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NYS Health Profiles
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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey and complaint investigation (NY 495) from 03/28/2025 to 04/02/2025, for two (2) (Resident #55 and #59) of nine (9) residents, the facility did not ensure residents who were unable to carry out activities of daily living (basic self-care tasks people perform regularly to maintain their well-being, such as bathing and nail care) received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #55 had not received a shower in four (4) weeks, had unshaved facial hair, and unclean hair and fingernails. Resident #59 had not received a shower in three (3) weeks, was unshaven, and was observed using their hands to eat with debris underneath their fingernails. This is evidenced by the following: The facility policy Activity of Daily Living Assistance and Supervision dated 01/08/2018 included the nursing assistant provides activity of daily living assistance to assigned residents and assists other nursing assistants in giving care as needed. The Unit Manager/designee and Team Leader monitors the activity of daily living assistance provided for residents throughout the shift and gives appropriate guidance and assistance to nursing staff. The facility policy Bath, Tub/Shower dated 08/07/2021 included a shower or tub bath will be given by an appropriately trained nursing assistant or licensed nurse once a week and/or as deemed necessary to all residents (unless contraindicated due to illness) or per the resident's preference. The facility policy Shaving a Female Resident dated 05/08/2018 included a nursing assistant will shave the face of a female resident as needed to remove extraneous facial hair. The facility policy Hand and Nail Care dated 01/25/2019 included residents will receive nail care for cleanliness and to prevent infection. Appropriately trained nursing assistants will provide nail care for all residents except those with diabetes or severe [MEDICAL CONDITION]. 1. Resident #55 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 01/16/2025 included the resident was cognitively intact and required assistance with showers. Review of the active Comprehensive Care Plan and Kardex (care plan used by certified nursing assistants to guide care) reviewed on 03/28/2025 revealed Resident #55 required staff assistance with lower body bathing and was independent with personal hygiene. During an observation and interview on 03/27/2025 at 9:27 AM, Resident #55 had facial hair growing on their chin, their hair was greasy and stringy, and there was dark debris under multiple fingernails on both hands. When interviewed at that time, Resident #55 stated they should receive a shower once a week but had not received a shower in approximately four (4) weeks. They were annoyed they had not received a shower and wanted one. Resident #55 stated they used to take care of shaving and fingernail care on their own but was now unable to do so. They stated they wanted their hair washed, facial hair shaved, and fingernails cleaned and trimmed. Review of the facility document Shower Assignment last updated 02/28/2025 revealed Resident #55's shower was scheduled on Friday, day (7:00 AM to 3:00 PM) shift. Review of the Certified Nursing Assistant Documentation Survey Report (a portion of the electronic health record where baths and showers were documented) revealed Resident #55's last documented shower was on 02/28/ 2025. During observations on 03/28/2025 at 3:17 PM (Friday) and 03/31/2025 at 9:56 AM, Resident #55's hair remained greasy and stringy, facial hair was unshaven, and fingernails on both hands had debris underneath. During an interview on 03/31/2025 at 11:24 AM, Certified Nursing Assistant #1 stated shaving, nail care, and hair washing was completed during showers and as needed. Resident #55 was on their assignment and required assistance with shaving and nail care. Certified Nursing Assistant #1 stated they did not notice if Resident #55 was unshaven or had unclean hair and fingernails. During an interview and observation on 03/31/2025 at 11:45 AM, Licensed Practical Nurse #1 stated they were responsible for nail care of diabetic residents and the certified nursing assistants would tell the nurses when nail care was needed. They stated hair, shaving, and nails were observed during skin checks on shower day and if something needed to be done, they would make sure it was completed. When observed at that time, Resident #55's hair, facial hair, and fingernails were unchanged. Licensed Practical Nurse #1 stated it did not look like Resident #55 had a shower in a while and needed to have their hair washed, facial hair shaved, and fingernails cleaned and trimmed. Licensed Practical Nurse #1 stated in the past year they had to provide more direct resident care due to short staffing. 2. Resident #59 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] included the resident had moderately impaired cognition and required assistance with showers and personal hygiene. The active Comprehensive Care Plan, last revised on 09/30/2024 and Kardex reviewed on 03/31/2025 included Resident #59 required staff assistance with showers and personal hygiene, fingernails were to be trimmed and cleaned twice weekly and assisted with shaving on their shower day. During an observation and interview on 03/27/2025 (Thursday) at 1:54 PM, Resident #59 had a full beard and long jagged fingernails with dark debris underneath. They were eating watermelon with their hands. Resident #59 stated their face was itchy and they wanted to be shaved. Review of the facility document Shower Assignment last updated 02/28/2025 revealed Resident #59's shower was scheduled Wednesday, day shift. Review of the Certified Nursing Assistant Documentation Survey Report revealed Resident #55's last documented shower was on 03/05/2025 (no documented shower in three (3) weeks). During observations on 03/28/2025 at 3:32 PM and 03/31/2025 at 9:28 AM, Resident #59's facial hair and fingernails were unchanged. During an interview on 03/31/2025 at 10:44 AM, Certified Nursing Assistant Unit Clerk #1 stated they had a direct care assignment today. They stated showers, shaving, and nail care were unable to be completed due to short staffing. During an interview and observation on 03/31/2025 at 12:59 PM, Registered Nurse Minimum Data Set Coordinator stated activities of daily living should be completed per the resident's care plan and showers should be completed on the resident's scheduled day. When observed at that time, Resident #59's facial hair was long and unshaven, and their fingernails were jagged with dark debris underneath. Registered Nurse Minimum Data Set Coordinator stated it did not look like Resident #59 had a shower or their nails trimmed or cleaned in a while and should have their nails cleaned and trimmed twice weekly. During an interview on 04/02/2025 at 11:58 AM, the Director of Nursing stated activities of daily living including showers, hair care, shaving, and nail care should be completed per the resident's plan of care, as needed, and per resident preference. The Director of Nursing stated residents should not go multiple weeks without a shower, should not go unshaven, and should not have long, jagged, or dirty fingernails. The Director of Nursing stated the inability to complete activities of daily living, including showers, was due to ongoing staffing issues and not completing activities of daily living could negatively impact the residents' self-esteem and mood. 10 NYCRR 415. 12(a)(3) | Plan of Correction: ApprovedApril 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action for the affected residents: Personal care was provided for residents #55 and # 59. This included showers, removal of facial hair/shaving, and nail trimming/cleaning. Identification of potentially affected residents: All residents are at risk of being affected by the deficiency. Personal care/grooming audits will be conducted on all residents by 4/28/ 25. Personal care including showers will be provided as indicated by 5/2/ 25. Measures to prevent reoccurrence: Education will be provided to all nursing staff. This will include the review of the following facility's policies: Hand and Nail care, Bath, Tub, Shower, and Shaving of Male and Female Resident. Emphasis will be placed on notifying the nurse in charge if care is unable to be completed for any reason. The nurse will ensure completion of care or document reasons why care was not completed (resident non-adherence). Diabetic nail care will be provided by Licensed Personnel. There will be an order for [REDACTED]. Continued compliance: Facility staff will complete auditing including personal care/grooming as well as auditing of shower compliance. Auditing will be completed on 6 residents per week for 30 days and then 12 residents per month. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 03/27/2025 to 04/02/2025, it was determined for one (1) (Resident #78) of seven (7) residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. Specifically, Resident #78 was on Enhanced Barrier Precautions (infection control measures used to reduce the spread of [MEDICAL CONDITION] and involves the use of gowns and gloves during high-contact resident care activities) due to having a wound, a nurse did not perform hand hygiene prior to entering the resident's room, did not wear gloves while handling a sterile wound dressing, and did not change gloves or perform hand hygiene after handling a soiled dressing and before applying a clean dressing to the wound. This is evidenced by the following: Review of the facility policy Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management Skilled Nursing Facility dated 02/27/2023 included the facility will ensure that every resident receives care consistent with professional standards of practice and those residents with pressure ulcers, injuries or skin conditions will receive treatment and services to promote healing and prevent infection. Resident #78 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 01/16/2025 revealed the resident was cognitively intact and had a stage three (3) pressure ulcer. Review of the Comprehensive Care Plan dated 01/28/2025 revealed Resident #78 had an alteration in skin integrity related to a current wound. Interventions included, but were not limited to, apply treatments per provider orders, monitor the wound for signs and symptoms of infection, and Enhanced Barrier Precautions in place. Review of a physician order, dated 03/24/2025, included but was not limited to apply calcium alginate (wound dressing) to the sacral wound daily and as needed. During an observation on 03/31/2025 at 2:03 PM, Licensed Practical Nurse #2 was performing wound care for Resident # 78. Licensed Practical Nurse #2 did not perform hand hygiene prior to entering the residents room and did not apply gloves prior to handling the sterile calcium alginate dressing. Licensed Practical Nurse #2 then put on gloves, removed the soiled dressing and applied the clean dressing without changing their gloves or performing hand hygiene in between. During an interview on 03/31/2025 at 3:23 PM, Licensed Practical Nurse #2 said they did not have gloves on while handling the sterile wound dressing, did not change gloves or perform hand hygiene after removing the soiled dressing and before applying the clean dressing but should have. During an interview on 04/01/2025 at 11:17 AM, the Director of Nursing said there were two missed opportunities to prevent contamination of Resident #78's wound. They stated Licensed Practical Nurse #2 should have worn gloves while handling sterile wound care supplies and should have changed gloves and performed hand hygiene in between handling the soiled and clean wound dressings. 10 NYCRR 415. 19(a)(1-3) (b)(4) | Plan of Correction: ApprovedApril 23, 2025 Corrective action for the affected residents: The nurse was immediately reeducated on proper infection control techniques as it pertains to dressing changes/wound care. Identification of potentially affected residents: All residents with wounds have the risk of being affected by the deficiency. All residents were assessed, and no identification of wound infections were identified as a result of the deficient practice. Measures to prevent reoccurrence: Education will be provided to all licensed staff to ensure that appropriate infection control techniques are practices with wound dressings/wound care. This will include review of the facility policy, Dressing , clean, incision Policy. Continued compliance: The facility staff will complete auditing for compliance. Skill observations will be completed 2 times per week for 30 days and then 4 times per month ensuring appropriate infection control techniques are followed during dressing changes/wound care Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 03/27/2025 to 04/02/2025, the facility did not ensure residents received care in accordance with professional standards of practice for 1 (Residents #55) of 21 residents reviewed. Specifically, Resident #55 had [MEDICAL CONDITION] (swelling in the legs) to both legs and did not receive compression therapy per physician order [REDACTED]. This is evidenced by the following: 1. Resident #55 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 01/16/2025 included the resident was cognitively intact and had active [DIAGNOSES REDACTED]. During an observation and interview on 03/27/2025 at 9:33 AM, Resident #55 had moderate swelling ([MEDICAL CONDITION]) to both lower extremities and stated they were supposed to wear elastic stockings. They said staff did not consistently assist with putting on the elastic stockings and had not put the stockings on that day. A physician order, dated 08/29/2024, included to apply [MEDICATION NAME] (elastic compression bandages used to reducing swelling) to both lower extremities (from toes to knees) daily in the morning and remove at bedtime. The current comprehensive care plan and Kardex (care plan used by the certified nursing assistants for daily care), reviewed on 03/28/2025, revealed no information, including measurable goals or interventions, related to Resident #55's [MEDICAL CONDITION], or [DIAGNOSES REDACTED]. During observations on 03/28/2025 at 3:17 PM and 03/31/2025 at 9:56 AM, Resident #55 had moderate swelling to both lower extremities and [MEDICATION NAME] were hanging on the footboard of the bed. Review of the Treatment Administration Record revealed the following: a. In (MONTH) 2025, for 6 of 31 opportunities, there was no documented evidence the [MEDICATION NAME] were put on. For three (3) additional opportunities, documentation revealed the [MEDICATION NAME] were not applied due to the resident sleeping. b. In (MONTH) 2025, for 4 of 31 opportunities there was no documented evidence the [MEDICATION NAME] were put on. For nine (9) additional opportunities, documentation revealed the [MEDICATION NAME] were not applied due to the resident sleeping. c. In (MONTH) 2025, for 8 of 31 opportunities there was no documented evidence the [MEDICATION NAME] were put on. For seven (7) additional opportunities, documentation revealed the [MEDICATION NAME] were not applied due to the resident sleeping. During an interview on 03/31/2025 at 11:24 AM, Certified Nursing Assistant #1 stated [MEDICATION NAME] were put on by the nurse. During an interview on 03/31/2025 at 11:45 AM, Licensed Practical Nurse #1 stated Resident #55 was supposed to wear [MEDICATION NAME] daily and instructions for applying the [MEDICATION NAME] should be on the resident's care plan. They stated [MEDICATION NAME] were placed and removed by the nurse and documented in the electronic health record. Most [MEDICATION NAME] are put on by the night shift nurse, removed by the evening shift, and were not checked for placement by the day shift nurse. Licensed Practical Nurse #1 stated they were not sure if Resident #55's [MEDICATION NAME] had been applied that day and if the [MEDICATION NAME] had not been put on, the night shift nurse should have reported it to them during shift report. During an interview on 03/31/2025 at 12:59 PM, the Registered Nurse Minimum Data Set Coordinator stated [MEDICATION NAME] were ordered by the physician and should be put on as prescribed. If the [MEDICATION NAME] were not put on, the information should be passed to the next shift to attempt to apply them. Registered Nurse Minimum Data Set Coordinator stated Resident #55 was prescribed [MEDICATION NAME] for their [MEDICAL CONDITION] and not wearing them could cause skin breakdown or worsening [MEDICAL CONDITION]. During an interview on 04/02/2025 at 11:58 AM, the Director of Nursing stated all physician orders [REDACTED]. A blank box in the treatment administration record meant there was missed documentation, and the treatment would be considered not completed. The Director of Nursing stated if [MEDICATION NAME] were not put on it should be documented in the electronic health record, passed along in shift report, and discussed with the physician to update orders as needed. They stated if a resident was asleep and did not want to be woken up for the [MEDICATION NAME] to be applied, the time should be adjusted to their awake/preferred time to ensure they are put on. 10 NYCRR 415. 12 | Plan of Correction: ApprovedApril 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action for the affected residents: The comprehensive care plan was updated for resident # 55. This included focus, goals, and interventions related to DM, CKD, and [MEDICAL CONDITION]. Compression therapy was applied per order. Identification of potentially affected residents: All residents with a significant [DIAGNOSES REDACTED]. All residents that have orders for compression therapy are at risk for not having application per order. The comprehensive care plan of all residents with the [DIAGNOSES REDACTED]. All residents with orders for compression therapy with be identified. The orders and treatment administration records will be reviewed for accuracy and completeness. All residents will be observed to ensure compression stockings are applied per order. Measures to prevent reoccurrence: Education will be provided to all licensed staff to ensure that the comprehensive care plan includes significant [DIAGNOSES REDACTED]. This will include a review of the facility policy, Care Planning (IDT). Education will be provided to all nursing staff regarding compression therapy. This will include a review of the following facilities policy, Compression Therapy. Emphasis will be placed on applying compression therapy per order and documenting completion in the treatment administration record. The nurse will ensure completion of application/removal of compression therapy or document reasons why care was not completed (resident non-adherence). Continued compliance: The facility staff will complete auditing of compliance for appropriate CCP and application of compression therapy. Auditing will be completed on 6 residents per week for 30 days and then 12 residents per month for appropriate comprehensive care plans. Ensuring the care plan includes the significant [DIAGNOSES REDACTED]. All residents that have compression therapy ordered will be audited monthly to ensure appropriate documentation in TAR and that they are being applied per order. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 03/27/2025 to 04/02/2025, for one (1)(Resident #55) of three (3) residents reviewed the facility did not provide proper treatment and assistive devices to maintain vision. Specifically, the facility did not ensure Resident #55 was seen by the facility medical provider in a timely manner after reporting changes in vision, did not make an appointment with the resident's eye doctor per medical provider recommendation, and did not ensure the resident made it to a scheduled eye doctor appointment. This is evidenced by the following: The facility policy Optometry and Eye Care dated 06/18/2018 included eye examinations and other consultant optometry services will be obtained as ordered by the attending physician. The resident or legally designated representative and/or responsible party will be contacted by the nursing staff to obtain approval for service and transportation arrangements. When the Attending Physician orders [REDACTED]., and to obtain transportation preferences. 1. Resident #55 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 01/16/2025 documented the resident was cognitively intact, wore glasses, and had adequate vision (able to see fine detail). During an interview on 03/27/2025 at 9:42 AM, Resident #55 stated they had changes in their eyesight starting in (MONTH) 2024 but had not seen the eye doctor yet. They stated they reported their vision changes to facility staff. In a progress note dated 09/18/2024, Certified Nursing Assistant #2 documented Resident #55 had a follow up appointment with the eye doctor scheduled for 03/17/ 2025. In a progress note dated 12/05/2024, Registered Nurse Minimum Data Set Coordinator documented Resident #55 had complained of eye heaviness and irritation and their concerns were placed in the medical book (a book used by nurses to communicate resident issues and concerns to the medical providers). In a progress note dated 12/06/2025, Certified Nursing Assistant #2 stated they called the eye doctor to schedule an earlier (before 03/17/2025) appointment for Resident #55 due to complaints of eye changes. In a progress note dated 12/30/2024 Nurse Practitioner #1 documented they saw Resident #55 for changes in eyesight and [MEDICAL CONDITION] and they needed to follow up with their eye doctor. During an interview on 03/31/2025 at 10:44 AM, Certified Nursing Assistant Unit Clerk #1 stated they were responsible for scheduling medical consult or specialist appointments and arranging transportation for appointments. They stated Resident #55 saw an outpatient (provider not affiliated with the facility) eye doctor and per the electronic health record was last seen in August 2024. Certified Nursing Assistant Unit Clerk #1 stated they did not know Resident #55 needed to be seen for changes in their eyesight, and did not know they had an appointment scheduled on 03/17/ 2025. They had not arranged transportation and Resident #55 missed the scheduled appointment. Certified Nursing Assistant Unit Clerk #1 stated they often had to work in a direct resident care capacity and was not able to complete their unit clerk responsibilities, as a result, Resident #55 was not scheduled for an earlier appointment and also missed their scheduled appointment on 03/17/ 2025. During an interview on 04/01/2025 at 3:03 PM, Registered Nurse Minimum Data Set Coordinator stated if a resident reports a concern, they should be seen timely by the facility medical provider. They stated outpatient appointments and transportation were arranged by the unit clerk, Resident #55's eye appointment should have been moved up per the facility medical provider, and the unit clerk should have ensured transportation was set up for Resident #55's appointment on 03/17/ 2025. During an interview on 04/02/2025 at 11:58 AM, the Director of Nursing stated all follow up appointments and consult appointments are made per medical provider recommendations and are made timely. They stated there was a 25-day gap (12/05/2025 to 12/30/2025) and Resident #55 was not seen timely between their complaint of eye changes and visit with the facility medical provider. The Director of Nursing stated the unit clerk or nurse manager should have followed up with the eye doctor in (MONTH) 2024 to make an appointment for Resident #55 to be seen and transportation should have been arranged, so they did not miss their appointment on 03/17/ 2025. 10 NYCRR 415. 12(a)(3)(b)(1-3) | Plan of Correction: ApprovedApril 23, 2025 Corrective action for the affected residents: Resident #55 was scheduled and attended a follow up eye appointment on 4/16/ 25. No changes recommended. Follow up schedule for 4 months. Identification of potentially affected residents: Residents that have reported a change in vision or require follow up eye appointments are at risk for this deficiency. All residents that require a follow up eye appointment will be identified and appointments/transportation will be arranged. Measures to prevent reoccurrence: Education will be provided to the unit clerk, unit managers, social workers, and medical records. This will include review of the facility policy, Clinic/Consult Appointment. Emphasis will be placed on the importance of scheduling/rescheduling appointments in a timely manner. Documentation and notification of the DON will be expected in the event that an appointment cannot be attended. Continued compliance: The facility staff will complete auditing for compliance. Auditing will be completed of all appointments weekly for a month then 6 per month on all residents with out of the facility appointments to ensure attendance and that follow up is completed appropriately. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: N/A
Citation Details Based on observations, interviews, and record review conducted during the Life Safety Code Survey from 03/27/2025 to 04/02/2025, for one (first floor) of four resident-use floors and two (east and west stairwells) of four exit stairwells, the facility did not ensure the sprinkler system was properly maintained. Specifically, there were mixed sprinkler heads and an exit stairwell lacked sprinkler coverage. The findings are: Record review on 03/28/2025 at 10:00 AM revealed quarterly sprinkler inspection reports dated 05/29/2024, 08/14/2024, 12/24/2024, and 03/03/2025 did not document deficiencies or recommendations. During observations on 03/27/2025 at 11:48 AM, the walk-in freezer in the main kitchen had one standard response sprinkler head and one quick response sprinkler head installed within. During observations on 03/27/2025 at 11:05 AM, the East stairwell had a quick response sprinkler head installed on the bottom landing (first floor) and all other landings had standard response sprinkler heads. During observations on 03/27/2025 at 11:43 AM, the area just inside the first floor loading dock area had five standard response sprinkler heads and one quick response sprinkler head. During an immediate interview at this time, the Maintenance Supervisor stated they were not aware of the code requirement concerning mixed sprinkler heads and were not aware of any work done to replace sprinkler heads. The Maintenance Supervisor also stated that they relied on the vendor to keep them code compliant. During observations on 03/27/2025 at 11:48 AM, there was no sprinkler head installed at the top of the West basement stairwell leading into the basement. During an interview at this time, the Maintenance Supervisor stated they were not aware of the need for sprinkler coverage at the top of the stairwell and would expect the vendor to take note of any missing coverage. The 2010 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, requires: 1) where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response, 2) in noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft, 3) where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. 10 NYCRR: 415. 29(a)(2), 711. 2(a)(1); 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 1. 1, 9. 7. 5, 2010 NFPA 13: 8. 3. 3. 2, 8. 15. 3. 2, 8. 15. 3. 2. 1, 8. 15. 3. 2. 2 | Plan of Correction: ApprovedApril 24, 2025 Corrective action for the affected residents: Item 1 ÔÇ£ As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - Facility will employ our sprinkler vendor within 60 days to replace all Quick Response sprinkler heads, unifying the facility to Standard Response sprinkler heads. Item 2 ÔÇ£ As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - Facility will employ our sprinkler vendor to add the additional Standard Response head to the West stairwell, top of shaft, at the first-floor level, within 60 days. Identification of potentially affected residents: All residents are at risk of being affected by the deficiency. Item 1 - As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - Facility will employ our sprinkler vendor to complete a full building audit looking for mixed heads throughout the building, as well as ensuring the correct heads are in the location they occupy within 60 days. Item 2 ÔÇ£ As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - Facility will employ our sprinkler vendor to complete a full building audit to verify that there are no other areas out of compliance for the same reason. Measures to prevent reoccurrence: Item 1 - As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - The Director of Facilities, with the help of the sprinkler vendor, will educate Facilities Staff on the requirements for where, and what style of sprinkler head is required and to monitor such during our annual TELS sprinkler head inspections task. Item 2 ÔÇ£ As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - The Director of Facilities, with the help of the sprinkler vendor, will educate Facilities Staff on the requirements for where, and what style of sprinkler head is required and to monitor such during our annual TELS sprinkler head inspections task. Continued compliance: Item 1 - As it pertains to having mixed sprinkler heads in the Main Kitchen Walk-In Freezer, East stairwell-bottom landing, and the Loading Dock: - The Maintenance Dept. will audit quarterly and report the results to the QA Committee. Item 2 ÔÇ£ As it pertains to the missing sprinkler head in the West Stairwell, top of shaft, at the 1st floor level: - The Maintenance Dept. will audit quarterly and report the results to the QA Committee. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. Person Responsible: Director of Maintenance. |