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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 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 02/11/2025 to 02/19/2025, for one (Residents #81) of three residents reviewed, the facility did not ensure that residents who were dependent on staff for assistance received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #81 did not receive assistance with nail care over an extended period of time. This is evidenced by the following: The facility policy Activities of Daily Living (ADLs) dated (MONTH) 2024 included a minimum of once per week shower or tub bath (per resident preference), all refusals need to be documented and if continued, care planned. Nail care cleaning and trimming are to be completed on shower days. Resident #81 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired of cognitive function and required assistance with personal hygiene. Review of the Comprehensive Care Plan dated 12/24/2024 and current Kardex (plan of care used by Certified Nursing Assistants) revealed Resident #81 required total assistance with bathing/showering, grooming and personal hygiene. Nail care included to clean and file as needed. During an observation and interview on 02/11/2025 at 9:22 AM Resident #81 had multiple fingernails that were long and filled with brown debris. In an immediate interview Resident #81 stated someone needs to cut these nails, they are going into my skin. During an observation on 02/13/2025 at 12:52 PM Resident #81 was eating a sandwich with their hands that continued to have brown debris under multiple nails. In an immediate interview Resident #81 stated they did not like to eat with their nails like this and it made them mad. During an observation on 02/18/2025 at 1:21 PM Resident #81 was eating a ham and cheese sandwich with their hand which continued to have long overgrown fingernails and brown debris under several nails. In an interview on 2/18/2025 at 2:01 PM Registered Nurse Manager #1 stated Resident #81's shower day was Wednesday's morning (six days prior) and nail care including cleaning and trimming should be completed on shower days, completed on request or as needed. In an interview on 02/19/2025 at 1:21 PM the Director of Nursing stated nail care should be completed as needed, and resident refusals should be documented and care planned appropriately. 10 NYCRR 415.12(a)(3) | Plan of Correction: ApprovedMarch 10, 2025 1. Immediately assessed and provided nail care to the resident affected. Checked for any sign of infection, overgrowth, or discomfort. 2. Identified residents who require routine or specialized nail care. Referred any residents with advanced nail care concerns to a podiatrist for further treatment. 3. Train nursing staff on proper nail care procedures, policy, hygiene importance, and documentation. Integrated nail care checks with all weekly showers. 4. Weekly nail care audits will be conducted on all units. These results will be presented to the QA committee for review. The committee will determine the frequency of the audit thereafter. Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 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 02/11/2025 to 02/19/2025 the facility did not ensure that person-centered comprehensive care plans were developed and/or implemented to address the resident's medical, physical, mental, and psychosocial needs for three (Residents #27, #81 and #108) of 25 residents reviewed. Specifically, Resident #27 was receiving oxygen per physician orders. The Comprehensive Care Plan did not include the use of oxygen or appropriate interventions. Resident #81 had physician orders and was care planned for a right-hand splint that was not in use on multiple observations. Resident #108 had [DIAGNOSES REDACTED]. The Comprehensive Care Plan included a focus for each of the identified issues but no interventions for staff to follow for the care of the resident. This is evidenced by the following: Review of the facility policy, Interdisciplinary Care Plan dated (MONTH) 2019, documented that the facility will develop a comprehensive care plan for each resident that will include measurable objectives to meet the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. The care plan will describe the services and interventions needed to attain resident goals. 1.Resident #81 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired of cognitive function, had no rejections of care, and was dependent on staff for upper and lower body dressing and personal hygiene. The Physician orders dated 01/04/2024, included right hand palm pro (splint) to be applied during waking hours with range of motion prior to application in the morning and upon removal at bedtime. Review of the Comprehensive Care Plan dated 12/24/2024 revealed Resident #81 had a problem area identified as a self-care performance deficit with activities of daily living. Interventions included a right-hand palm pro splint during waking hours with range of motion prior and upon removal and to notify occupational therapy of any changes and/or concerns. The Comprehensive Care Plan did not include that Resident #81 had any history of refusing care. Review of the Activities of Daily Living Assignment sheet dated as updated on 02/14/2025 revealed Resident #81 required a right-hand palm pro splint during waking hours. In an Occupational Therapy note dated 08/13/2024 Occupational Therapist #1 documented there was a request for Resident #81 to be provided with a soft hand right-hand splint. Occupational Therapist #1 reviewed with Nurse Practitioner #1 that Resident #81 had already been provided with right-hand palm pro splint which was the most appropriate and tolerated by the resident. In the note dated 08/22/2024 Occupational Therapist #1 documented they were unable to locate the resident's right-hand palm pro splint so they replaced it with two more with instructions to nursing staff to use one and keep one to be utilized when the other was soiled. During an observation and interview on 02/11/2025 at 9:23 AM, Resident #81 was sitting in their room. There was no splint on their right hand. When interviewed at the time Resident #81 stated they need the splint on their hand, but they could not find it and it had been months since they last had it. During an observation and interview on 02/13/2025 at 11:14 AM Resident #81 was in their room and again there was no palm pro splint on their right hand. Resident #81 stated the Certified Nursing Assistants needed to put it on and take it off because they were not able to do it themselves. During an observation on 02/14/2025 at 11:10 AM Resident #81 did not have palm pro splint on their right hand. Review of interdisciplinary progress notes for the prior month did not include any documentation that Resident #81 had refused the splint. During an observation and interview on 02/19/2025 at 10:51 AM, Resident #81 had a rolled washcloth in their right hand. When interviewed at the time Certified Nursing Assistant #1 stated Resident #81 should have something in their hand to help open it a bit and that the resident has a splint, but it was dirty, so they placed a washcloth in the resident's hand instead. Certified Nursing Assistant #1 stated they thought it was the Certified Nursing Assistants responsibility to wash the residents palm guard when soiled but they have only seen one splint in the resident's room. During an interview on 02/19/2025 at 11:08 AM Occupational Therapist #1 stated that Resident #81 had an order for [REDACTED].#1 stated the resident had two palm pro splints in case one got soiled and needed to be washed. Occupational Therapist #1 said they were not aware one had gone missing and that it was still indicated for the resident to use. During an interview on 02/19/2025 at 1:21 PM the Director of Nursing stated that if a resident's splint was not in place it should be documented that the resident refused or removed it, or if it was being cleaned or why it was not on the resident's hand. 2.Resident #108 was admitted approximately three months prior with [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively intact; occasionally incontinent of urine and frequently incontinent of bowel; rated their pain a six out of ten for pain intensity; was at risk for developing pressure ulcers/injuries; and received antidepressant, anticoagulant, and opioid drug classifications. In a medical progress note dated 11/08/2024 Nurse Practitioner #1 documented that Resident #108 was admitted to the facility for rehabilitation following a motor vehicle collision with multiple injuries and fractures (left fibula, left ankle, and right third and fourth ribs), right lower extremity cast placement, surgical incisions to left lower extremity, and blood loss [MEDICAL CONDITION]. Medications included [MEDICATION NAME] (for pain), [MEDICATION NAME] (opioid used to treat moderate to severe pain); and [MEDICATION NAME] sodium (anticoagulant used to prevent blood clots). Review of Resident #108's current Comprehensive Care Plan revealed that the resident had the following problem areas: a.[MEDICAL CONDITION] (created on 12/26/2024) with a goal that the resident will remain free of signs of symptoms of complications related to [MEDICAL CONDITION]. There were no interventions listed. b. Pain medication therapy (created on 12/13/2024) with a goal that the resident will be free of any discomfort or adverse side effects from pain medication. There were no interventions listed. c. Antidepressant medications (created on 12/13/2024) with goals that the resident will be free from discomfort or adverse reactions related to antidepressant therapy and will show decreased episodes of signs and symptoms of depression. There were no interventions listed. d. Potential/actual impairment to skin integrity (created on 12/13/2024) with goals that the resident will have no complications and will be free from skin injury. There were no interventions listed. e. Bladder incontinence (created on 12/13/2024). There were no goals or interventions listed. f. Impaired visual function (created on 12/13/2024). There were no goals or interventions listed. g. An actual fall (created on 12/26/2024). There were no goals or interventions listed. h.Anticoagulant therapy (to prevent blood clots. There were no goals or interventions listed. During an interview on 02/19/2025 at 10:30 AM Registered Nurse Manager #1 stated they complete the care plans with appropriate interventions for each of the problems listed and they should have gone back and filled it out completely. 3.Resident #27 had [DIAGNOSES REDACTED]. Physician orders dated 07/23/2024 included oxygen via nasal cannula at two liters per minute as needed and to wean oxygen to keep oxygen saturation greater than 90. Review of Resident #27's current Comprehensive Care Plan, revised on 07/23/2024, revealed the resident had asthma with interventions including to give medications as ordered and monitor for signs and symptoms of impending asthma attacks and has altered respiratory status and difficulty breathing related to [MEDICAL CONDITION]. Interventions did not include the use of oxygen or goals and interventions for the care of the oxygen. During observations on 02/11/2025 at 9:58 AM, 02/13/2025 at 11:19 AM, and 02/14/2025 at 9:13 AM Resident #27 was receiving oxygen via nasal cannula from an oxygen concentrator. During an interview on 02/19/2025 at 1:21 PM the Director of Nursing stated if a resident had an order for [REDACTED]. The Director of Nursing said it was important to have interventions in place for anticoagulant use due to potential for bleeding and antidepressant usage as staff should be looking for any behaviors. 10 NYCRR 415.11(c)(1) | Plan of Correction: ApprovedMarch 12, 2025 1. Conducted an immediate review of the care plans for all affected residents. Updated the care plans to reflect individualized needs, preferences, interventions, and goals. Communicated changes with interdisciplinary team members and residents to ensure alignment. 2. Reviewed documentation to ensure care plans are current, accurate, and person-centered. Resident #27, #81, and #108 care plans were updated on 02/20/2025 to reflect intervention. All resident's care plans were audited on 03/10/2025. 3. Conduct mandatory training for all nurse managers, clinical coordinators, and interdisciplinary team members on proper care plan development and reinforce training on resident-centered planning, assessment accuracy, and regulatory requirements. Reviewed Interdisciplinary Care Plan. Implemented a standardized checklist for care plan completeness and accuracy, 4. Monthly care plan audit will be completed, and the results of audits will be presented to QAPI for three months. The committee will determine the frequency of the audit thereafter. Responsible party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 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 02/11/2025 to 02/19/2025, for two (Resident #34 and #110) of six residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were four medication errors for 32 opportunities resulting in a medication error rate of 12.5 percent. Specifically, during observations of medication administration, multiple [MEDICATION NAME] coated pills (coating that protects mediation from being dissolved in the stomach), an extended release medication (one that is released gradually over a specific duration), and a sustained action medication (one that is released over an extended period of time) all with pharmacy labels instructing 'Do Not Crush' on the packaging were crushed and administered. In addition, two cardiovascular medications were administered without evidence that a blood pressure or heart rate was checked prior to being administered as per ordered by the Physician. This is evidenced by the following: The facility policy Medication Administration dated (MONTH) 2024, included that the nurse was responsible for questioning any medication order that in their judgment, is an error, not clear or illegible, or if they are uncertain (of an order). They should contact the physician, pharmacy or nursing supervisor for additional clarification. Additionally, medications that required vital sign parameters must be checked prior to preparing the medication and documented appropriately. Resident #110 had [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. a. [MEDICATION NAME] sustained release 60 milligrams twice daily for [MEDICAL CONDITION], with instructions to hold the dose and call the provider for heart rate less than 60 beats per minute or systolic blood pressure less than 100. b. [MEDICATION NAME] extended release 200 milligrams once daily for [MEDICAL CONDITION] with instructions to hold the dose and call the provider for heart rate less than 60 beats per minute or systolic blood pressure less than 100. c. Potassium chloride sustained action 10 milliequivalents daily for [DIAGNOSES REDACTED] (low potassium level). During an observation of medication administration on 02/14/2025 at 9:33 AM, Licensed Practical Nurse Clinical Coordinator #1 said Resident #110 took their medications crushed. Licensed Practical Nurse Clinical Coordinator #1 placed the [MEDICATION NAME] capsule in a medication cup and crushed the [MEDICATION NAME] and potassium chloride extended-release tables along with other medications and administered them. Licensed Practical Nurse Clinical Coordinator #1 was not observed to have obtained Resident #110's blood pressure or heart rate prior to giving the medications. Review of the electronic medical record on 02/14/2025 at 9:51 AM, revealed no documented evidence that vital signs including a blood pressure or heart rate had been obtained prior to administration of the resident's medications. During an observation and interview on 02/14/2025 at 11:03 AM, Resident #110's [MEDICATION NAME] and potassium chloride medication packages had 'Do Not Crush' on the pharmacy labels. Licensed Practical Nurse Clinical Coordinator #1 stated they may have missed the hold parameters (for [MEDICATION NAME] and [MEDICATION NAME]) and that Resident #110 should have had a blood pressure and heart rate checked (prior to administering), but they did not do that and crushing the medications (extended release) had been in error. During an interview on 02/14/2025 at 11:03 AM, Registered Nurse Manager #1 said if medication package was labeled to not crush, it should not be crushed. Registered Nurse Manager #1 stated the nurses should read the medication order to determine if there were hold parameters, and if there were parameters, they should be obtained shortly before giving the medication. 2. Resident #34 had [DIAGNOSES REDACTED]. Review of current physician's orders [REDACTED]. During an observation of medication administration on 02/18/2025 at 9:38 AM, Licensed Practical Nurse #1 crushed Resident #34's pantoprazole [MEDICATION NAME]-coated tablet and administered it. The pharmacy label on the pantoprazole package read 'Do Not Crush.' In an immediate interview Licensed Practical Nurse #1 said even though the package was labeled 'Do Not Crush,' staff still crush it. During an interview on 02/19/2025 at 9:04 AM, Physician Assistant #1 said [MEDICATION NAME]-coated or extended-release tablets should not be crushed because the medication would be too concentrated, would be released faster and might be absorbed too quickly or not enough. Physician Assistant #1 stated the purpose of hold parameters is to determine if the intended use of the medication was not needed, with an example being if the intended use of a medication was to lower the resident's blood pressure and if the blood pressure was low, it should not be given. During an interview on 02/19/2025 at 10:42 AM, Registered Nurse Manager #3 said an example of a medication error would be crushing a medication that should not be crushed. During an interview on 02/19/2025 at 1:21 PM, the Director of Nursing said a medication error is any medication that was not given as prescribed by the medical provider. The Director of Nursing said if a medication had hold parameters related to blood pressure and heart rate, they should be obtained within 15 minutes of administering the medications, and the medication should not be given if the hold parameters were not checked. The Director of Nursing said [MEDICATION NAME]-coated or extended-release tablets should not be crushed if the package was labeled to not crush. 10 NYCRR 415.12(m)(1) | Plan of Correction: ApprovedMarch 17, 2025 1. The Licensed practical nurse immediately acknowledged the error and gave the residents uncrushed prescribed medication. 2. Assessments were done for all other residents on the Nurse's assignment, and no other residents were affected. 3. Nurse educator will provide all licensed practical nurses mandatory medication administration, documentation, and error prevention training starting 3/10/2025. 4. Two to three weekly medication audits will be conducted for all nurses. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audits thereafter. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the Recertification Survey 02/11/2025- 02/19/2025 the facility did not ensure they established and maintained an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #21) of one resident reviewed for wound care. Specifically, appropriate Personal Protective Equipment (PPE-gown, gloves, masks) was not worn by nursing staff during high contact activity (wound care) for Resident #21 who was on Enhanced Barrier Precautions (steps taken by the facility to prevent the transmission of infectious diseases). This is evidenced by the following: The facility policy Infection Communication Plan dated (MONTH) 2025 documented: Daily communication related to the measures in place to prevent transmission occurs in the following manner: a. Resident rooms requiring transmission-based precautions will have signage on the door, along with the appropriate Personal Protective Equipment. b. Signage is visible to all residents, staff, and visitors. Resident #21 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE] documented the resident was moderately impaired of cognitive function and had an unstageable (obscured full-thickness skin and tissue loss) pressure ulcer (wound). Review of Resident #21's physician orders [REDACTED]. Wound care included to clean the wound with normal saline, pack it with calcium alginate with silver (dressing often used for infected wounds) and cover with a foam dressing. In an observation and interview on 02/14/2025 at 11:57 AM Resident #21 had an Enhanced Barrier Precaution sign at the entrance to their room instructing staff to wear Personal Protective Equipment (gown and gloves) when providing high contact resident care including dressing, bathing, transferring, linen change, personal hygiene, changing briefs, and wound care. Personal Protective Equipment supplies were located next to the signage. Licensed Practical Nurse #2 wearing gloves, but no gown provided the wound care to Resident #21 sacrum area which included removal of soiled dressing and packing which contained moderate amount of brown and yellow drainage, cleansing the wound, reapplying the appropriate packing, and applying a clean cover dressing. Licensed Practical Nurse #2 stated Resident #21 was on Enhanced Barrier Precautions due to a Covid- 19 outbreak on the unit and that they should have worn a gown for the wound care. In an interview on 02/18/2025 at 2:25 PM Registered Nurse Manager #2 stated residents with indwelling catheters and wounds are placed on Enhanced Barrier Precautions to prevent the spread of microorganisms and staff should be wearing gloves and gowns when caring for these residents. In an interview 02/19/2025 at 3:56 PM the Director of Nursing stated nurses preforming wound care should wear Personal Protective Equipment including gloves and a gown to decrease the potential spread of infection. 415.19(a)(b)(1-3) | Plan of Correction: ApprovedMarch 12, 2025 Directed Plan of Correction 1. The facility hired the services of a consultant to in-service infection Preventionist and staff educator on 03/10/2025. The consultant developed and implemented an acceptable plan of correction. 2. The facility QA Committee met on 03/06/2025 to examine the deficiencies cited. A. The QA committee's assessment of the causative factors contributing to the deficiencies was that agency staff was not adequately trained on using PPE for Enhanced Barrier Precaution. B. Facility infection Preventionists educated Licensed practical nurses on proper PPE use regarding resident #21. The infection prevention will round the facility daily on each shift to ensure staff and contracted services adhere to appropriate PPE use. C. Two Weekly PPE audits will be conducted on all units. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Directed Inservice All nursing staff will be in service from 3/10/2025 through 04/14/2025 on proper PPE use for all residents during wound care. B. The infection preventionist or designee will conduct a walkthrough of the building. Observation of nursing staff on the proper use of PPE C. Ad hoc education will be provided to persons not correctly implementing infection prevention and control procedures. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey 02/11/2025 to 02/19/2025, the facility did not ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated for 7 (Resident #1, #47, #63, #77, #80, #81, and #103) of 12 residents reviewed. Specifically, Resident #1, Resident #47, Resident #63 and Resident #77 had injuries of unknown origin, and the facility was unable to provide documented evidence that potential abuse, neglect or mistreatment were appropriately ruled out via a thorough investigation. Resident #80 had an acute medical incident requiring medication that was not available, and the facility was unable to provide a complete investigation to rule out neglect. Resident #81 and Resident #103 had allegations of physical and/or verbal abuse by staff and the facility was unable to provide evidence that the allegations were thoroughly investigated to rule out abuse. This is evidenced by but not limited to the following: The facility policy Incident/Accident Report Process dated (MONTH) 2024, included the incident/accident reporting form will be completed by a licensed nurse for any occurrence of a resident incident or accident. When applicable the staff version shall be completed as part of the report, and the Director of Nursing, or their designee, will review all reports for completeness and further follow-up if necessary. The facility policy Abuse, Neglect and Mistreatment Prohibition, Investigation, and Reporting dated (MONTH) (YEAR) included the facility shall investigate and report any accident/incident/grievance and crime where there is a reasonable cause for suspicion of staff abuse, neglect, involuntary seclusion, injury of unknown source or mistreatment of [REDACTED]. before or after the incident. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. The final determination of whether there is abuse, neglect, or mistreatment and actions taken, must be indicated and evidence of administrative review and final directive, with signature and date must be documented in the report. 1.Resident #63 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE] included the resident was severely impaired of cognitive function and was dependent on staff for all care including eating, transferring and bed mobility. Review of the resident's Comprehensive Care Plan dated 01/24/2023 and the Resident Care Card (care plan used by Certified Nursing Assistants to direct daily care) revealed Resident #63 was totally dependent on staff for care related to dementia and fatigue. Interventions included to provide the resident with two persons assist using a mechanical lift for transfers and required staff assistance with bed mobility and toileting. Review of an x-ray report signed by the radiologist and Physician Assistant #1 on 11/11/2024 revealed Resident #63 had an anterior dislocation of the left humeral head (left shoulder dislocation). Review of an Investigation Summary initiated on 11/14/2024 and completed by the Director of Nursing revealed that on 11/11/2024 Resident #63 was observed to have facial grimacing when their left arm was moved and had reduced range of motion in their left upper arm. X-rays were completed for the left elbow, humerus (upper arm) and forearm which showed a dislocation of the left shoulder. Resident #63 was sent to the hospital on [DATE] (three days later) for a left shoulder reduction which was unsuccessful. Resident #63 was referred to an orthopedic provider for follow up. The Investigation Summary incorrectly included that the x-ray taken on 11/11/2024 did not show the dislocation of the left shoulder. When pain did not improve on 11/14/2024 Resident #63 receoved a second x-ray, and the dislocation was again reported. The Investigation Summary indicated Resident #63 was unable to give details on how the injury occurred. The investigation did not include any statements from any staff members regarding this incident. In an orthopedic consult note dated 11/14/2025 the Physician's Assistant documented that the resident presented to the emergency room for a left shoulder dislocation likely secondary to hoyer (mechanical) lift. The facility was unable to provide any documented evidence that abuse, neglect or mistreatment had been ruled out related to the injury of unknown origin. In an interview on 02/14/2025 at 1:13 PM Registered Nurse Manager #3 stated that if a resident showed signs of pain and/or had signs of bruising they should start an investigation, go back 72 hours and have all staff write statements. Registered Nurse Manager #3 stated that they had misread Resident #63's x-ray dated 11/11/2024 and when they thought the x-ray was negative, they did not get staff statement or complete the investigation. In an interview on 02/14/2025 at 3:27 PM The Director of Nursing stated that they should investigate any injury of unknown origin to try to find the cause. After reviewing the investigation for Resident #63 The Director of Nursing stated that it was not a complete investigation and abuse, neglect, mistreatment could not be ruled out. 2.Resident #47 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE] included Resident #47 was severely impaired of cognitive function. Review of Resident #47 Comprehensive Care Plan dated 12/10/2024 revealed Resident #47 had impaired thought processes related to Alzheimer's dementia and a self-care deficit related to activities of daily living with impaired mobility secondary to cognitive function. Resident #47 required the assistance from staff with bed mobility and transfers. In an observation on 02/11/2025 at 11:00 AM Resident #47 had bruising to the left side of their face, a left eye bruise yellow green in color extending under the eye and to the side of the face. and blue/purple bruising to the lower jaw line extending down to left side of their neck, Review of an Injury of Unknown Cause report dated 02/07/2025 and completed by the Director of Nursing revealed that Resident #47 was being seen for bruises to the left side of the face near the temple and the left side of the neck under the ear (noted on 02/07/2025). The report included the resident required a mechanical lift for transfer and a possible cause could be improper sling placement. The report did not include if abuse, neglect or mistreatment had been identified or ruled out, and did not include statements from staff for the time prior to identification of the bruises. In an interview on 02/13/2025 at 12:08 PM a family member stated they had noticed the bruising first on 02/07/2025 and told the Social Worker. In an interview on 02/18/2025 at 2:33 PM Registered Nurse Manager #2 stated another nurse wrote the nursing progress note that they found bruising on Resident #47's neck and face and notified the Physician's Assistant. Registered Nurse Manager #2 said they did not know they needed to write anything up. In an interview on 02/19/2025 at 1:21 PM the Director of Nursing stated they were not made aware of this incident until yesterday (02/18/2025 11 days after the incident). 3.Resident #81 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated , 03/10/2024 documented that Resident #81 was cognitively intact and required substantial and/or maximal assistance for toileting hygiene and partial/moderate assistance for personal hygiene. Review of the Comprehensive Care Plan revised on 12/10/2023 revealed Resident #81 had an activities of daily living self-care performance deficit, limited physical mobility, and bowel incontinence. Interventions included that the resident was totally dependent on one staff for bathing, was non-weight bearing and required a mechanical lift for transfers and for staff to check (for incontinence) every two hours and assist with toileting as needed. Review of an Investigation Summary dated 03/27/2024 completed by Registered Nurse #1 revealed that on 03/24/2024 Resident #81 requested to see the Social Worker to report an incident that occurred when they requested to be changed. Resident #81 reported that Certified Nursing Assistant #3 came into the resident's room, was rough with them while they were on the edge of the bed and feared of falling and called them a curse word (started with a b). The summary of the investigation documented that profane language was said to the resident, the resident felt unsafe and was bothered by the Certified Nursing Assistants actions. There were no contributing factors identified. The Certified Nursing Assistant was removed from the schedule and was placed on the do not return list from the agency they were employed through. The investigation did not include any witness statements or follow up with the resident and/or other residents. During an interview on 02/19/2025 at 1:21 PM the Director of Nursing stated there should have been a statement from Certified Nursing Assistant #3 and after reviewing the documented investigation, the Director of Nursing stated they (the facility) could not rule out abuse, neglect, or mistreatment regarding Resident #81 and that the investigation was not complete. 4.Resident #80 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE], revealed Resident #80 was rarely or never understood. Review of an Investigation Summary initiated on 03/13/2024 signed by the Administrator revealed that an event occurred on 03/13/2024 at approximately 9:15 AM where Resident #80 had a sudden change in status and was noted to be rigid, shaking, and unresponsive to voice and touch. [MEDICATION NAME] (anti-anxiety medication often used to treat [MEDICAL CONDITION]) intramuscularly (administration of a medication by injecting into a muscle) was ordered for potential [MEDICAL CONDITION] activity. The [MEDICATION NAME] vial was unable to be obtained from the emergency box and the dose was not administered. Resident #80 received [MEDICATION NAME] (generic for [MEDICATION NAME]) sublingual (administration of a medication by placing under the tongue, which dissolves and is absorbed into the bloodstream) instead and was sent to the hospital for further evaluation related to the provider being concerned that there may have been a delay in treatment and to assess the resident's acute change in condition. Review of the facility's investigation related to the event did not include identified staff that were involved with the event, statements from staff involved, or investigative evidence as to why the intramuscular [MEDICATION NAME] was unavailable and actions taken to prevent future occurrences. Review of the facility's Nursing Home Investigative Report (submitted to the New York State Department of Health) dated 03/19/2024 included that all supervisors were reminded to make sure the keys (to the emergency narcotic medication box) were handed off to the next supervisor, and that reeducation was provided on the location of an extra set of keys. In an interview on 02/13/2025 at 3:54 PM, the Administrator stated they remembered the event, they (staff) thought Resident #80 was having a [MEDICAL CONDITION] and needed medication from the box, but they could not find the keys, so the resident was given the medication orally (by mouth). In an interview on 02/19/2025 at 1:21 PM, the Director of Nursing (not in the role at time of the event) said based on what they read in the record and review of the facility investigation, a complete review of what occurred at the time was not done. The Director of Nursing said that Investigative Summary did not address why the keys were missing and why the intramuscular medication was not given. The Director of Nursing stated there should have been statements from the staff members involved, and the facility's investigation was not thorough and complete. 10 NYCRR 415.4(b)(3) | Plan of Correction: ApprovedMarch 17, 2025 1. Immediate assessment of all residents involved to ensure safety. Residents' allegations were ruled out of neglect: mistreatment or potential abuse for residents #1, #63, #81, #80, and #103. No other residents were affected after the assessment. Injuries of Unknown Origin: Education a. Review of all reportable events. b. What is reportable? c. Process of report to DON/Administrator. 2. Process Change I. The nurse manager/nursing supervisor will obtain all statements when the event is noted. II. Discussion regarding the report done by DON and Administrator III. The report made IV. Investigation completed V. A and I committee scheduled before the 5th business day to review the statement, lab, x-ray results, care plan, care card, and other potential process issues. VI. Recommendations made a. Small subgroup will meet and adjust policies and procedures as needed. b. The final report will be placed in the folder with the reportable based on the recommendations made. Review and update facility Abuse, Neglect, and Mistreatment Prohibition, Investigation, and Reporting policy. The staff has been educated regarding the process that should be taken when the emergency medication box keys concerning resident #80 or any other resident. Discussions with the Lead Pharmacist and the Consultant Pharmacist have led us to discover that some processes need to be reviewed. This meeting will occur at 11 AM on Thursday, (MONTH) 19. The agenda items include but are not limited to the following things A. What is in the current e-box for resident changes in orders? A new list will be placed in the pharmacy book that sits on each unit. B. The Narcotic E box will list available items for the provider to order and nurses to use in an emergent situation. c. Addition of the most current policies regarding the pharmacy and obtaining medication after hours. D. Update of all 3 Pharmacy books and Education will be provided to all the Nursing staff on all three units. 3. Implemented mandatory training for all unit managers and clinical coordinators on reporting and proper investigation procedures. Established a dedicated investigative team chaired by the Administrator to handle all abuse, neglect, and mistreatment investigations. The committee will recommend education based on the nature of the inquiry; all education will be completed in 30 days. The facility will initiate an investigation checklist. 4. All investigation checklists will be audited monthly for three months and presented to the QAPI committee. The committee will determine the frequency of the audit thereafter. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review conducted during the Recertification Survey from 02/11/2025 to 02/19/2025, for two (first and third floors) of three resident-use floors, the facility did not properly maintain the resident call system. Specifically, nurse call system lights were not functioning properly to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area from each resident's bedside and toilet/bathing facilities. The findings are: Record review of the manufacturer's specification manual for the nurse call system, listed as Ascom, revealed the following: The system is equipped with a staff console for desktop communications, wall mounted annunciators similar to the staff consoles, and wall-mounted communications devices with buttons for creating nurse call events. Patients can place calls to the nursing station using handset buttons and pull cords which connect to room modules mounted on the wall near the bed or in bathrooms. Staff consoles and annunciators emit a tone to indicate when new calls are received, and the volume can be adjusted and the alert tone can be silenced temporarily. Console nighttime mode lets you quickly reduce the volume of a staff console to a preset level. Bedside modules and patient stations are mounted near beds in patient rooms which allow patients to call the nursing station from a bed or chair by pressing a button. Pressing a button for longer than 3 seconds without releasing the button may reset the module. When a cable is not connected properly or disconnected the lights on the bedside module flashes quickly to indicate an error condition (cord fault). To make a call from a handset a patient presses the large nurse call button on the handset and associated corridor and zone lights turn on to indicate active event, the call status light on the module illuminates, and tones sound at staff consoles and annunciators. The manufacturer's specification manual for the nurse call system also included a list of many different dome light signals for 8 auxiliary emergency nurse call event types including, but not limited to the following: Dome light colors red, blue, pink, amber, white, and green. Dome light flash rates fast, slow, on steady. Nurse call priority types room alarm, code blue, lavatory emergency, cord fault, urgent, staff presence, and service tasks. In an observation and interview on 02/11/2025 at 2:08 PM, Resident #109 (resident room [ROOM NUMBER]) pressed their bedside call button. When interviewed at this time, the resident stated they had not seen a Certified Nursing Assistant in a while since the call bell system did not work. Further observations included that upon pressing the call bell, two beeps were heard in the resident's room and no light outside the room was observed on or blinking. At 2:09 PM, Certified Nursing Assistant #3, entered the room and Resident #109 pressed their call button again. Certified Nursing Assistant #3 observed that the light outside the resident's room was not on. Certified Nursing Assistant #3 stated when a resident presses their call button and two beeps are heard, it means their call button needs to be reset. The call button was then reset by Certified Nursing Assistant #3 after several attempts. Certified Nursing Assistant #3 stated about three weeks prior, all call buttons were reset. Observations and interview on 02/12/2025 at 8:48 AM included the call light in resident room [ROOM NUMBER] (right side for Resident #88), was on and blinking white. When the surveyor pressed the button, the device on the wall beeped twice and then the entire box on the wall lit up in different colors. At this time, Certified Nursing Assistant #2 tried removing the call light from the wall, putting it in other slots, and pushing the call light twice, but the call light did not light up in the hall outside the room. During an interview at this time, Certified Nursing Assistant #2 stated they (call lights) do this sometimes, that the system is very sensitive, and if it is green, it means that it is working, if it is not green, then it does not work, and staff have to reset it. Observations on 02/12/2025 at 8:55 AM included review of call lights to see if they were working properly. Each of the following call lights were pushed by the surveyor and the device on the wall in the room blinked red twice, but the light above each door in the corridor did not light up, and there was no sound at the nurses station alerting that a resident needed help: resident room [ROOM NUMBER] left side (Resident #10), resident room [ROOM NUMBER] right side, #307 left side (no call light attached to the wall - Resident #28), #308 right side (Resident #88), #312 left side (Resident #64), #312 right side (Resident #29), #315 (Resident #106), #321 right side (Resident #15), and #330 (Resident #98). During an interview on 02/12/2025 at 9:53 AM, Registered Nurse #2 stated they have only one resident (Resident #10) that uses their call light and that staff use the call light to alert other staff that they need help, especially when in the bathroom or to get nurses to come to do a skin evaluation. Registered Nurse #2 stated if one of the call lights does not work, then the staff should let me know, and call maintenance to fix it. During on observation and interview on 02/12/2025 at 9:57 AM, the surveyor showed Registered Nurse #2 that resident room [ROOM NUMBER] left side (Resident #28) did not have a call light/cord plugged into the wall. Registered Nurse #2 stated this resident can use their call light. The call system panel on the wall near the bed was observed to not blink or provide indication that the call cord was not attached to the wall. Registered Nurse #2 then found the call light at the end of the bed, stated they did not know why it was pulled out of the wall, put the call light back on the wall, and it lit up green. During an observation and interview on 02/12/2025 at 9:58 AM the call light in resident room [ROOM NUMBER] left side (Resident #10) was pressed. The wall panel near the bed blinked and beeped twice but did not light up in the hall above the door. Registered Nurse #2 then removed the nurse call cord from the wall, put it back in, pressed the button, and the call light on the wall was still not working. When interviewed at this time Registered Nurse #2 stated they were not aware the light was not working, would let maintenance know, and that the evening and night shift staff use the call lights more than the day shift staff do. During an observation on 02/13/2025 at 11:26 AM the call light in resident room [ROOM NUMBER] (Resident #98) was pressed, the fixture on the wall turned red and beeped twice, then went blank. Additionally, the light above the door in the hall did not light up and the screen at the nurses' station did not alert that the call light in this room was activated. During an observation and interview on 02/13/2025 at 4:07 PM the nurse call light in resident room [ROOM NUMBER] (Resident #98) was pushed, blinked red twice at the panel in the room, and did not stay on in the hallway. Registered Nurse #2 pushed the call light again, a white light above the door in the hall came on for less than one second then turned off. During an interview at this time, Registered Nurse #2 stated it was not working, and if the light does not stay on in the hall, then it will not ring at the desk or at the stations in the hall, and staff would not know that the call light was on. In an observation on 02/14/2025 at 9:35 AM in resident room [ROOM NUMBER] Resident #28 was sitting in a chair with their call light/button in their hand and the other end of the call cord was not attached to the wall. The nurse call device on the wall in the room was not making any noise, did not show any activations, and the light above the door outside the room was not lit up. Additionally, a nurse call annunciator panel in the hallway displayed no active alerts and the screen at the nurses' station was not displaying any active calls. 10 NYCRR: 415.29, 415.29(b); 415.29(j)(1), 10 NYCRR: 713-3.25(g) | Plan of Correction: ApprovedMarch 17, 2025 1. Immediately inspected and tested all nurse call systems in the facility. All non-functional call lights were replaced, and all nurse call panels were reset. 2. Conducted a facility-wide audit to check the functionality of all nurse's calls in all residents?ÇÖ rooms. 3. Established a daily check by staff to ensure all call lights are operational. Implemented a preventive maintenance schedule for routine inspections and testing of the nurse call system. Training for nursing and maintenance staff on the importance of the nurse call system and how to report, reset, and escalate malfunctions to the facilities director will begin on 03/10/2025. Training will include video in-service training provided by the nurse call system company for all nursing and maintenance staff. 4. Weekly nurse call audits will be conducted on all units. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Responsible party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 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 02/11/2025 to 02/19/2025, the facility did not ensure the resident was free from significant medication errors for one (Resident #110) of six residents reviewed. Specifically, during an observation of medication administration, two cardiovascular medications were administered without evidence that vital signs were obtained prior to administration per physician orders [REDACTED]. This is evidenced by the following: The facility policy Medication Administration dated (MONTH) 2024, included that the nurse was responsible for questioning any medication order that in their judgment, is an error, not clear or illegible, or if they are uncertain, they should contact the physician, pharmacy or nursing supervisor for additional clarification. Additionally, medications that required vital sign parameters (included but not limited to blood pressure or heart rate), must be checked prior to preparing the medication and documented appropriately. Resident #110 had [DIAGNOSES REDACTED]. The Minimum Data Set Resident assessment dated [DATE], revealed Resident #110 was severely impaired cognitively. Review of current physician's orders [REDACTED]. a.[MEDICATION NAME] sustained release (medication that is released slowly over an extended period of time to sustain therapeutic levels) 60 milligrams twice daily for [MEDICAL CONDITION], with instructions to hold the dose and call the provider for heart rate less than 60 beats per minute or systolic blood pressure less than 100. b.[MEDICATION NAME] extended release (medication that is released gradually over a specific duration) 200 milligrams once daily for [MEDICAL CONDITION], with instructions to hold the dose and call the provider for heart rate less than 60 beats per minute or systolic blood pressure less than 100. During an observation of medication administration on 02/14/2025 at 9:33 AM, Licensed Practical Nurse Clinical Coordinator #1 said Resident #110 took their medications crushed, placed the [MEDICATION NAME] capsule in a medication cup then crushed the rest of the resident's medications (including the [MEDICATION NAME] extended-release tablet) and administered them. Licensed Practical Nurse Clinical Coordinator #1 was not observed to have obtained Resident #110's blood pressure or heart rate prior to giving the medications. Review of the electronic medical record on 02/14/2025 at 9:51 AM, revealed no documented evidence that vital signs including a blood pressure or heart rate had been obtained prior to administration of the resident's [MEDICATION NAME] and [MEDICATION NAME]. During an observation and interview on 02/14/2025 at 11:03 AM, Resident #110's [MEDICATION NAME] medication package had a pharmacy label with 'do not crush on it. When interviewed at the time Licensed Practical Nurse Clinical Coordinator #1 stated it was an error (to crush the pill). Licensed Practical Nurse Clinical Coordinator #1 stated they may have missed the hold parameters (in the physician orders [REDACTED].#110 should have had a blood pressure and heart rate checked (prior to administering) but they did not obtain them. During an interview on 02/14/2025 at 11:03 AM, Registered Nurse Manager #1 said if medication packaging was labeled to not crush, it should not be crushed. Registered Nurse Manager #1 stated the nurses should read the medication order to determine if there were hold parameters, and if there were parameters, they should be obtained shortly before giving the medication. During an interview on 02/9/2025 at 9:04 AM, Physician Assistant #1 said [MEDICATION NAME]-coated or extended-release tablets cannot be crushed because the medication would be too concentrated, would be released faster, and might be absorbed too quickly or not enough. Physician Assistant #1 stated the purpose of hold parameters would be to determine if the intended use of the medication was not needed. 10 NYCRR 415.12 (m)(2) | Plan of Correction: ApprovedMarch 17, 2025 1. Assessed resident #110 for any adverse reactions; none were noted. 2. The nurse manager was notified of the errors, and the Licensed practical nurse was immediately re-trained on proper medication administration. The facility has initiated identifying the resident's ability to take medication as a banner in the EMR. 3. The nurse educator initiated Immediate and ongoing education on medication administration, documentation, and error prevention strategies for all Licensed practical nurses. Conduct medication pass observation for all licensed practical nurses to ensure proper techniques and adherence to policies and procedures, starting 03/10/2025. 4. Implement two to three random weekly medication pass audits. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audits thereafter. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview conducted during the Recertification Survey from 02/11/2025 to 02/19/2025, for three (first, second and third floors) of three resident-use floors, the facility did not provide a functional and sanitary environment for residents and staff. Specifically, handwash sinks were not provided with hot water, a handwash sink was not functional, and resident stand assist lift footrests were dirty. The findings are: Observations during the initial tour of the main kitchen on 02/11/2025 at 8:55 AM included two self-dispensing motion activated hand washing sinks, one located near the dishwashing area and the other located near the walk-in coolers. When activated, each sink dispensed only cold water, one of which was measured at 43 degrees Fahrenheit using a digital thermometer. During an interview at this time, a dining services worker stated the water usually comes out cold. Observations on 02/11/2025 at 9:45 AM included a manual stand aid lift located on the third floor outside resident room [ROOM NUMBER] was marked as Unit 3 and the footrest tray was dirty with an accumulation of crumbs and debris. Observations on 02/11/2025 at 10:10 AM included a manual stand aid lift located on the second floor outside resident room [ROOM NUMBER] was marked as #9 and the footrest tray was dirty with an accumulation of crumbs and debris. Observations on 02/11/2025 at 10:48 AM included two stand assist lifts located on the first floor outside resident rooms #145 and #117 and the footrest trays were dirty with an accumulation of crumbs and debris. Observations on 02/12/2025 at 2:45 PM included the self-dispensing motion activated handwash sink in the third-floor beauty salon did not dispense water. Further observations throughout the day on 02/12/2025 revealed multiple residents receiving hair and grooming services in this room. During an interview via email on 02/13/2025 at 10:52 AM, the Director of Facilities stated the water was turned off (to the sink). Observations on 02/13/2025 at 11:18 AM included a Tollos brand sit-to-stand electric lift located on the first floor outside resident room [ROOM NUMBER] was marked as #11 and the footrest tray was dirty with an accumulation of crumbs and debris. 10 NYCRR: 415.29, 415.29(d), 415.29(j)(1), 10 NYCRR: 713-3.12, 10 NYCRR: 14-1.143(b) | Plan of Correction: ApprovedMarch 17, 2025 1. All manual stand-aid lifts were immediately cleaned. The sink mixing valve in the kitchen was replaced on 02/13/2025, and the beauty shop water was turned back on. 2. All sinks in the facility were checked and are in working order. Both hand-washing sinks provide adequate hot water on 02/13/2025 3. The director of facilities educated the beautician on the importance of not turning the sink water off. 4. Weekly cleaning audits for footrests on all manual and electrical residents' stand-assist lifts on all units and handwashing sinks will be conducted in the kitchen/Beauty shop. These results will be presented to the QA committee monthly for three months. The committee will determine the frequency of the audit thereafter. Responsible Party: Director of Facilities |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the Emergency Preparedness Plan review in conjunction with a Life Safety Code Survey from 02/11/2025 to 02/19/2025, the facility did not comply with emergency preparedness requirements. Specifically, the facility emergency contacts listed in the New York State Health Commerce System were not updated annually or with a change in staff. The findings are: On 02/12/2025 at 10:45 AM, the surveyor reviewed Emergency Office Roles listed for the facility in the New York State Health Commerce System. The contact information listed the following: the 24 by 7 Facility Contact was last updated 08/09/2021, the Director of Nursing was last updated 06/07/2023, the Emergency Medical Supplies Receiving Office was last updated 03/10/2020, and the Office of the Administrator was last updated 08/09/2021. Additionally, the name and contact information for the Director of Nursing was not current and listed an email address for a prior employee. During an interview on 02/13/2025 at 3:05 PM, the Administrator stated the information for the Director of Nursing was not current, and they would update the contact information. 42 CFR 483.73 - Emergency Preparedness 42 CFR: 483.73(c), 10 NYCRR: Part 400, Section 400.10, 400.10(d) | Plan of Correction: ApprovedMarch 5, 2025 1.Facility emergency contacts list was updated 02/13/2025 on the Health Commerce System. 2.All other facility contact lists were reviewed to ensure they were up to date as well to reflect our current staff. 3.The Contact list will be updated annually by Administrator. All pertinent staff will be educated on the need to ensure this list is always current and up to date. 4.A copy of emergency contact list will be presented to QAPI committee monthly for three months to ensure accuracy. Then the QA committee will determine the needed audit frequency thereafter. Responsible Party: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on observations and interview conducted during a Life Safety Code Survey from 02/11/2025 to 02/19/2025, for one of one outdoor oxygen storage location, the facility did not properly maintain medical gases. Specifically, oxygen cylinders were stored in an outdoor storage area unprotected from inclement weather. The findings are: Observations on 02/13/2025 at 10:12 AM included a large wheeled green metal rack holding 77 full E-size oxygen cylinders with an accumulation of snow and melting snow on some of the oxygen tanks located outside the first-floor Mechanical room. This large rack was observed to be covered on the top, only, and open on all four sides. Additionally, at this time there as was an uncovered wheeled cart holding 10 full E-size oxygen cylinders, next to the larger mobile rack. During an interview at this time, the Director of Facilities stated they could probably put the tanks in the lean to area or an enclosure. The 2012 edition of NFPA 99, Standard for Health Care Facilities, requires: Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. Cylinders stored in the open shall be protected as follows: (1) Against extremes of weather and from the ground beneath to prevent rusting. (2) During winter, against accumulations of ice or snow. (3) During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail. 10 NYCRR 415.29(a)(2), 711.2(a)(1), 2012 NFPA 101: 19.3.2.4, 2012 NFPA 99: 11.3.2.1, 11.6.5.4 | Plan of Correction: ApprovedMarch 5, 2025 1.Facility ordered and will install an enclosure that meets NFPA 99 standards. Facility immediately ensured all gas cylinders are stored upright and were properly secured with chains and straps to prevent tipping. ?Ç£No smoking?Ç¥ and ?Ç£Flammable gas?Ç¥ signs have also been placed in visible locations around storage area. Also, the facility clearly labeled full and empty cylinders to ensure separation. 2.A facility wide review was conducted to ensure all 02 cylinders throughout the facility were stored properly. The facility also Implements a weekly inspection checklist for gas storage compliance and documentation. 3.All pertinent facility staff will be educated on the proper use, transport and storage of full and empty 02 cylinders. 4.The facility will conduct a monthly audit of 02-cylinder storage for three months. These results will be presented to the QA committee for review. The committee will determine the needed frequency of the audit thereafter. Responsible Party: Director of Facilities |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 19, 2025
Corrected date: N/A
Citation Details Based on observations?áand interview during a Life Safety Code?áSurvey from 02/11/2025 to 02/19/2025, for one (first floor) of three resident use floors the facility did not properly maintain vertical openings.?á Specifically, there were unsealed openings through a fire rated enclosure of an elevator shaft. The findings are:?á Observations on 02/11/2025 at 10:48 AM, included unsealed openings through the elevator shaft located in the first-floor elevator equipment room as follows: two approximately 1/2-inch by three-inch openings around electrical raceways, and two approximately 1/2-inch by three-inch semi-circular openings around hydraulic lines. The openings were observed to extend through the concrete block wall into the elevator shaft. Further observations included two elevators serving the first, second, and third floors of the facility. During an interview at this time, a Maintenance Staff Member stated that some upgrades to the elevators were done a couple months ago. 10 NYCRR: 415.29(a)(2), 711.2(a)(1),?á 2012 NFPA 101: 19.3.1, 19.3.1.1, 8.6.2 | Plan of Correction: ApprovedMarch 5, 2025 1.Facility conducted an immediate inspection on all vertical openings in the elevator shaft on 02/12/2025. All unsealed openings were sealed immediately by facilities staff using fire rated materials on 02/12/2025. 2.Maintenance performed a facility wide audit of all openings to identify any additional unsealed openings. All openings were sealed by facilities staff. 3.Education will be provided to all pertinent staff regarding the importance of sealing any needed openings/penetrations in fire walls. 4.A monthly audit of fire wall penetrations will be conducted monthly for three months. A copy of the audits will be presented to QAPI committee who will then decide the needed frequency of the audits thereafter. Responsible Party: Director of Facilities |