NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: February 25, 2025
Citation Details Based on observations, record review, and interviews during the Recertification Survey initiated on 12/26/2024 and completed on 1/2/2025, the facility did not ensure that food was served in accordance with professional standards for food service safety. This was identified for one (Madison) of three dining rooms during the Dining Task. Specifically, the facility did not monitor the temperature of cold food items served to the residents during a lunch meal observation on 12/30/2024 at 12:22 PM. The temperature of two yogurt containers measured at 60 and 62 degrees Fahrenheit (normal range: below 41 degrees Fahrenheit.) The finding is: The facility's policy and procedure titled Food Safety/Storage/Distribution/Service/Procurement - General dated 6/2024, documented Danger Zone refers to temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Food Service/Distribution refers to the processes involved in getting food to the resident. This may include holding foods under refrigeration for cold temperature control. Refrigerated Storage: potentially hazardous foods (examples include yogurt) must be maintained at or below 41 degrees Fahrenheit. During the lunch meal service in the(NAME)dining room on 12/30/2024 at 12:22 PM, the Dietary Supervisor measured the temperature of two yogurt containers on the individual resident trays prior to being delivered from the kitchen to the dining room. The yogurt measured 60 degrees and 62 degrees Fahrenheit. The Dietary Supervisor was immediately interviewed and stated there was an increased risk for infection and/or gastrointestinal issues if the food was served outside of the proper serving/holding temperatures. During an interview on 12/30/2024 at 1:03 PM, the Food Service Director stated the temperature of the yogurt and cold food items are checked when the items are placed onto the individual resident trays and the trays are then stored in the walk-in refrigerator unit until the time of service. The Food Service Director stated that the resident trays were delivered to the dining room at approximately 11:55 AM-12 noon. The Food Service Director stated that 60 degrees Fahrenheit is not the proper serving temperature for yogurt or any cold food and should be below 42 degrees Fahrenheit. The Food Service Director the residents can get sick from the cold food served at a temperature above 42 degrees as there is an increased risk of bacterial growth. During an interview on 1/2/2025 at 12:10 PM, the Administrator stated they were not aware of an issue with the cold food items being served above the safe temperature zone prior to notification during the survey process. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedJanuary 28, 2025 Plan of Correction FTAG 657 SS:D I. Immediate Action a. Resident #21 is still residing in the facility. resident #21 was affected by this deficient practice. All residents requiring staff assistance with activities of daily living including toileting transfer and toileting hygiene and are non-compliant with activities of daily living have the potential to be affected by this practice No other residents were affected. b. Certified Nurse's Aide #1was educated on 1/16/25 by the Assistant Director of Nursing on following all the instructions for providing care to the residents as documented on the Nursing Assistant Accountability Records with emphasis on reporting all non-compliance observed by the resident to the Nurse and rendering the level of assistance as instructed on the residents Accountability Records. Emphasis also reinforcing that a resident noncompliance does not remove the responsibility from the staff member to render the level of assistance documented on the Accountability record to provide the resident care. c. The resident's noncompliance care plan was reviewed by the ADNS on 1/15/25 and updated with interventions including staff member offering toileting q 2 hours and prn and must always remain with the resident during toileting hygiene and toileting transfer task to maintain the safety of the resident at all times and to ensure any non-compliance with care is addressed. d. The Residents Activity of Daily Living Care plan was reviewed by the ADNS on 1/15/25 and updated with interventions including offering toileting q2 and prn staff member must remain with the resident at all times for all ADL care requiring staff assistance to monitor and provide assistance and maintain the resident's safety at all times. Also updated to include minimal assistance of one person for toileting hygiene and moderate assist of one person for toilet transfer. e. The Nursing Aide Accountability record was reviewed by the ADNS on 1/15/25 and updated to include staff member must render the level of assistance as documented on the residents' instructions. Also updated to include offer resident toileting q2 hrs. and prn, minimal assistance of one person for toileting hygiene and moderate assistance of one person for toilet transfer and to report all residents refusal of care and noncompliance to the nurse. f. RN #1 was provided with 1:1 education by the ADNS on 1/16/2025 on updating the Accountability record for the resident care to include intervention for monitoring residents with noncompliance. Ensuring noncompliance behavior has an intervention including interventions for offering toileting to the resident q2 and prn and for staff members to remain with the resident during all tasks requiring assistance and to ensure residents safety is maintained and also to follow up and reevaluate the effectiveness of these interventions with the IDT Team to ensure compliance. g. All LPN's who worked on unit(NAME)on 12/26/24 were provided with 1:1 education by the ADNS on 1/17/25 on following all instructions for care for the residents and reinforcing and ensuring the Aides are following the resident's plan of care. If a resident demonstrates non-compliance the RN should be notified and the necessary, follow up be done with the MD and the IDT team. The resident's non-compliance does not remove the staff responsibility for rendering the level of care documented on the care instructions. II. Identification of Others: a. An audit was conducted on 1/15/25 by the ADNS for all residents in house with noncompliance care plans related to ADL care including toileting self and requiring staff assistance. There were no negative findings of this audit. III. System Changes a. The Facility's Policy and Procedure Titled Comprehensive Care Plan and Resident Meeting dated (MONTH) 2024 was reviewed on 1/16/25 by the Medical Director, Director of Nursing, and the Administrator with no changes made. b. All Licensed Nurses will be re-educated by the Inservice Coordinator/designee on the Policy and Procedure Titled Comprehensive Care Plan and Resident/Patient Meeting with emphasis on reviewing and revising the comprehensive care plan with interventions to meet the resident's current needs. IV. Quality Assurance a. An audit tool was created by the Director of Nursing to review all residents with new episodes of non-compliance with Activities of Daily Living to ensure there are appropriate interventions to address the resident's non-compliance and ensure the Aides accountability record and the residents noncompliance care plan is updated with these instructions and interventions. b. Audits will be completed by the ADNS/Designee on 25 % of all residents on each unit weekly x 4, then monthly x 2 months and quarterly thereafter until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Director of Nursing immediately. All negative findings will be immediately addressed by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4. ( to review and discuss any unfavorable patterns that may prevent achieving 100% compliance) V. Person Responsible. Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: February 25, 2025
Citation Details 2012 NFPA 101: 19. 3. 6. 3. 5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19. 3. 5. 7. 2012 NFPA 101: 19. 3. 6. 3. 10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled. Based on observation and staff interviews the facility did not ensure that corridor doors were provided with suitable means to keep the door open in accordance with NFPA 101:Life Safety Code. Specifically, a corridor door observed held open with an unapproved hold open device. The finding is: On (MONTH) 27, 2024, at approximately 10:50 AM, during the Life Safety Code recertification survey, it was noted that the door to the(NAME)dining room was held open with a hand sanitizer portable stand. The Director of Environmental Services, who was present at the time of observation, acknowledged the finding. On (MONTH) 27, 2024, at approximately 3:45 PM, during the exit interview, the Corporate Environmental Coordinator stated that a magnet tied to the fire alarm will be placed to hold open the door. 2012 NFPA 101: 19. 3. 6. 3. 5*, 19. 3. 6. 3. 10* NYCRR 711. 2(a) (1) | Plan of Correction: ApprovedJanuary 28, 2025 Plan of Correction F812 SS:D I. Immediate Action a. All residents' trays in the(NAME)dining room receiving yogurts on 12/30/24 was immediately removed from the trays and replaced with new items from the kitchen transported to the dining room on ice by the Food Service Director. All residents receiving yogurt at meals have the potential to be affected by this practice. No residents were affected. b. The Dietary Supervisor received 1:1 education on 1/16/25 by the Assistant Director of Nursing with the Food Service Director present on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served within the safe temperature. Any items identified outside the safe temperature zone must be immediately discarded. All items requiring refrigeration must be refrigerated. c. The Food Service Director was in serviced on 1/16/25 by the RN (ADNS)on transporting all yogurt and milk on ice to the assigned serving area and adding items to tray at the time the tray is being served to the resident to ensure the items are served to the resident within the safe temperature. All food items requiring refrigeration must be refrigerated and any items identified outside of the safe temperature zone must be immediately discarded. II. Identification of Others: a. All residents receiving yogurt at meal services have the potential to be affected by this deficient practice. No residents were affected. b. An audit was conducted on 1/16/25 by the Food Service Director including temperature check of all yogurts for resident in house receiving yogurt at meals with no negative findings. III. System Changes a. The Policy and Procedure Titled Food Safety/Storage/Distribution/Service Procurement General dated 6/2024 was reviewed on 1/16/25 by the Medical Director, Food service Director and the Administrator with no changes made. b. All Dietary employees will be re-in-service on the Facility's Policy Titled Food Safety/Storage/Distribution/Service/Procurement by the Food Service Director and the Educator /Designee. IV. Quality Assurance a. An audit tool was created by the Administrator to conduct random temperature checks for all residents receiving yogurt and milk at random meals to identify any unsafe temperature to ensure items are stored and served at a safe temperature. b. Audits will be completed by the Food Service Director daily x 30 days then bi -weekly x 4, then monthly x 2 months and quarterly x 3 quarters until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Administrator immediately and addressed by the Food Service Director/Designee immediately. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable trend that may prevent achieving 100% compliance. V. Person Responsible. Administrator. VI. Completion date: 2/25/25 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2025
Corrected date: January 27, 2025
Citation Details None | Plan of Correction: ApprovedJanuary 28, 2025 I. Plan of Correction for Affected Residents: The facility respectively states that no Residents were affected by this deficient practice 2) On 12/27/2024 The Director of Maintenance removed the portable hand sanitizer stand that was preventing the(NAME)dining room door from closing. 3) 0n 01/14/2025 The Director of Maintenance contacted the Fire Alarm contractor to provide a proposal to install magnetic hold open devices that are connected to the fire alarm system that will release when the fire alarm is activated. That proposal was received on 01/17/2025 and has been approved. The magnetic hold open devices will be installed by 02/28/ 2025. II. Plan of Correction to identify other Residents Potentially Affected: All residents have the potential to be affected by this deficient practice. On 01/14/2025 The Director of Maintenance inspected all corridors doors and no other areas of noncompliance were noted. III. Plan of Correction for Systems Changes and Measures to Prevent Recurrence: A) On 01/14/2025 The Director of Maintenance in conjunction with maintenance staff reviewed the requirements for K363 to understand and implement the corrective actions. B) Environment rounds will be done for all corridor doors to ensure that they resist the passage of smoke. C) Findings of rounds will be recorded in an audit tool located in the maintenance log book. IV. Plan of Correction for Monitoring Corrective Actions: A) The Director of Maintenance/designee created an audit tool and will conduct quarterly audits of the corridor doors for 12 months to ensure compliance with 2012 NFPA 101: 7. 10. 2, 7. 10. 2. 1, 10 NYCRR: 711. 2 (a) B) The Director of Maintenance/designee will report findings of the audit to Administrator. C) Any negative findings from these audits will be immediately addressed by the Director of Maintenance and Administrator. The findings of these audits will be discussed at the quarterly QAPI meetings to discuss any unfavorable trends and patterns that may prevent achieving 100% compliance. I. Responsible Discipline: The Director of Maintenance is responsible to ensure that all components of the plan of correction have been implemented and that compliance has been achieved. Date of Completion: 02/28/202 |