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NYS Health Profiles
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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and abbreviated (NY 429) surveys conducted 1/2/2025-1/8/2025 the facility did not ensure the resident's physician was consulted and the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #61) reviewed. Specifically, Resident #61 did not receive 5 doses of their [MEDICAL CONDITION] (a progressive neurological disorder) medication (pramipexole [MEDICATION NAME]) and there was no documented evidence the physician or resident's representative were notified of the omission. Findings include: The facility policy, Notification of Medical Condition Changes, reviewed 6/2022, documented the nurse immediately reported specific changes in a resident's condition or treatment to their attending physician and shared with the resident and/or the resident's representative. The notification was documented in the resident's medical record. The pharmacy policy Provider Pharmacy Requirements, effective 9/2018, documented the provider pharmacy agreed to provide routine and timely pharmacy services, as well as emergency pharmacy service 24 hours per day, seven days per week. New medication orders were available for administration on the next routine delivery, unless otherwise requested by facility staff. Medications would be delivered by the primary pharmacy or back-up pharmacy or were available from the emergency medication kit/back-up medication supply. Resident #61 had [DIAGNOSES REDACTED]. The 12/3/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment. The 11/29/2024 physician order [REDACTED]. The 12/2/2024 History and Physical completed by the Medical Director documented the resident's plan was to continue [MEDICATION NAME] 25/100 ([MEDICAL CONDITION] medication) two tabs four times a day, [MEDICATION NAME] ([MEDICAL CONDITION] medication) 0.5 milligrams a day, and pramipexole 1.5 milligrams three times per day for [MEDICAL CONDITION]. The resident was also on [MEDICATION NAME] extended release 50/200 one tab once a day. The Comprehensive Care Plan initiated 12/19/2024 documented the resident had impaired cognition related to [DIAGNOSES REDACTED]. Interventions included their family was involved in decision making. The 12/30/2024 at 8:48 PM pharmacy alert message documented the pramipexole [MEDICATION NAME] refill was rejected and could not be filled because it was too soon and needed to be resubmitted for refill on or after 1/1/2025. The 12/2024 and 1/2025 Medication Administration Record [REDACTED]. The pramipexole [MEDICATION NAME] was signed off as a 9 chart code which indicated other/ see progress notes, at the following times: - On 12/31/2024 at 9:00 AM by Licensed Practical Nurse #6 and at 3:00 PM and 9:00 PM by Licensed Practical Nurse #7. - On 1/1/2025 at 9:00 AM and 3:00 PM by Licensed Practical Nurse #8. The nursing administration progress notes documented the pramipexole [MEDICATION NAME] medication: - Was on order on 12/31/2024 at 9:08 AM by Licensed Practical Nurse #6. - Was on order on 12/31/2024 at 3:56 PM and 8:04 PM by Licensed Practical Nurse #7 - On 1/1/2025 at 9:20 AM Licensed Practical Nurse #8 documented Registered Nurse #5 called the pharmacy and the medication would be delivered on the second pharmacy run that day. - On 1/1/2025 at 3:50 PM Licensed Practical Nurse #8 documented they were waiting on pharmacy to deliver the medication. There was no documented evidence in the nursing progress notes the medical provider was notified of missed doses of pramipexole [MEDICATION NAME] or that the medication was unavailable, or the resident's representative was notified of the missed medication doses. During an interview on 1/2/2025 at 11:13 AM, Resident #61's family member stated the resident did not receive doses of their [MEDICAL CONDITION] medication on 12/31/2024 and 1/1/2025. They were not notified by the facility and was only made aware of this while visiting during a medication administration. When they questioned the nurse why the resident was not given the medication, they were told the facility was waiting on pharmacy for delivery of the medication. They were upset the medication was not given because it was a vital medication. They could have brought the medication from home, so the resident did not go without it. During an interview on 1/7/2025 at 10:57 AM, Licensed Practical Nurse #6 stated they thought they reported to Registered Nurse #4 (charge nurse) the resident's pramipexole [MEDICATION NAME] medication was not available on 12/31/2024. They did not notify the provider or the family. Missed doses meant the body's medication levels were not as they should be and therefore was less effective. During a telephone interview on 1/7/2025 at 2:53 PM, Licensed Practical Nurse #7 stated there was often a delay in medications getting to the facility from the pharmacy and it was not uncommon for residents to miss a day or two of their ordered medications. On 12/31/2024 they stated they called the pharmacy, was not sure who they talked to, and was told the medication was on its way. It was not delivered before the end of their shift. They did not report the missed doses, or that the medication was unavailable. The resident got the pramipexole [MEDICATION NAME] for their tremors and the tremors could get worse if it was not given as ordered. During an interview on 1/8/2025 at 10:15 AM, the Charge Registered Nurse #4 stated they had not been notified the pramipexole [MEDICATION NAME] for Resident #61 was unavailable and doses were missed. They would have called the pharmacy directly and the provider and the family would have been notified. It was important the provider was informed of missed medication doses as it was a delay in treatment that could cause negative effects. During an interview on 1/8/2025 at 11:01 AM, Medical Director/ Physician #3 stated they were supposed to be notified of any medications not given regardless of the reason why. They did not recall being notified of missed doses of the pramipexole [MEDICATION NAME] for Resident #61, but they should have been. The resident should have received all ordered doses for their safety and to treat their [MEDICAL CONDITION]. Either the licensed practical nurse that administered medications, or the registered nurse should have called. If there was a pharmacy issue, they could have changed the treatment plan if they were made aware. During an interview on 1/8/2025 at 11:15 AM, the Director of Nursing stated nurses were responsible for physician notification of missed medications. The nurse that was supposed to administer the medication should have reported to the registered nurse the medication was unavailable. The registered nurse would then notify the resident or the family as well as the provider. They were made aware yesterday of Resident #61's missed pramipexole [MEDICATION NAME] doses and the provider should have been notified at that time. The resident and or family should have been made aware the treatment plan was not followed as ordered. 10NYCRR 415.3(2)(ii)(a) | Plan of Correction: ApprovedJanuary 30, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. F ?Çô 580 1.Resident # 61 was successfully discharged from the facility. The medical provider and responsible party were notified upon discovery. 2.House wide audit was completed for any medication(s) that were not available for administration. If any concerns were found, notification to medical provider and responsibly party were notified. 3. Reviewed and revised policy on Medication Administration Reviewed and revised policy on Notification of Change in Condition All license nurses will be in-serviced on procedure of when a medication is not available. And notification process 4.QAPI process will audit 5 licenses nurse knowledge for medication not available and documentation of notifications process on a week for 4 weeks then once a month for 3 months then QAPI will review for frequency and or need based on trends. 5.Director of Nursing or designee to oversee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every 3 months for 3 of 3 residents (Residents #28, #46, and #53) reviewed. Specifically, Residents #28's, #46's, and #53's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gathering information about a resident's condition when completing the assessment). Findings include: The facility policy, Interdisciplinary Minimum Data Set 3.0 Completion, revised 1/2023, documented to complete an accurate Minimum Data Set on all residents based on New York State Department of Health and Centers for Medicare and Medicaid Services guidelines. Assessments would be completed based on the Minimum Data Set 3.0 Manual. The Minimum Data Set Coordinator was responsible for setting up timely assessments within the guidelines as defined in the Minimum Data Set 3.0 Manual. The Centers for Medicare and Medicaid Service's, Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented An Omnibus Budget Reconciliation Act assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between Omnibus Budget Reconciliation Act assessments. 1) Resident #53 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment document an Assessment Reference Date of 11/13/2024 and the assessment was completed on 1/4/2025. 2) Resident #28 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 11/22/2024 and the assessment was completed on 1/4/2025. 3) Resident #46 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 12/14/2024 and the assessment was not completed as of 1/7/2025. During a telephone interview on 1/7/2025 at 12:56 PM, Minimum Data Set Consultant #9 stated they created the schedule to complete the Minimum Data Set assessments. The Minimum Data Set was completed by the various departments, if they were not done on time, they would reach out to the department to have them completed. They had 14 days from the Assessment Reference Date to complete the assessment. It was important to complete the Minimum Data Set assessment for the resident as it was part of their plan of care. It tracked their progress and helped direct their care. Resident #53 should have had their assessment completed by 11/27/2024 and submitted by 12/4/2025. It was not completed until 1/4/2025. Resident #28 should have had their assessment completed by 12/6/2024 and submitted by 12/13/2024. It was not completed until 1/4/2025. Resident #46 should have had their assessment completed by 12/17/2024 and submitted by 1/3/2025. It was not completed and would be completed on 1/7/2025, and they would submit it after completion. They stated they usually only submitted the Minimum Data Set assessments once a week. The Minimum Data Set assessments for Residents #28, #46, and #53 were not completed timely because section GG (Functional Abilities and Goals) was not completed, all other sections were completed. During an interview on 1/8/2025 at 11:01 AM, the Administrator stated it was the responsibility of the Minimum Data Set Consultant to ensure Minimum Data Set assessments were completed, and they did the audits for those assessments. 10NYCRR 415.11(a)(4) | Plan of Correction: ApprovedJanuary 30, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. F ?Çô 638 1. Resident # 28, #46, and #53 MDS were completed and submitted. 2. House wide audit was completed for any other MDS outside the submission timelines. For any that were found outside the timeframe, they were completed and submitted. 3. Reviewed policy on Interdisciplinary Minimum Data Set 3.0 Completion MDS Consultant Education on require timely submissions. 4. QAPI process will audit 5 MDS to ensure timely submissions a week for 4 weeks then once a month for 3 months then QAPI will review for frequency and or need based on trends. 5. Date of compliance: 3/3/2025 Director of Nursing or designee to oversee. |
Scope: N/A
Severity: N/A
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the recertification survey conducted 1/2/2025 - 1/8/2025, the facility did not ensure termination forms (Form 105e, used to deactivate an employee in the Criminal History Record Check) were submitted to the New York State Department of Health within 30 calendar days of termination for 2 of 7 prospective employees (Prospective Employees #12 and #13) reviewed. Specifically, prospective employees #12 and #13 were not terminated from the Criminal History Record Check within 30 days of termination from the facility. Findings include: The facility policy, Employment Process, last reviewed 3/2023, documented in compliance with New York State Department of Health regulations, non-licensed personnel who provide direct care to residents on would be required to authorize and complete a Criminal History Record Check submitted to the Federal Bureau of Investigation. Upon receipt of a response from the Department of Health, Human Resources would verify whether the employee was eligible for permanent employment. An applicant who has been convicted of a disqualifying event may be denied employment and will receive notice of this decision from Human Resources. The policy did not address terminating an employee from Criminal History Record Check (form 105e) when their employment ended. Prospective employee #12 received a negative determination letter from the Department of Health on 1/30/2024. The Criminal History Record Check Form 105e was completed for Employee #12 on 1/7/2025. Prospective employee #13 received a negative determination from the Department of Health on 11/15/2024. The Criminal History Record Check Form 105e was completed for Employee #13 on 12/30/2024. During an interview on 1/8/2025 at 11:15 AM, Human Resources Employee #11 stated when a prospective employee received a negative determination letter, Human Resources reviewed the charges and determined if the prospective employee would continue with their pursuit of employment. If the prospective employee was not able to clear their charges, they should be terminated and removed from the Criminal History Record Check within 30 days. They stated Prospective Employee #12 should have been terminated from Criminal History Record Check within 30 days of the negative determination letter but was not. They stated when they pulled the files for Prospective Employee #12 on 1/7/2025, they realized they were not terminated from Criminal History Record Check, so they terminated them on 1/7/2025. They stated Criminal History Record Check Form 105 should have been submitted within 30 days, but was not, and they did not know the reason why prospective employee #12 was not terminated from Criminal History Record Check timely. Prospective employee #13 should have been terminated from Criminal History Record Check within 30 days of receipt of the negative determination letter but was not. They stated prospective employee #13 had a pending denial (indicates the individual had criminal convictions that may result in a denial of employment), and Human Resources gave them time to submit the information to the Department of Health for the pending denial. After a period of time passed, and Prospective Employee #13 did not submit the required information, they were terminated, and removed from Criminal History Record Check. They stated Criminal History Record Check Form 105 should have been submitted within 30 days of receipt of the negative determination but was not. 10NYCRR 402.9(b)(2) | Plan of Correction: ApprovedJanuary 30, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. R- 1022 1. Prospective employee #12 received a negative determination letter from the Department of Health on 1/30/2024. The Criminal History Record Check Form 105e was completed for Employee #12 on 1/7/2025. Prospective employee #13 received a negative determination from the Department of Health on 11/15/2024. The Criminal History Record Check Form 105e was completed for Employee #13 on 12/30/2024. 2. HR completed an audit comparing CHRC active Roster to Active RHCF roster to ensure all termination were completed out of the system. 3. Reviewed and revised the facility policy, Employment Process to include terminating an employee from Criminal History Record Check (form 105e) when their employment ended. 4. QAPI process will audit bi weekly for any terminations from the facility that Form 105e was completed and submitted for 8 weeks then once a month for 3 months then QAPI will review for frequency and or need based on trends. 5. Date of compliance: 3/3/2025 Assistant Administrator or designee to oversee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, the facility did not ensure corridor doors and door frames were properly maintained for 2 rooms (third floor south unit shower room, third floor east unit tub room). Specifically, the corridor access doors for the third-floor south unit shower room and the third-floor east unit tub room did not latch properly. Findings include: During an observation on 1/2/2025 at 9:44 AM, the third-floor south unit shower room access door did not latch when tested . Three attempts were made. During an observation on 1/2/2025 at 10:50 AM, the third-floor east unit tub room access door did not latch when tested . Three attempts were made. During an interview on 1/7/2025 at 1:30 PM, the Director of Plant Operations stated that corridor room doors may have been checked during the bi-annual facility inspections and was not aware that the corridor doors for the third-floor south unit shower room and the third-floor east unit tub room were not latching as required. They stated they could not find any work orders for the doors. The Director of Plant Operations stated it was important that corridor doors were maintained for the safety of the residents and staff. 2012 NFPA 101 19.3.6.3 10 NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedFebruary 17, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. k-363 1. The Two Corridor ?Çô Doors (3 south unit shower room, third floor east unit tub room). Have been fixed 2. Full house audit was conducted for ensure all corridor doors are functional and latch. 3. Education of what steps to be completed when a issue is found will be conducted with all nursing home leadership, as they conduct environmental rounds, that all corridor doors need to be functional and latch. 4. Plant Operations Director or designee will complete monthly inspections of doors or one calendar year and track the results utilizing the audit tool. Upon completion of the years inspections, compliance will be measured to determine future frequency of inspections. All deficiencies will be corrected utilizing the CMMS Brightly for tracking purposes. Along with this a Preventative Maintenance schedule and work orders have been developed to ensure the facility is inspecting these items on a regular basis according to NFPA 99 and 101 Life Safety Code. 5. Date of Compliance 3/3/2025 Director of plant operations responsible |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, the facility did not ensure electrical equipment was maintained in accordance with National Fire Protection Association 99 for 2 of 4 facility owned electrical equipment reviewed (third floor south unit nursing station compact disc player, third floor east unit dining room karaoke machine). Specifically, the third-floor south unit nursing station compact disc player and the third-floor east unit dining room karaoke machine both lacked electrical inspection labels. Findings include: The facility's policy, Safety Inspection of Incoming Electrical Equipment, last revised 3/2024, did not document facility owned non-patient equipment or the frequency this type of equipment would be required to be electrically inspected. During an observation on 1/2/2025 at 9:40 AM, the third-floor south unit nursing station had a compact disc player that lacked an electrical inspection label. During an observation on 1/2/2025 at 10:03 AM, the third-floor east unit dining room had a karaoke machine that lacked an electrical inspection label. During an interview in 1/7/2025 at 1:35 PM, maintenance worker #10 stated the third-floor south unit nursing station compact disc player and the third-floor east unit dining room karaoke machine both had residue marks from where inspection labels had been previously placed, but they did not currently have an electrical inspection label. During an interview on 1/7/2025 at 1:38 PM, the Director of Plant Operations stated the protocol was to initially electrically inspect facility owned non-patient equipment and there was no other electrical inspection required by policy or a national fire protection association (NFPA) code. The Director of Plant Operations stated there was no other documentation to verify that the above-mentioned equipment had ever been electrically inspected. 2012 NFPA 99: 10.5.3 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedFebruary 17, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. k-921 1. The two non-patient care electric devices have been re-inspected and re-stickered as validation. 2. Full house audit was conducted for ensure all non-patient care electrical devices that activities dept. uses have been through inspection with plant operations. 3. Education will be conducted with all nursing home leadership staff, that all non-patient care electrical devices need to be inspected and have a label as validation. The facility?ÇÖs policy of Safety inspection of incoming electrical equipment will be reviewed for any revisions. 4. QAPI Process to audit all of the non-patient care electric devices q month for 6 months. Then the process will be reviewed by QAPI committee for trends and frequency. 5. Date of Compliance 3/3/2025 Assistant Administrator or designee will oversee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 11, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, the facility did not ensure that hazardous areas were maintained for 1 isolated room (third floor east unit clean utility room). Specifically, the third-floor east unit clean utility room lacked a fire rated door and door frame. Findings include: The building floor plan, dated 1/23/2022, did not document the third-floor east unit clean utility room as a fire rated hazardous area. During an observation on 1/2/2025 at 10:30 AM, the third-floor east unit clean utility room access door and frame both lacked fire rated labels. This room contained two fall mats, a K-sized oxygen tank, a cart of adult briefs, 3 containers of 70% ethyl alcohol wipes, and other miscellaneous medical equipment. This room was approximately 80 square feet in size and used for combustible storage. During an interview on 1/7/2025 at 1:15 PM, the Director of Plant Operations verified the third floor east clean utility room door and door frame both lacked a fire rated label. They stated the building floor plan did not identify this room as a hazardous area. The Director of Plant Operations stated the room was over 50 square feet and that any storage room that size was required to have a fire rated door and door frame. They stated it was important that all hazardous areas had fire rated doors and door frames for the safety of residents and staff. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, with a post survey revisit completed on 3/11/2025, the facility did not ensure that hazardous areas were maintained for 1 isolated room (third floor east unit clean utility room). Specifically, the third-floor east unit clean utility room lacked a fire rated door and door frame. Findings include: The building floor plan, dated 1/23/2022, did not document the third-floor east unit clean utility room as a fire rated hazardous area. During an observation on 1/2/2025 at 10:30 AM, the third-floor east unit clean utility room access door and frame both lacked fire rated labels. This room contained two fall mats, a K-sized oxygen tank, a cart of adult briefs, 3 containers of 70% ethyl alcohol wipes, and other miscellaneous medical equipment. This room was approximately 80 square feet in size and used for combustible storage. During an interview on 1/7/2025 at 1:15 PM, the Director of Plant Operations verified the third floor east clean utility room door and door frame both lacked a fire rated label. They stated the building floor plan did not identify this room as a hazardous area. The Director of Plant Operations stated the room was over 50 square feet and that any storage room that size was required to have a fire rated door and door frame. They stated it was important that all hazardous areas had fire rated doors and door frames for the safety of residents and staff. The Administrator contacted our office on 3/7/2025 to inform us that they had an issue with correcting the door and just learned that they would need to replace the door. They stated they put in an order for [REDACTED]. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedMarch 31, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. k-321 1. 3 East clean utility room: a. Third-floor north dining room are being evaluated and quotes being obtained to test and re-certification. Actively working with vendor and lab. 2. Full house audit was conducted for ensure all fire rated doors and frames are labeled. 3. Education of what steps to be completed when a issue is found will be conducted with all nursing home leadership, as they conduct environmental rounds, all fire doors and door frames are to have a label for proof that they are certified fire doors. 4. Plant Operations Director or designee will complete monthly inspections of doors for one calendar year and track the results utilizing the audit tool. Upon completion of the years inspections, compliance will be measured to determine future frequency of inspections. All deficiencies will be corrected utilizing the CMMS Brightly for tracking purposes. Along with this a Preventative Maintenance schedule and work orders have been developed to ensure the facility is inspecting these items on a regular basis according to NFPA 99 and 101 Life Safety Code. 5. Date of Compliance 3/3/2025 Director of plant operations is responsible. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 11, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, the facility did not ensure that fire-rated barriers were maintained for 2 areas reviewed (third floor north dining room double doors, third floor north fire barrier). Specifically, both of the third-floor north dining room double doors were damaged, and the third-floor north fire barrier had unsealed penetrations. Findings include: 1. Damaged Fire Rated Doors Maintenance work order # , an annual door/frame preventative maintenance that had been completed 11/19/2024, documented the third-floor north dining room doors were compliant with no issues identified. Specifically, the task #3 question from this form asked if the doors were in working order with no signs of visible damage. During an observation on 1/2/2025 at 10:56 AM, the third-floor north dining room fire rated double doors had the following damage: - the left side door had a section in which the bottom wooden frame of the rated glass did not cover all off the door material in the cut area of the door and there was exposed inner door material; - the right-side door had a section in which the bottom wooden frame was not installed close to the rated glass and there was a gap between the frame and the glass; and - the right-side door hold open magnet had worn a groove into the top of the door and inner door material was exposed. During an interview on 1/7/2025 at 12:55 PM, the Director of Plant Operations verified that the 11/19/2024 annual door inspection for the third-floor north dining room doors were documented as not having any issues. They stated that task #3 from the door inspection form should have had an X in the results column instead of a check mark and these doors had failed. The Director of Plant Operations stated it was important that all fire rated doors were maintained properly for the safety of the residents and staff. 2. Fire Barrier Unsealed Penetrations During an observation on 1/2/2025 at 12:50 PM, the third-floor north unit fire barrier had three unsealed data wires that passed through the barrier. During an interview on 1/7/2025 at 12:55 PM, the Director of Plant Operations stated the last check of the third-floor north unit fire barrier was not documented, and this fire barrier was not checked with a specific frequency. They stated that after data wires were run by third party vendors, they would then have general discussions with the vendor to ensure the holes created for the data wires were sealed. They stated the facility had not followed behind the third-party vendors because they were paid to do a job. The Director of Plant Operations stated it was important for all unsealed data wires and unsealed conduits to be sealed so smoke and fire would not spread to other areas. 2012 NFPA 101 19.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, with a post survey review completed on 3/11/2025, the facility did not ensure that fire-rated barriers were maintained for 1 area reviewed. Specifically, both of the third-floor north dining room double doors were damaged. Findings include: Maintenance work order # , an annual door/frame preventative maintenance that had been completed 11/19/2024, documented the third-floor north dining room doors were compliant with no issues identified. During an observation on 1/2/2025 at 10:56 AM, the third-floor north dining room fire rated double doors had the following damage: - the left side door had a section in which the bottom wooden frame of the rated glass did not cover all off the door material in the cut area of the door and there was exposed inner door material; - the right-side door had a section in which the bottom wooden frame was not installed close to the rated glass and there was a gap between the frame and the glass; and - the right-side door hold open magnet had worn a groove into the top of the door and inner door material was exposed. During an interview on 1/7/2025 at 12:55 PM, the Director of Plant Operations verified that the 11/19/2024 annual door inspection for the third-floor north dining room doors were documented as not having any issues. They stated that task #3 from the door inspection form should have had an X in the results column instead of a check mark and these doors had failed. The Director of Plant Operations stated it was important that all fire rated doors were maintained properly for the safety of the residents and staff. The Administrator contacted our office on 3/3/2025 to inform us that they had a delay with replacing the damaged doors. They stated they put in an order for [REDACTED]. 2012 NFPA 101 19.2.1, 7.1.10.1 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedApril 10, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. k-211 1. Damaged Fire Rated Doors: a. Third-floor north dining room are being evaluated and quotes being obtained to replace. Actively working on timeframe with vendors. Fire Barrier Unsealed Penetrations b. Third-floor north unit fire barrier had three unsealed data wires that passed through the barrier. At this time, they have all been sealed. 2. Full house audit was conducted for ensure no other penetrations in fire rated barriers were found. 3. Education of what steps to be completed when a issue is found will be conducted with all nursing home leadership, as they conduct environmental rounds, that all fire penetrations are to be sealed. 4. Plant Operations Director or designee will complete monthly inspections of Fire barrier/penetrations for one calendar year and track the results utilizing the audit tool. Upon completion of the years inspections, compliance will be measured to determine future frequency of inspections. All deficiencies will be corrected utilizing the CMMS Brightly for tracking purposes. Along with this a Preventative Maintenance schedule and work orders have been developed to ensure the facility is inspecting these items on a regular basis according to NFPA 99 and 101 Life Safety Code. 5. Date of Compliance 3/3/2025 Director of plant operations is responsible. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview during the Life Safety Code recertification survey conducted 1/2/2025 to 1/8/2025, the facility did not ensure that the two-hour fire-rated building separation barriers were maintained for 4 occupancy separation barriers observed (third floor nursing home occupancy east unit electrical room [ROOM NUMBER] into second floor hospital occupancy below, third floor nursing home occupancy east unit electrical room [ROOM NUMBER] into second floor hospital occupancy below, fourth floor hospital occupancy central stairwell penthouse into third floor nursing home occupancy below, and the north east center stairwell into the third floor nursing home occupancy). Specifically, the third-floor nursing home occupancy had unsealed penetrations and conduits in the above-mentioned locations. Findings include: During observations on 1/2/2025 the third-floor nursing home, which was contained within the separate four-story hospital occupancy, had the following unsealed vertical penetrations: - at 10:17 AM, the third-floor east unit electrical room [ROOM NUMBER] had a two-inch conduit that passed into the second floor below and the inside of the conduit was not sealed; - at 10:40 AM, the third-floor east unit electrical room [ROOM NUMBER] had two data wires that passed into the second floor below and the unsealed hole for these data wires was drilled through fire stopping material that had sealed an existing 4-inch conduit; - at 10:44 AM, the fourth-floor central stairwell penthouse had a four-inch conduit with multiple data wires that passed into the third floor below and the inside of the conduit was not sealed; and - at 11:20 AM, the northeast center stairwell, had an unsealed 2 1/2-inch conduit and an unsealed 1-inch conduit that passed through a fire rated wall into an area above the third-floor north unit dining room ceiling tiles. During an interview on 1/7/2025 at 12:35 PM, the Director of Plant Operations stated the maintenance staff would enter electrical rooms when a work order for those rooms had been requested and would not enter these types of rooms during the bi-annual facility inspections. They stated there should not have been any unsealed conduits or penetrations within the vertical or horizontal barriers that separated the nursing home occupancy. The Director of Plant Operations stated that after data wires were run by third party vendors, they would then have general discussions with the vendor to ensure the holes created for the data wires were sealed. They stated the facility had not followed behind the third-party vendors because they were paid to do a job. The Director of Plant Operations stated it was important for all unsealed data wires and unsealed conduits to be sealed so smoke and fire would not spread to other areas. During an interview on 1/7/2025 at 1:08 PM, the Director of Plant Operations stated the two unsealed conduits in the northeast center stairwell had been installed in 2023 as part of a hospital occupancy project. They stated the general contractor had missed these penetrations and that the maintenance department had not followed up to check after the conduit installations. 2012 NFPA 101 19.1.3.5 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedFebruary 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. k-133 1. unsealed vertical penetrations: #1 the third-floor east unit electrical room [ROOM NUMBER] had a two-inch conduit that passed into the second floor below and the inside of the conduit was not sealed; #2 the third-floor east unit electrical room [ROOM NUMBER] had two data wires that passed into the second floor below and the unsealed hole for these data wires was drilled through fire stopping material that had sealed an existing 4-inch conduit; #3 , the fourth-floor central stairwell penthouse had a four-inch conduit with multiple data wires that passed into the third floor below and the inside of the conduit was not sealed; and #4, the northeast center stairwell, had an unsealed 2 1/2-inch conduit and an unsealed 1-inch conduit that passed through a fire rated wall into an area above the third-floor north unit dining room ceiling tiles. a. (#1,#2,#3,#4)Have all been sealed. 2. Full house audit was conducted for ensure not other unsealed vertical penetrations were found. 3. Education of what steps to be completed when a issue is found will be conducted with all nursing home leadership, as they conduct environmental rounds, all vertical penetrations are to be sealed. 4. Plant Operations Director or designee will complete monthly inspections of penetrations for one calendar year and track the results utilizing the audit tool. Upon completion of the years inspections, compliance will be measured to determine future frequency of inspections. All deficiencies will be corrected utilizing the CMMS Brightly for tracking purposes. Along with this a Preventative Maintenance schedule and work orders have been developed to ensure the facility is inspecting these items on a regular basis according to NFPA 99 and 101 Life Safety Code. 5. Date of Compliance 3/3/2025 Director of plant operations is responsible. |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview and record review conducted during the Emergency Preparedness Plan (EPP) review in conjunction with a Life Safety Code Survey completed 1/2/2025 - 1/8/2025, the facility did not ensure that subsidence needs for staff and residents were properly and completely identified in the Emergency Preparedness Plan. Specifically, the facility's plan did not identify the quantity of emergency water supplies and they were not maintained on site, and the facility did not have the amount of food on hand as required by their plan. Findings include: The facility's policy Coordination of Emergency Food and Nutrition Supplies last revised 3/2023, documented the following: - the quantity of water available will be based on the number of patients/residents, staff and visitors as derived from the food menu calculations, 1 gallon all purpose water per person per day. - emergency water will be stored in a safe and easily accessible manner and labeled Emergency Use Only. The facility's Emergency Food Supply Cage Inventory sheet documented they needed 1 case plus 2 cans of chili with beef and beans. On 9/30/2024 the Food Service Production Manager documented the facility had 1 case of chili on hand. During an observation on 1/7/2025 at 12:53 PM, the emergency food supplies contained 1 case of chili. During an interview on 1/8/2025 at 12:36 PM, the Food Service Production Manager stated they had checked the emergency food supply inventory. They did not recall if they had noticed they were short chili the last time the inventory was checked. If they had ordered additional chili, it may have gone into the regular stock room as part of the regular rotated supply on hand. They stated they should have put two cans in with the emergency supplies, so they ensured the facility had the appropriate supplies on hand as required by their emergency plan. The facility did not have any documentation to show the chili had been ordered. During an observation and interview on 1/7/2025 at 12:59 PM, the Director of Nutrition stated they were responsible for tracking and maintaining the emergency food and water supplies. They went to where the emergency water was stored in the facility, but nothing was available. They stated the bulk of their emergency water was stored in a warehouse offsite, but they were not sure where that was located. During an interview on 1/7/2025 at 2:01 PM, the Director of Plant Operations stated their emergency water was stored off site at a warehouse on the other side of the City of Rome. They stated there should have been some water in the facility and they were not aware that the facility did not have any emergency water on hand. They confirmed the facility's policy did not specify the storage location and specific quantity the facility was required to have on hand. 42 CFR: 483.73(b)(1) | Plan of Correction: ApprovedJanuary 31, 2025 This Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. E- 015 1. There is now two cases of chili onsite. There is an active plan for ?Ç£Emergency use only?Ç¥ water to be moved onsite. 2. A full audit is being conducted to ensure all items required for Emergency Use Only menu to ensure all required items are onsite. 3. Review of the Coordination of Emergency Food and Nutrition Supplies policy is being conducted for any revisions. 4. Education is being conducted with the Food Service ordering personnel. 5. QAPI Process to audit Emergency Use Only items Bi weekly for 8 weeks and then once a month for 3 months. Then the QAPI committee will review for trends and frequency. Date of Compliance 3/3/2025 Director of Food Service will oversee. |