to the Department of Health on. The CNA involved in this incident is no longer employed at this facility. The residents care plan was reviewed with no changes at this time. Identification of Other Residents Who Could Be Affected A facility-wide review will be conducted for all residents requiring 2-person assist for bed mobility, transfers, or ADLs. The review will include audits of care plans and direct observation of CNA compliance. Systemic Changes Made to Prevent Recurrence Mandatory in-service training will be completed on for all CNAs and nursing staff covering - Reading and interpreting care plans - The importance of following assistance level requirements - Reporting discrepancies or uncertainties immediately Monitoring and Quality Assurance - The Unit Managers or designee will conduct weekly audits of 5 resident care plans per unit and corresponding staff performance for 8 weeks to ensure care is delivered per plan. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. - If 100% compliance is observed for 8 weeks, audits will reduce to monthly for 3 additional months. Person Responsible: Director of Nursing or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 9, 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 a Standard survey completed on 4/9/2025, the facility did not ensure that residents who receive a [MEDICAL CONDITION] medication have gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for one (1) (Resident #60) of five (5) residents reviewed for [MEDICAL CONDITION] medication use. Specifically, there was no gradual dose reduction attempted for a resident started on an antidepressant medication and there was no documented evidence that a gradual dose reduction was contraindicated. The finding is: The policy and procedure titled Tapering of a Medication Dose/Gradual Dose Reduction-GDR, dated 11/2017 documented the purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. Within the first year after the facility has initiated a [MEDICAL CONDITION] medication, the facility must attempt a gradual dose reduction in two separate quarters, unless clinically contraindicated. Resident #60 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 3/7/25, documented Resident #60 was cognitively intact, understands and was understood. The assessment documented there were no behaviors exhibited and they were receiving an antidepressant medication. The comprehensive care plan initiated 4/11/23 documented Resident #60 had potential for sleep pattern disturbances related to [MEDICAL CONDITION]. Interventions included to administer medications as ordered and monitor sleep pattern. Additionally, the care plan initiated on 4/16/24 documented Resident #60 used antidepressant medication related to [MEDICAL CONDITION]. Intervention documented to administer antidepressant medication as ordered by physician. The Order Summary Report printed 4/9/25 documented Resident #60 had [MEDICATION NAME] (antidepressant) 50 milligrams at bedtime for [MEDICAL CONDITION] ordered/started on 10/31/ 2023. The order was changed on 2/27/25 to [MEDICATION NAME] 50 milligrams every 24 hours, give at 10:00 PM for [MEDICAL CONDITION]. Review of medical provider Progress Notes from 10/30/23 through 4/2/25 contained no documented evidence of a clinical rationale for the gradual dose reduction of Resident #60's Trazadone being clinically contraindicated. Medical provider Progress Note dated 9/6/24, 12/26/24 documented none for [MEDICAL CONDITION] meds. Review of Behavior Modifying Agent and Review Committee (BMARC) form dated 6/26/24, 9/25/24, 11/20/24, 12/23/24, 1/30/25 and 3/27/25 documented Resident #60 was ordered Trazadone 50 milligrams every hour of sleep for [MEDICAL CONDITION]. No gradual dose reduction was marked with a x on all the forms without a rational documented. All the Behavior Modifying Agent and Review Committee (BMARC) forms were signed by a medical provider. During observations on 4/7/25 at 3:19 PM, 4/9/25 at 10:25 AM, Resident #60 was in their room asleep in bed. During an interview on 4/8/25 at 1:35 PM, the Director of Nursing stated they have a monthly Behavior Modifying Agent and Review Committee meetings with the interdisciplinary team. The interdisciplinary team discusses medications listed, the last gradual dose reduction and the date it was documented. Upon review of Resident #60's Behavior Modifying Agent and Review Committee forms, the Director of Nursing stated Resident #60 has not had a gradual dose reduction of their Trazadone and the rational was not documented the form and it should have been. Additionally, they stated an attempt to reduce [MEDICAL CONDITION] medication is important to maintain the lowest, safest dose possible, or get rid of all together as they can have side effects and contribute to the falls of residents. During an interview on 4/9/25 at 9:53 AM, the Pharmacy Consultant stated the reason for not completing a gradual dose reduction on Resident #60's Trazadone was addressed in conversation during the Behavior Modifying Agent and Review Committee meeting and should have been documented. During an interview on 4/9/25 at 10:16 AM, the Director of Social Services stated [MEDICAL CONDITION] medications were reviewed at the Behavior Modifying Agent and Review Committee meeting and the form should have been completed to indicate why there was no gradual dose reduction attempted. They stated it was important to review [MEDICAL CONDITION] medications to ensure residents were receiving appropriate medications and that it was part of a resident's plan of care. During an interview on 4/9/25 at 11:13 AM, Licensed Practical Nurse Unit Manager #2 stated residents receiving [MEDICAL CONDITION] medications should be reviewed by the Behavior Modifying Agent and Review Committee quarterly and as needed. Licensed Practical Nurse Unit Manager #2 stated there was no gradual dose reduction marked on the form when it was contraindicated for that resident who was stable on the medication. Additionally, they stated it should have been indicated on the form the reason why a no gradual dose reduction was recommended. During a follow up interview on 4/9/25 at 11:23 AM, the Director of Nursing stated there was no documented evidence from a medical provider to justify why a gradual dose reduction was not completed on Resident #60's Trazadone. During an interview on 4/9/25 at 1:07 PM, the Administrator stated they expected [MEDICAL CONDITION] medications be reviewed at the Behavior Modifying Agent and Review Committee meetings and that gradual dose reductions be attempted. They stated they expected a rational to be documented to prove they discussed why or why not a gradual dose reduction was recommended. During a telephone interview on 4/9/25 at 1:10 PM, the Medical Director stated the medical provider attending the Behavior Modifying Agent and Review Committee meetings should have been documenting a reason why a gradual dose reduction wasn't being done. 10 NYCRR 415. 12(I)(2)(ii) | Plan of Correction: ApprovedMay 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for the Resident Identified The resident was reviewed by BMARC with no changes recommended, and the provider to complete a clinical visit to document the medical justification for continued use without GDR. That documentation has since been completed and placed in the medical record. Identification of Other Residents Who Could Be Affected The pharmacy consultant was assigned to conduct a comprehensive house-wide review of all residents currently prescribed [MEDICAL CONDITION] medications, to ensure: - Proper GDR evaluations were conducted; - Provider documentation is present if GDR was deemed clinically contraindicated; - Compliance with regulatory guidelines. Any residents found lacking appropriate documentation will be brought to the provider's attention for timely evaluation and documentation. Systemic Changes to Prevent Recurrence - The facility's Tapering of a Medication/Gradual Dose Reduction (GDR) Policy to be reviewed and updated as needed. - The BMARC review form was updated to include mandatory language and prompts for providers to document: - Clinical justification when GDR is deemed not appropriate, - Specific contraindications or resident-specific factors supporting continued use. - All providers, clinical staff, and Social Workers involved in [MEDICAL CONDITION] medication management received re- education on the GDR policy and documentation requirements. Monitoring and Quality Assurance -The pharmacy consultant will conduct monthly audits for 3 months of all [MEDICAL CONDITION] medications prescribed within the facility to ensure: - GDRs are attempted as appropriate; - Provider documentation is present for all GDR exceptions; - BMARC documentation aligns with medical records. Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. Responsible Person: Director of Nursing or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. record review, conducted during the Standard survey completed on 4/9/25, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive centered care plan for one (1) (Resident #52) of one (1) resident reviewed. Specifically, a wound treatment was initiated without a physicians order, and lack there was a delay in assessment of the wound. The finding is: The policy titled Skin Care dated 10/2017 documented the purpose was to identify altered skin integrity, facilitate adequate assessment of skin integrity, determine need for preventative/therapeutic intervention, and ensure proper treatment was provided to residents with altered skin. Staff would remain alert to skin changes on a daily basis and report areas of concern immediately to ensure prompt intervention. Every resident would have a weekly full-body skin inspection completed by a nurse. Documentation and evaluation would be completed in the electronic record under skin assessments. If a new skin alteration was found, it would be assessed and documented at the time of identification in the electronic medical record under wound assessment, a notation would be placed in the nurse's notes and on the 24-hour house report. Resident #52 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #52 was cognitively intact, was understood, understands, and had no open [MEDICAL CONDITION], skin tears or ulcers. The comprehensive care plan dated 2/27/24 documented Resident #52 required assistance with activities of daily living and had contractures to their left ankle and knee. Additionally, the resident was to have a padded bedside tray table dated 4/5/ 25. Review of nursing bath day skin evaluations dated 3/5/25 to 4/2/25 documented on 3/26/25 Resident #52 had a left knee scab. Review of 24-Hour Report Log Sheets dated 3/31/25 to 4/6/25 revealed there was no documented evidence Resident #52's left knee wound was assessed or that a physician's orders [REDACTED]. Review of the physician's orders [REDACTED].#52's left knee until 4/5/ 25. During an observation on 4/3/25 at 9:53 AM Resident #52 was lying in bed with their left knee exposed from under the blanket. The resident was noted to have a large white square adhesive dressing (approx. 6 x 6 inches) covering their left knee. The dressing was lifting at the corners edge; it was undated and unlabeled. During the observation Resident #52 lifted the white patch and revealed an open oval shaped wound to their left knee, approximately 3 x 2 inches in diameter, with a moist pink wound bed. At this time Resident #52 stated the dressing was applied about two days ago after a tray table hit their knee. Resident #52 stated they could not recall who did it, who put the dressing on, or exactly when it happened. During a follow up observation on 4/4/25 at 8:18 AM Resident #52 was lying in bed with their left knee exposed, the wound remained to their left knee with a scab forming. Review of late entry nursing progress note dated 4/5/25 at 8:52 AM but created on 4/6/25 at 9:35 AM, Licensed Practical Nurse Assistant Unit Manager #3 documented Resident #52 reported their bedside tray table hit their left knee. Resident had fragile scar tissue on the knee and there was fresh blood present. Resident frequently held their left knee in the upward position, so tray table was padded for protection. There was no documented evidence that Resident #52's left knee wound was assessed or that a treatment was in place prior to 4/5/ 25. Wound evaluations for Resident #52 were requested from the Administrator on 4/8/25 at 2:56 PM and could not be provided. There was no documented evidence that a wound assessment was completed prior to 4/5/ 25. Review of Resident #52's Medication Administration Record [REDACTED]. The order was created on 4/6/25 and revised on 4/9/ 25. During an interview on 4/7/25 at 10:39 AM, Licensed Practical Nurse Assistant Unit Manager #3 stated it was reported to them on 4/5/25 that Resident #52 had an open wound on their left knee that was bleeding. They stated they were unaware Resident #52 had an open wound to that area prior to 4/5/ 25. They interviewed staff who also stated they did not notice anything prior, and did not know why a treatment would have been started without a physician's orders [REDACTED]. During an interview on 4/7/25 at 2:36 PM, Licensed Practical Nurse Unit Manager #2 stated they were not aware Resident #52 had any new skin areas prior to 4/5/ 25. They stated it should have been reported as soon as it happened so that a physician's orders [REDACTED]. During an interview on 4/8/25 at 12:49 PM, Licensed Practical Nurse #7 stated they were Resident #52's assigned nurse on 4/3/25 and saw the white adhesive dressing to their left knee. They stated they realized there was no order in place and thought they updated either Licensed Practical Nurse Unit Manager #2 or Registered Nurse Supervisor #1, but they could not remember exactly. They stated they removed the dressing, looked at the area, and waited for a reply on what treatment to apply but never received an update prior to the end of their shift. They stated they did not document it anywhere. During an interview on 4/8/25 at 12:55 PM, Certified Nurse Aide #5 stated they were Resident #52's assigned aide on the 6:00 AM to 2:00 PM shift five days a week and could not recall when they first saw a white dressing on Resident #52's left knee, but did recall seeing a white dressing to their left knee on 4/3/ 25. They stated they did not report it to anyone because the resident stated someone was already aware and there was a dressing in place. During an interview on 4/8/25 at 1:02 PM, Licensed Practical Nurse Unit Manager #2 stated that no one had made them aware Resident #52 required a treatment for [REDACTED]. 25. During a telephone interview on 4/8/25 at 1:17 PM, Registered Nurse Nursing Supervisor #1 stated they worked as the overnight nursing supervisor and was never informed that Resident #52 had a new skin issue that required a treatment to their left knee on 4/3/ 25. During an interview on 4/9/25 at 10:18 AM, the Director of Nursing stated they would have expected staff to let someone know as soon as Resident #52 acquired the wound to their left knee. They stated they would have expected staff to question why a treatment was in place without a physician order [REDACTED]. The Director of Nursing stated it was important to update the supervisor so that the wound could have been assessed, the physician could have been updated, a treatment order put into place, and an accident and investigation be completed if needed. During an interview on 4/9/25 at 11:43 AM, the Inservice Coordinator and Clinical Director of Education and Training stated staff were trained to report any new skin finding to their superior and acquire an order from a physician for an appropriate treatment then apply. They stated staff should never assume, and just report it so that the issue could be addressed immediately and did not get worse. 10 NYCRR 415. 12 | Plan of Correction: ApprovedMay 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for the Resident Identified Upon discovery, the resident was assessed immediately by the nurse, and an incident report was completed. A provider was notified, and an order for [REDACTED]. Identification of Other Residents Who Could Be Affected No other instances of undocumented or unauthorized wound care were found. Systemic Changes to Prevent Recurrence - The Skin Care Policy was reviewed to ensure that it clearly requires: Full documentation of any skin issues or injuries, Immediate provider notification for new wounds, Physician order [REDACTED]. -All licensed nursing staff will receive re-education on: Skin assessment documentation, Wound identification and reporting procedures, The importance of adhering to physician orders [REDACTED]. -Weekly Shower/Skin notification sheet for all residents will be documented and submitted to the Director of Nursing (DON) or Designee for review to ensure: -All skin concerns are promptly identified, -Treatment orders are in place, -Documentation is complete and accurate. Monitoring and Quality Assurance - The Director of Nursing or designee will audit 10% of resident Shower/Skin Notification Sheets weekly for 8 weeks to ensure compliance with documentation, physician orders, and care plan accuracy. - Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. - After 8 weeks of 100% compliance, monitoring will transition to monthly audits for 3 additional months. Responsible Person: Director of Nursing or Designee |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 9, 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 a Standard survey completed on 4/9/25, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #66) of one (1) resident reviewed. Specifically, Resident #66 was observed with medications in their room, and they self-administered the medications without being evaluated as to whether they could safely do so. The finding is: The policy and procedure titled Resident Self-Medication/Self-Treatment Instructions dated 8/2012 documented at the request of the resident to self-medicate, complete an assessment to determine if the resident has the ability to self-administer. Once it has been determined the resident can self-administer safely, obtain a physician's order to store medication or medicated preparation at the bedside. Inappropriate use should be addressed with the resident and physician by the nurse. An assessment of resident's ability to self-administer medications or treatments will be conducted on a quarterly basis. Resident #66 had [DIAGNOSES REDACTED]. The Minimum Data Set (resident assessment tool) dated 1/7/25 documented Resident #66 was understood, understands and was cognitively intact. The comprehensive care plan dated 3/29/24 documented Resident #66 had capacity to make their own healthcare decisions. The care plan lacked documented evidence that Resident #66 had the ability to self-administer any medications. Review of the order summary report dated 4/8/25 documented an order for [REDACTED]. 25. There were no physician's orders for Resident #66 to self-administer those medications or to leave those medications at the bedside. There was no order for Pepto-Bismol. Review of the Medication Administration Record [REDACTED]. The medication was initialed as being administered by nursing staff. There was no documented evidence that Resident #66 had the ability to or that they self-administered any of their medications. There was no documented evidence that Resident #66 self-administered Pepto-Bismol. Review of Nurse Practitioner #1's progress notes dated 2/24/25 and 3/13/25 lacked documented evidence Resident #66 was able to self-administer medications. Review of the nursing progress notes 3/1/25-4/7/25, there was no documented evidence Resident #66 had self-administered any medications, any medications were removed from the bedside, or that Resident #66 was evaluated to keep medications at their bedside. During an observation on 4/3/25 at 11:08 AM, Resident #66 had a large clear bottle of purple gummies labeled [MEDICATION NAME] five milligrams on their tray table, a large green pill bottle labeled Vitamin C, a large darker colored bottle labeled Men's Multivitamin, and a smaller bottle labeled Pepto-Bismol that was approximately half full on their bedside nightstand. During an observation on 4/4/25 at 8:12 AM, the same bottles of medications remained on Resident #66's tray table and nightstand. During an observation and interview on 4/4/25 at 2:51 PM, the same bottles of medications were on the tray table and nightstand, Resident #66 stated they purchased the medications online approximately every 2. 5 months. They stated they take two of the [MEDICATION NAME] gummies every night, take two of the multivitamins once a day and prefer to take the Vitamin C tablets only through the winter months until there was consistently good weather. Resident #66 stated they did not believe that the nurses brought them any multivitamins, Vitamin C or [MEDICATION NAME]. They stated they have had the bottle of Pepto-Bismol for approximately one month and they only took 30 milliliters (ml-a unit of measurement) of it when they had heartburn or indigestion. They stated they had asked for Pepto-Bismol in the past but was told the facility did not have any, so they purchased it themselves. During an interview on 4/4/25 at 3:03 PM, Licensed Practical Nurse #4 stated that Resident #66 should not have medications at their bedside because it was not part of their orders. They stated during the day shift medication pass, they had given Resident #66 Vitamin C in the morning and a multivitamin. They stated the nurses did not provide Resident #66 with the pill bottles to keep at their bedside and was not aware that they were taking any of those medications at their bedside. They stated they did not see any orders for Pepto-Bismol in the electronic medical record. Licensed Practical Nurse #4 stated Resident #66 probably ordered the medications themselves and they should have been removed from the bedside because there was no order to self-administer. They stated they believed Resident #66 would have been competent enough to self-administer medications but there needs to be an order written [REDACTED]. During an observation and interview on 4/4/25 at 3:17 PM, Registered Nurse Supervisor #2 stated Resident #66 frequently bought a copious number of things from an online retailer, and they believed that was where the medications were purchased. They stated Resident #66 knew they were not allowed to have medications at their bedside, but Resident #66 would be safe to self-administer some medications. Registered Nurse Supervisor #2 stated they have seen medications at Resident #66's bedside in the past. They stated the protocol for a resident to self-administer medication was to choose a bubble stating self-administer when entering the order into the electronic medical record. Registered Nurse Supervisor #2 entered Resident #66's room and observed they had a bottle of multivitamins, Vitamin C, Pepto-Bismol and [MEDICATION NAME] at their bedside. The Registered Nurse Supervisor #2 removed the medications from the resident's room. During an interview on 4/8/25 at 11:30 AM, Certified Nurse Aide #3 stated they were a full-time certified nurse aide and regularly took care of Resident # 66. They stated they remembered noticing pill bottles on Resident #66's tray table and nightstand and it was not an uncommon occurrence. They stated they would tell the nurse who was responsible for Resident #66 whenever they saw the pill bottles but, the nurses usually left the pill bottles to keep Resident #66 from yelling when the nurses removed them. During an interview on 4/8/24 at 3:08 PM, Licensed Practical Nurse #5 stated they were the evening shift nurse for Resident #66 on a regular basis. They stated that they had told Resident #66 that they were not allowed to display their medications but should keep them in their locked drawer and Resident #66 knew they were not supposed to just order medications through an online retailer. Licensed Practical Nurse #5 stated they were aware that Resident #66 had some medications but was unaware that they had [MEDICATION NAME]. Licensed Practical Nurse #5 stated that they provided Resident #66 with [MEDICATION NAME] five milligrams every night as ordered and was unaware that they were taking an additional 10 milligram of [MEDICATION NAME] from their own supply. They stated they were unaware that Resident #66 had Pepto-Bismol at their bedside and had never complained of acid reflux or diarrhea to them. Licensed Practical Nurse #5 stated they would have taken the medications from Resident #66 and notified the Unit Manager to follow up. During a telephone interview on 4/9/25 at 9:36 AM, Nurse Practitioner #1 stated they were the Nurse Practitioner that the nurses would call whenever they had a concern or needed something for Resident # 66. They stated th | Plan of Correction: ApprovedMay 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action Taken for the Resident(s) Identified The medications were removed from resident #66, as resident already had physician orders [REDACTED]. Identification of Other Residents Who Could Be Affected A facility-wide audit to be conducted to identify other residents who would like to self-administer their medications. If residents are identified wanting to self-administer they will be assessed by the interdisciplinary team for appropriateness. Systemic Changes to Prevent Recurrence - The Resident Self-Medication/Self-Treatment Instructions Policy was reviewed to ensure there are clear procedures for resident requests, assessments, care planning, documentation, and ongoing monitoring. - A new Self Administration Evaluation Tool for self-administration capability will be implemented and must be completed by the interdisciplinary team within 72 hours of a residents request. - All licensed staff to be re-educated on resident rights to self-administer medications, including the requirement for assessment and care plan updates. Monitoring and Quality Assurance - The Quality Assurance Director or designee will audit 10% of all resident records weekly for 8 weeks to ensure: Proper assessments are completed Care plans reflect the self-administration status Medications are stored and administered in accordance with facility policy Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. After 8 weeks, if 100% compliance is sustained, monitoring will continue monthly for an additional 3 months. Responsible Person: The Quality Assurance Director or Designee |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 4/9/24, patient care related electrical equipment was not inspected and tested per manufacturer's recommendations. This affected portable resident lifts, which were utilized on two (first and second floors) of two resident use floors. The finding is: The policy and procedure titled Maintaining Resident Medical Equipment, dated (MONTH) 2024, documented the facility will inspect all medical equipment to ensure proper operation. Equipment manufacturer manuals for specific preventative maintenance shall be referenced and maintained. Observation on the first floor on 4/3/25 at 9:30 AM revealed a Hoyer-type resident lift, manufactured by Company A, had a sticker on it that stated an outside contractor inspected the lift (MONTH) 2025 and was due for the next inspection July 2025. Review of Company A's User Manual revealed it included a Maintenance Safety Inspection Checklist, which listed items to be inspected/ adjusted monthly. The items included the caster base, shifter handle, mast, boom, hangar bar, slings, and hardware. Review of a document titled Lift Inspections revealed it indicated eight resident lifts were inspected at that time. The document was undated. During an interview on 4/4/25 at 9:35 AM, the Executive Director of Environmental Services stated they located one undated Lift Inspections document in the former Maintenance Director's office and the Maintenance Director's position was currently vacant. During an interview on 4/4/25 at 1:40 PM, Maintenance Staff #2 stated they had not done preventative maintenance checks on lifts recently. During an interview on 4/8/25 at 10:15 PM, Maintenance Staff #1 stated they had not done preventative maintenance checks on lifts recently. During an interview on 4/8/25 at 11:10 AM, the Administrator stated the facility should follow the owner's manual for maintenance of equipment. They stated an outside contractor inspected the facility's lifts two times per year, and the maintenance staff should be performing preventative maintenance, as indicated in the owner's manual. During a second interview on 4/8/25 at 11:15 AM, the Executive Director of Environmental Services stated most of the facility's Hoyer-type resident lifts were manufactured by Company A. They stated manufacturer's recommendations should be followed, and they would expect monthly lift inspections to be completed and documented. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 99: 10. 5. 3, 10. 5. 3. 1. 2, 10. 5. 6 | Plan of Correction: ApprovedMay 5, 2025 Corrective Action: An audit was conducted by maintenance staff for all lifts in the house, all lifts were inspected at that time with no negative findings. At the time of the audit maintenance ensured that all lifts were accounted for and we were following the manufacturer manuals for all lifts in use. Identify Other Residents All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. The Director of Facilities to review the policy and procedure titled Maintaining Resident Medical Equipment. Systemic Changes Director of Facilities or Designee to in-service all maintenance staff on preventative maintenance of equipment based on the manufacturers manual, as well as on the updated lift inspection form. Monitor Corrective Actions: The Director of Facilities or Designee will review the monthly lift inspection and report all findings to the Administrator and the QAPI Committee at the monthly meeting. The QAPI Committee is responsible for ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities will be responsible for monitoring the plan. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 4/9/25, electrical systems were not properly maintained. Specifically, three feet of clearance was not maintained in front of electrical panels. This affected two (first and second floors) of two resident use floors. The findings are: 1a. Observation on the second floor on 4/3/25 at 9:00 AM revealed two bags of soiled linen were on the floor immediately in front of the electrical panels in the South Hall Soiled Linen Room. Additionally, on 4/7/25 at 3:33 PM, four bags of soiled linen were on the floor immediately in front of the electrical panels in the South Hall Soiled Linen Room. Also, on 4/8/25 at 8:40 AM, two mobile hampers were immediately in front of the electrical panels in the South Hall Soiled Linen Room. 1b. Observation on the first floor on 4/7/25 at 3:40 PM revealed two mobile hampers of soiled linen were immediately in front of the electrical panels in the South Hall Soiled Linen Room. Additionally, on 4/8/25 at 8:25 AM, one bag on soiled linen was on the floor immediately in front of the electrical panels in the South Hall Soiled Linen Room. 1c. Observation on the first floor on 4/7/25 at 3:42 PM revealed five bags and one mobile hamper of soiled linen were immediately in front of the electrical panels in the North Hall Soiled Linen Room. Additionally, on 4/8/25 at 8:27 AM, three bags of soiled linen were on the floor immediately in front of the electrical panels in the North Hall Soiled Linen Room. 1d. Observation on the first floor on 4/7/25 at 3:46 PM revealed two bags of garbage and soiled linen and one empty mobile hamper were immediately in front of the electrical panels in the East Hall Soiled Linen Room. Additionally, on 4/8/25 at 8:30 AM, four bags of soiled linen were on the floor immediately in front of the electrical panels in the East Hall Soiled Linen Room. 1e. Observation on the second floor on 4/7/25 at 8:38 AM revealed three bags of soiled linen were on the floor immediately in front of the electrical panels in the East Hall Soiled Linen Room. Additional observation revealed the Soiled Linen Rooms in the Second Floor South Hall, First Floor South Hall, First Floor North Hall, First Floor East Hall, and Second Floor East Hall each had a sign posted that read, Please do not place any items within 36 inches of the electrical panels and the floor in each room had red tape that marked off the area within 36 inches of the panels. During an interview on 4/8/25 at 8:30 AM, Certified Nurse Aide #1 stated the bags in the Soiled Linen rooms contained garbage and soiled linen. They stated the bags come and go, and sometimes can pile up. Certified Nurse Aide #1 also stated this morning, the garbage and soiled linen were picked up around 7:00 AM and the current bags (ten total bags on the floor, four bags in front of the electrical panels) had been placed there since 7:00 AM. They stated they knew not to block the electrical panels, but they also were mindful not to place the bags in front of the door. During an interview on 4/8/25 at 9:45 AM, Licensed Practical Nurse #1 stated staff started by filling the mobile hampers in the Soiled Linen Rooms, then when they were full, staff would place bags of soiled linen and garbage on the floor, outside of the red taped area. They stated maintenance staff picked up the bags several times per day, but sometimes the bags piled up, especially after morning care or total bed changes. On 4/8/25 at 10:45 AM, Licensed Practical Nurse #1 also stated the mobile hampers were usually stored in the corner location, which was within the red taped area, and they knew to keep the area within the red tape clear, but were not sure what the red tape was for. During an interview on 4/8/25 at 9:50 AM, Maintenance Staff #2 stated soiled linen and garbage was picked up at 7:00 AM and 10:30 AM by first shift maintenance staff, and two additional pickups by second shift maintenance staff. Maintenance Staff #2 stated they knew to keep the area around electrical panels clear and they put red tape on the floor to remind staff. They stated sometimes the bags would accumulate between pickups along the side wall of the room, including where the electrical panels were located. During an interview on 4/8/25 at 10:15 AM, Maintenance Staff #1 stated they picked up the soiled linen and garbage bags from the Soiled Linen Rooms two times during first shift, and there was one maintenance staff member who did it on second shift. They stated on days that the second shift maintenance staff member did not work, there would be more bags in the Soiled Linen Rooms the next morning, and the bags would be along the side wall of the room, which included where the electrical panels were located. Maintenance Staff #1 stated the area around electrical panels must be kept clear. During an interview on 4/8/25 at 11:05 AM, the Administrator stated the area around electrical panels should be kept clear, but the Soiled Linen Rooms were oddly shaped and the electrical panels were located in a tough spot. They stated signs were posted to remind staff to keep the area clear. They also stated maintenance staff was responsible for picking up the bags from the Soiled Linen Rooms. If the second shift maintenance staff member was off, the Maintenance Director would stay late to pick up the bags during second shift or the second shift Housekeeper would be assigned to pickup the bags The Administrator stated both the Maintenance Director position and the second shift Housekeeper position were currently vacant. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 99: 6. 1, 6. 1. 1, 1. 3, 6. 3. 2, 6. 3. 2. 1 2011 NFPA 70: 110. 3(A)(8), 110. 26(A)(1), Table 110. 26(A)(1) | Plan of Correction: ApprovedMay 5, 2025 Corrective Action: All soiled linen, garbage bags, and mobile hampers found obstructing the 36-inch clearance in front of electrical panels were immediately removed from the South, East, and North Hall Soiled Linen Rooms on both the first and second floors. Identify Other Residents All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes A facility wide audit will be conducted to check for clearance around all electrical panels. The red tape and signage have been enhanced with floor decals labeled ?ôDO NOT BL(NAME)K ÔÇ£ ELECTRICAL PANEL CLEARANCE ZONE?Ø to provide clearer visual warnings. All Nursing, Environmental, and Maintenance Staff received in-service training on electrical panel clearance requirements. An audit tool will be created to check the electrical panel, the maintenance department will be educated on the audit tool. The soiled utility rooms will be audited by the maintenance department daily for four (4) weeks, then three (3) times per week for eight (8) weeks than weekly for three (3) months. Monitor Corrective Actions: The Director of Facilities or designee will report the audit results monthly to the QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance Person Responsible for Implementation: The Director of Facilities |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 4/9/25, the fire alarm system was not maintained. Issues included devices in the fire alarm system were not functionally tested annually and the facility did not have documentation that the batteries in the fire alarm system were load tested semi-annually. This affected one of one fire alarm system that served two (first and second floors) of two resident use floors. The findings are: Observations made throughout the facility on 4/3/25 from 8:35 AM until 10:45 AM revealed the facility was protected by a complete fire alarm system and the fire alarm control panel was located in the Maintenance Shop. 1. According to the 2010 edition of the National Fire Protection Association 72: National Fire Alarm and Signaling Code, initiating devices, including duct detectors, shall be functionally tested on an annual basis. Review of the fire alarm system outside contractor's inspection and testing report dated 12/5/24 revealed the following three items were listed under the Deficiency Summary: duct detector M1-165 Administration Board Room unable to locate, duct detector M1-169 Activities unable to locate, duct detector M2-82 second floor bathing unable to locate. Additionally, the report indicated duct detector M1-176 was listed as visual inspection only. Review of the fire alarm system outside contractor's inspection and testing report from 2023 revealed the four identified duct detectors were last inspected and functionally tested in December 2023. 2. According to the 2010 edition of the National Fire Protection Association 72: National Fire Alarm and Signaling Code, sealed lead acid batteries are to be visually inspected and load tested semi-annually. Observation in the Maintenance Shop on 4/8/25 at 11:20 AM revealed the fire alarm control panel was equipped with two sealed lead acid batteries, and they were each dated December 2023. Review of the fire alarm system outside contractor's inspection and testing reports revealed two batteries were load tested on [DATE] and 12/5/ 24. During an interview on 4/3/25 at 2:00 PM, the Executive Director of Environmental Services stated they were not aware that the outside contractor could not locate three duct detectors and only visually tested on e additional duct detector during their most recent inspection of the facility's fire alarm system. They stated the duct detectors were present and did not know why the outside contractor indicated that they could not locate them. Additionally, the Executive Director of Environmental Services stated the batteries for the fire alarm system were load tested annually by the outside contractor. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 4, 9. 6, 9. 6. 1. 3 2010 NFPA 72: 14. 3, Table 14. 3. 1, 14. 4, 14. 4. 5, Table 14. 4. 5, 14. 4. 5. 5 | Plan of Correction: ApprovedMay 5, 2025 Corrective Action: Outside Contractor returned to facility on 04/04/2025 and tested the three previously missed duct detectors M1- 165 Administration Board Room, M1-169 Activities, and M2-82 second floor bathing. As well as they tested duct detector M1-176 that was noted on the report as ?ôvisual inspection only.?Ø The contractor was notified to schedule load testing every six months/semiannually on the batteries in the fire alarm system. Identify Other Residents Director of Facilities to review all fire alarm system inspection reports since the last survey for any other missed devices/missed inspections/additional batteries. All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes Facility to revise its fire alarm service agreement to require full compliance with NFPA 72 testing standards, including mandatory documentation of device locations and test outcomes, as well as twice a year load testing of the batteries within the fire alarm system. The Director of Facilities to be educated by the Administrator on thoroughly reviewing the inspection reports after each inspection to identify any discrepancies and addressing timely. to The Director of Facilities or Designee to be onsite to ensure proper completion of the annual and semiannual inspection. All maintenance staff to be educated Monitor Corrective Actions: Director of Facilities to report the results of our recent fire alarm system inspection at our monthly MAY QAPI meeting, then moving forward the Director of Facilities will report the results of the semiannual and annual inspection to the QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance Person Responsible for Implementation: Director of Facilities |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Life Safety Code survey completed on 4/9/25, fire drills were not completed at least once per shift per quarter. This affected two (first and second floors) of two resident use floors. The findings are: The policy and procedure titled Fire Safety Training Program, dated (MONTH) 2007, documented twelve fire drills will be held annually according to the fire drill schedule which is set up at the end of the year for the preceding year. Each shift will conduct a fire drill once every quarter. A fire drill report will be completed and sent to Administration. Upon being returned, it will be filed in the fire drill report binder. Review of the policy and procedure titled Conducting Fire Drills, dated (MONTH) (YEAR), documented the Trainer will conduct the drill and document the event. 1a. Review of the fire drill report binder revealed fire drills were held at the following dates in the first quarter of 2024: 2/20/24 at 4:00 AM (third shift) 3/6/24 at 2:45 PM (first shift) 1b. Review of the fire drill report binder revealed fire drills were held at the following dates in the second quarter of 2024: 4/29/24 at 11:00 PM (third shift) 5/8/24 at 6:30 AM (third shift) 6/11/24 at 8:00 AM (first shift) Additionally, the reports dated 5/8/24 and 6/11/24 were titled Review Policy and Fire Panel. 1c. Review of the fire drill report binder revealed fire drills were held at the following dates in the third quarter of 2024: 7/24/24 at 6:15 PM (second shift) 8/9/24 at 5:22 PM (second shift) 9/26/24 at 1:00 PM (first shift) During an interview on 4/8/25 at 11:00 AM, the Administrator stated they had no further fire drill reports to submit at this time. They stated the Maintenance Director was responsible to schedule and perform fire drills. The facility had been without a Maintenance Director since last week, but in 2024, the former Maintenance Director did report the completed fire drills at the facility's monthly quality assurance meetings, and they were not made aware of any missed fire drills. The Administrator also stated they expected all fire drills to be documented and the Trainer mentioned in the policy referred to the Maintenance Director. 10NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 7, 19. 7. 1, 19. 7. 1. 6, 4. 7, 4. 7. 4, 4. 7. 6 | Plan of Correction: ApprovedMay 5, 2025 Corrective Action: No residents were identified as being affected by this deficiency Identify Other Residents All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. Systemic Changes Director of Facilities or Designee to in-service all maintenance staff on the minimum requirement to conduct one fire drill, per shift, per quarter. Director of Maintenance to review the policy and procedure titled Fire Safety Training Program. Maintenance to conduct 2 fire drills monthly for the first 4 months on alternating shifts to ensure that the minimum requirement of one fire drill on every shift per quarter takes place. All drills will be planned 4 months in advance by the Director of Maintenance to ensure drills will be done on the appropriate shift. Monitor Corrective Actions: The Director of Facilities or Designee will review all completed fire drills monthly and report all findings to the Administrator and the QAPI Committee monthly. The QAPI Committee is responsible for the ongoing monitoring and compliance. Person Responsible for Implementation: The Director of Facilities will be responsible for monitoring the plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 9, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 4/9/25, a smoke barrier door did not fully close. This affected one (second floor) of two resident use floors. The finding is: Observation on the second floor on 4/4/25 at 9:55 AM revealed the door to the lavatory across from Resident room [ROOM NUMBER] did not fully close. Further observation revealed the door was hung up on its door frame. During an interview at the time of the observation, Maintenance Staff #2 stated the door to the lavatory had been checked in the past, but they could not recall whether this door was checked recently. Also at the time of the observation, the Executive Director of Environmental Services stated the screws were loose and the door needed an adjustment in order to close fully. They stated they believed this door was located along a smoke barrier wall. Review of an undated facility floor plan revealed the door to the lavatory across from Resident room [ROOM NUMBER] was located along a smoke barrier wall. On 4/8/25 at 8:45 AM, the Executive Director of Environmental Services stated they could not locate architectural drawings of the facility to confirm smoke barrier wall locations. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7, 19. 3. 7. 6, 19. 3. 7. 8, 8. 5. 4, 8. 5. 4. 1, 8. 5. 4. 4 | Plan of Correction: ApprovedMay 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action: Following the observation of the lavatory across from resident room [ROOM NUMBER] not fully closing, due to the door being hung up on its door frame. Maintenance immediately fixed the lavatory door to ensure proper closure. Identify Other Residents All residents have the potential to be affected by this deficient practice. No other residents were identified as being affected by this deficient practice. All doors identified within the smoke barriers walls were inspected, with no negative findings. Systemic Changes All maintenance staff to be re-educated by the Facilities Director or designee re-educated on the proper closing and latching of smoke barrier doors. The Director of Maintenance or Designee will create a new audit tool that will be utilized to perform bi-monthly audits of smoke barrier doors for 6 months. Monitor Corrective Actions: Director of Facilities to report the results of the bi-monthly audits at the monthly QAPI Committee. The QAPI Committee is responsible for the ongoing monitoring and compliance Person Responsible for Implementation: The Director of Facilities |