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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification and abbreviated (NY 93 and NY 139) surveys conducted 1/13/2025-1/17/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 1 resident (Resident #119) reviewed. Specifically, Resident #119 was not provided oral care as planned. Findings include: The facility policy, Activities of Daily Living Support, revised 1/2025, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility policy, Mouth Care, dated 1/2022, documented residents' lips and oral tissues were kept moist, and the mouth should be cleansed and freshened to prevent oral infection. The equipment and supplies necessary included toothpaste, emesis basin, and applicators or gauze sponges. Resident #119 had a [DIAGNOSES REDACTED]. The 11/8/2024 Minimum Data Set Assessment documented that the resident was cognitively intact, did not reject care, and required substantial/maximal assistance with oral hygiene. The 12/20/2024 Comprehensive Care Plan for activities of daily living documented that the resident required substantial/maximum assistance for oral hygiene. Intervention included a helper was needed to perform more than half of the oral hygiene for the resident, the resident had their own teeth, and observe the mouth for sores, gum irritation, and any complaint of tooth pain. During an interview and observation on 1/13/2025 at 1:21 PM the resident had a thick white substance on their mouth and tongue. The resident stated their teeth were not brushed at all that day or the day before. They stated, historically when they had the ability to care for their own mouth, it was done 2-3 times a day. The resident stated the aides were busy and did not get time to clean their mouth every day. During an interviews and observations on 1/14/2025 at 1:43 PM the resident was in bed and stated oral care was not done and they had a very dry mouth. The resident's mouth appeared dry. At 3:45 PM the resident stated they had not received oral care. The resident's tongue and lips were dry. During an interview and observation on 1/15/2025 at 10:02 AM Certified Nurse Aide # 8 provided care to Resident # 119. Certified Nurse Aide # 8 completed the bed bath and incontinence care, dressed the resident in a clean gown, gave the resident their call bell and exited the room. Certified Nurse Aide # 8 stated the care for the resident was complete and they did not offer oral care. Oral care should have been offered and provided but was missed in error. They stated it was important to maintain excellent oral care for the resident to maintain cleanliness and to check for sores in resident's mouth. During an interview on 1/16/25 at 9:00 AM Licensed Practical Nurse Unit Manager #5 stated the resident should have oral care done morning and night. It was important to maintain optimal oral care as it was essential to the resident's hygiene and just to feel good. Licensed Practical Nurse Unit Manager #5 stated the resident was on thickened liquids and their mouth had thick secretions as a result. The resident was also on a blood thinner, and they used the green sponge swabs to clean their mouth to avoid bleeding. Licensed Practical Nurse Unit Manager #5 was unaware that oral care was not provided for Resident # 119. During an interview on 1/16/2025 at 2:00 PM Registered Nurse Unit Manager #9 stated they expected oral care to be done minimally in the morning and in the evening by the certified nurse aides and documented in the electronic medical record. Oral care was documented as not being done for the resident on 1/13/2025, 1/14/1025, and 1/15/2025 during the day shifts. 10 NYCRR 412. 12(A)(3) | Plan of Correction: ApprovedMarch 6, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Educate #8 C.N.A and all C.N.As on oral care under ADLs - Resident #119 was provided oral care The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit ADL/Oral care for residents who are care planned for assistance The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on ADL/Oral Care to all CNAs - Check Resident #119 morning and afternoon for 2 weeks, then weekly x3 months for ensuring oral care is being provided. The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit Oral/ADL care for residents who need assistance x5 per unit/week for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager |
Scope: N/A
Severity: N/A
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on interviews and record review during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure the submission of a New York State Department of Health Request for Criminal History Record Check (department of Health Criminal History Record Check form 103) for 2 of 5 employees (Employees #28 and #29) reviewed. Specifically, there was no documented evidence New York State Department of Health Request for Criminal History Record Check form 103 was submitted for Employees #28 and # 29. Finding Include: The facility policy, Criminal History Record Checks, revised 11/29/18, documented the Director of Human Resources or designee must obtain from the prospective employee a signed authorization for the search and exchange of the records, Form 102. There was no documented evidence in Employees #28 and #29 personnel files a New York State Department of Health Request for Criminal History Record Check form 103 was submitted. During an interview on 1/15/2025 at 9:45 AM, Human Resources Director #30 stated Form 102 was part of the application packet received by prospective employees. Human Resources Director #30 stated they did not have Form 103 for Employees #28 and# 29. They realized staff did not have the required Criminal History Record Check paperwork when they pulled the files requested by the surveyor. Human Resources Director #30 stated there were gaps in the policy that required procedures be put in place to ensure this did not happen again. 10 NYCRR 402. 6 | Plan of Correction: ApprovedFebruary 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Form 103 Criminal History and Record Check completed for employees #28 & #29 The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit employee files for form 103 for CHRC The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education to Human Resources on CHRC regulation/license The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Auditing of new hires and current employees for form 103 to occur x10/month for 3 months at 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Human Resources |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 kitchen walk-in coolers. Specifically, the left walk-in cooler was not maintaining proper temperature. Findings include: The facility did not have a policy or procedure for preventative maintenance of the walk-in coolers. The facility policy, Food Storage, revised 7/2023, documented perishable food such as meat, poultry, fish, dairy products, fruits, vegetables, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees Fahrenheit. All refrigerator units were kept clean and in good working condition at all times. Potentially hazardous food, or time/temperature control for safety food must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures were maintained at or below 41 degrees Fahrenheit. During an interview on 1/14/25 at 11:03 AM, Food Service Director #26 stated coolers were checked every morning between 2:30 AM and 3:30 AM, and every evening between 7:30 PM and 8:30 PM. They stated they did not check the cooler temperature at any other times during the day. The facility's Refrigeration Temperature Record for the left walk-in cooler (log sheet labeled #2) documented the temperature was 36 at 3:30 AM on 1/14/ 2025. Staff could not identify the initials of the person who recorded the temperature. During an observation on 1/14/2025 at 10:46 AM, a small plastic 6-inch by 6-inch container labeled ground frank and beans and dated 1/9 was located on the top shelf of the left walk-in cooler and was measured at 45 degrees Fahrenheit. On a lower shelf, a shallow plastic container of ham salad was measured at 47 degrees Fahrenheit; and pulled pork measured at 46 degrees Fahrenheit. The external thermometer on the walk-in cooler read 45 degrees Fahrenheit. A small white plastic thermometer just inside the cooler read 30 degrees Fahrenheit. During an observation and interview on 1/14/2025 at 1:00 PM, the contents of the left walk-in cooler were measured with Regional Food Service Director # 18. The plastic 6-inch by 6-inch container of ground frank and beans was measured at 45 degrees Fahrenheit, ham salad was measured at 47 degrees Fahrenheit, a one gallon jug of olives measured at 48 degrees Fahrenheit, a 5-pound block of ham measured at 46 degrees Fahrenheit, and left over pork chops were measured at 46 degrees Fahrenheit. A small white thermometer at the front of the cooler read 32 degrees Fahrenheit and the external thermometer read 45 degrees Fahrenheit. Regional Food Service Director #18 stated the cooler temperatures were checked daily. The morning staff had already left for the day, and they could not find anyone who knew how long some items were in the cooler. They stated they did not know how long the cooler was out of temperature. The following items were measured and discarded: items dated 1/15/2025: rice 51 degrees Fahrenheit; ground pork 46 degrees Fahrenheit; ground chicken 47 degrees Fahrenheit; 2 full hotel pans of pork 49 - 51 degrees Fahrenheit, 1 and a half hotel pans of turkey stew 52 degrees Fahrenheit, pureed chicken 54 degrees Fahrenheit; items dated 1/13: hot dogs (half hotel pan) 47 degrees Fahrenheit, pureed chicken 49 degrees Fahrenheit; beef stew 46 degrees Fahrenheit; ground chicken 47 degrees Fahrenheit; pureed pasta 46 degrees Fahrenheit; pureed tuna 46 degrees Fahrenheit; half deli ham - 46 degrees Fahrenheit; half deli turkey 47 degrees Fahrenheit; and 3 full hotel pans of beef stew 46 - 47 degrees Fahrenheit 47; and a pan of ground turkey dated 1/12 was measured at 50 degrees Fahrenheit. During an interview on 1/14/2025 at 1:07 PM, Dietary Aide #17 stated they checked and documented cooler temperatures occasionally as part of their routine duties. They stated for the left walk-in cooler, they used the small white thermometer just inside the cooler. They stated they were not sure what the required temperatures were and would have to look on the form posted beside the cooler. During an interview on 1/15/2025 at 3:13 PM, Regional Food Service Director #18 stated the cooler temperatures should have been 41 degrees and below. If something was out of temperature, the process was to notify the supervisor who checked the food, transferred the food within temperature to another location, and discarded food out of temperature. They stated staff checked the cooler by reading the thermometer and they did not measure the temperature of the contents to ensure the thermometer was correct. They stated it was important for foods to be properly stored to prevent the growth of bacteria that could cause foodborne illness. Bacteria could grow quickly resulting in residents becoming sick which was of great concern due to resident's underlying conditions and immune systems that might not be strong enough to fight off the bacteria. 10NYCRR 415. 29 | Plan of Correction: ApprovedFebruary 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Disposal of all food within the left walk-in cooler - Vendor came in the same day to inspect the unit, adjustment to the thermostat made The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - All refrigeration units in the kitchen were inspected to ensure they are in proper working order and maintaining temps within required range The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Implement a Policy and Procedure for preventative maintenance on walk-in coolers - Cooler temperature log revised to monitor temps 3x/day - Dietary staff educated on the new temperature log and the requirements for cold food storage The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Auditing walk-in cooler x3 a day for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, food stored in the walk-in freezer was not protected, kitchen lighting was not properly shielded, and there were multiple unclean and uncleanable surfaces. Findings include: The facility policy, Food Storage, last reviewed 7/2023 documented: - food was stored in an area that was clean, dry, and free from contaminants. - all foods should be covered, labeled, and dated. - all refrigerator units were always kept clean and in good working condition. - all freezer units were always kept clean and in good working condition. The light bulb specifications provided by the facility did not document the bulbs were coated or shatter resistant. The following observations were made in the main kitchen: - on 1/14/2025 at 10:47 AM, there was an uncovered open box of hamburgers, an open junction box with exposed wiring, ice build-up on the ceiling, and food and packaging debris under shelving in the walk-in freezer. - on 1/14/2025 at 10:53 AM, the majority of the lights in the kitchen were not protected. - on 1/14/2025 at 11:26 AM, the condenser outside of the cooler had dirt and grease build-up. - on 1/14/2025 at 12:47 PM, the cove molding tiling was in disrepair beneath the two-bay sink. - on 1/14/2025 at 1:49 PM, there were several broken floor tiles under the three-door freezer in the dry storage room. During an interview on 1/15/2025 at 3:13 PM, Regional Food Service Director #18 stated it was important to have foods properly stored in the coolers to prevent contamination from something spilling into the food and fans blowing material into the food products. Floors should have been swept during the day and mopped at night. The stock person was responsible for cleaning the walk-in coolers. The walk-in freezer should have been cleaned weekly. There should not be packaging or food debris under the shelving. Broken floor tiles were not smooth and not easily cleanable. They stated it was important floors and equipment were kept clean to prevent cross-contamination, bacteria transmission, and pest control. Cleaning of the kitchen should be documented on the sanitation logs and periodic audits were conducted. The Kitchen Cleaning log audit for 12/2024 and 1/2025 was blank without entries. During an interview on 1/15/2025 at 3:36 PM, Kitchen Supervisor #27 stated they were not sure how long exactly the light covers had been missing from the kitchen, but they had been missing for several years. They were also not sure if the bulbs were shatter resistant. They stated it was important lights in the kitchen were protected to prevent light bulb fragments and other foreign objects such as insects and dust from falling into food. 10NYCRR 415. 14(h) | Plan of Correction: ApprovedMarch 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Dispose of uncovered hamburgers in box in cooler - Fixed and cover the exposed wiring within the junction box - Remove ice buildup on the ceiling, and identify and correct source of ice - Remove and dispose of food and packaging debris under shelving in walk-in-freezer - Lights uncovered in kitchen ÔÇ£ Replace with Shatterproof bulbs - Clean outside cooler of debris and dirt - Repair cove base below 2- sink bay - Repair/Replace tiles under 3-door freezer The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit kitchen for food procurement, storage, preparedness and serving - Work orders placed for any areas requiring repair The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on food procurement and storage in the kitchen to dietary staff The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Auditing food procurement and storage in the kitchen through the cleaning log for the kitchen for x1/day for 4 weeks, then x1/week for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview during the recertification and abbreviated (NY 139) surveys conducted 1/13/2025-1/17/2025, the facility did not ensure prompt efforts were made to resolve grievances for 9 of 9 anonymous residents and 1 additional resident (Resident #446) reviewed. Specifically, 9 of 9 residents during the resident group meeting stated they did not know who the grievance official was or how to file a grievance. Long call bell wait times were a recurrent complaint in the monthly resident council meetings and Resident #446 had filed a grievance regarding long call bell wait times. Findings include: The facility policy, Grievance/ Complaint Procedure, reviewed 11/2023 documented the facility provided residents the means and assistance to file a grievance or complaint concerning their treatment. The Director of Social Services served as the facility's grievance official. The facility policy, Call (NAME), reviewed 3/2024 documented call bells were answered promptly by all employees. The facility policy, Resident Rights, reviewed 3/2024 documented residents had the right to voice grievances and have the facility respond to those grievances. During a resident group meeting on 1/13/2025 at 2:03 PM, 9 anonymous residents stated the Director of Activities was present during monthly resident council meetings and recorded the group's concerns. They were not sure if the facility had an official grievance officer or who that person was. They had never filed a formal grievance and were not sure of the process. Long call bell wait times were an ongoing problem they voiced at the monthly meetings and continued to be an issue. Certified nurse aides were taking breaks together leaving minimal staff on the floor to answer the call bells. The resident council meeting notes documented call bell timeliness concerns were included in the 7/17/2024, 8/21/2024, 9/18/2024, 10/16/2024, and 11/27/2024 meetings. The Director of Social Services and the Director of Activities were listed as staff in attendance for the (MONTH) 2024- (MONTH) 2024 meetings. The grievance log from (MONTH) 2024-January 2025 documented a formal grievance was filed for call bell timeliness on 1/11/2025 by Resident # 446. From 1/13/2025-1/17/2025, there was no posted information observed in the facility related to the facility grievance officer, contact information, or accessible grievance forms. The following call bell observations were made: - On 1/13/2025 at 12:22 PM, the call light in room [ROOM NUMBER] went off. At 12:35 PM an unidentified staff member entered and exited the room, and the call bell continued to go off. At 12:35 PM, the Registered Nurse Unit Manager #7, looked down the hallway with the active call bell and went into their office. At 12:36 PM, an unidentified staff walked past room [ROOM NUMBER] with the call bell still activated. At 12:39 PM, the call bell was answered. - On 1/13/2025 at 12:31 PM, the 3-tone alarm panel displayed room [ROOM NUMBER]'s call bell had been going off for 43 minutes. - On 1/14/2025 at 8:21 AM, the 3-tone alarm panel displayed room [ROOM NUMBER]'s call bell had been going off for 28 minutes. An unidentified licensed practical nurse was standing at the nurse's station desk and an unidentified staff was in the office labeled unit manager across from the alarm panel display and 2 unidentified staff members were talking in the secretary's office behind the nurse's station. - On 1/14/2025 at 2:36 PM, the call bell was initiated in room 358. At 3:03 PM, the call bell was answered. - On 1/15/2025 at 9:20 AM, the 3-tone alarm panel displayed room [ROOM NUMBER]'s call bell had been going off for 45 minutes. During an interview on 1/17/2025 at 9:12 AM, the Director of Activities stated they attended all resident council meetings and long call bell times were a recurrent monthly complaint and had been as long as they had been employed at the facility. These concerns went to the Administrator and the Director of Nursing. It was important call bells were answered timely because it meant the resident needed something and staff was there to take care of the residents' needs. During an interview on 1/17/2025 at 9:35 AM, the Director of Social Services stated they were the official grievance officer. There were frequent complaints of long call bell wait times on all units. Long call bell times were investigated through the formal grievance process. The nurse managers investigated what staff were working on during the call bell complaint and education was provided. They were aware of certified nurse aides going on breaks together, but they should not be unless they were on separate units. It was important call bells were answered timely for resident safety and care. It was important grievances were responded to timely, so the residents felt heard and that they were taken seriously. During an interview on 1/17/2025 at 9:46 AM, the Director of Nursing stated long call bell wait times were a frequent grievance. In-services were completed and staff assignments were changed. The goal was as nursing management strengthened; long call bell times could be corrected. This was a global issue, and all staff were responsible to answer the call bells. They had not yet found a solution that worked to correct long call bell wait times but was working on it. It was important call bells were answered timely because the resident needed attention in that moment. 10NYCRR 415. 13(C)(1)(ii) | Plan of Correction: ApprovedMarch 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Public post throughout the facility the Official Grievance Officer, their contact information, and where to file an official grievance - Educate nursing staff on call bell timeliness - Review with resident council who the grievance officer is and how to contact them - Notify Resident #446 of grievance outcome and resolution and complainant satisfaction and reassessment if needed. The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit Call (NAME) wait times, educate, monitor and enforce timeliness - Audit units for posting on Grievance Officer name, contact information and process/availability ÔÇ£ ensure posting of information is available throughout the facility The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on the Grievance Procedure/Officer to resident council - Education on Call-Bell Timeliness to LPN/CNA staff The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Post information on Grievance Officer, contact information and process/availability to file a grievance - Audit Call (NAME) Timeliness x5 a week per unit for 3 continuous months for 100% compliance The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure they established and maintained an infection prevention and 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 1 of 1 resident (Resident #17) reviewed and 1 of 5 medications rooms (2 South B). Specifically, Resident #17's urinary drainage collection bag was not stored in a manner to prevent contamination and was observed lying directly on the floor, and the 2 South B side medication room sink was not functional. Findings include: The facility policy, Infection Prevention and Control, revised 5/2024, documented to prevent the spread of disease, handwashing was encouraged. The facility policy, Urinary Catheter Care, revised 5/2024, documented catheter tubing and drainage bags were kept off the floor. 1) Resident #17 had [DIAGNOSES REDACTED]. The 10/25/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, had an indwelling urinary, and had [MEDICAL CONDITION]. The 7/1/2024 Nurse Practitioner #20 medical order documented the resident was to have a 16-inch French (size of the catheter) urinary catheter for [MEDICAL CONDITION]. The Comprehensive Care Plan dated 11/1/2024 documented Resident #17 had an alteration in bladder elimination related to [MEDICAL CONDITION]. Interventions included a urinary catheter, the urinary drainage bag should be covered with a dignity bag and kept below the bladder and observe for signs and symptoms of urinary tract infections. During observations on 1/14/2025 at 1:22 PM and 2:56 PM, Resident #17's urinary catheter drainage bag was laying under the bed directly on the floor without a barrier. During an interview on 1/15/2025 at 8:19 AM, Certified Nurse Aide #13 stated they cared for Resident #17 a few times that week during the day shift. They received catheter training when they were hired, and it was important to keep drainage bags off the floor for infection control reasons. The floor was dirty, and Resident #17 could develop a urinary tract infection. During an interview on 1/15/2025 at 8:51 AM, Licensed Practical Nurse #21 stated certified nurse aides and nurses were responsible for catheter care. The drainage bag should never touch the floor and should always be in a dignity bag. If the drainage bag was on the floor, it should be sanitized and switched out for a new one. They stated floors were dirty with bacteria, which could cause Resident #17 to develop a urinary tract infection. During an interview on 1/16/2025 at 3:53 PM, Registered Nurse Unit Manager #22 stated nursing staff received training on catheters when hired. Urinary drainage bags were to be hung on the wheelchair or bedframe, so they did not touch the floor. If the drainage bag was on the floor, they expected nursing staff to pick it up off the floor immediately and clean the bag or change it out for a new one. They stated it was important for Resident #17's drainage bags to be kept off the floor because floors were dirty, and it could put the resident at risk for an infection. During an interview on 1/17/2025 at 9:20 AM, Infection Preventionist #23 stated urinary drainage bags should be kept below the resident's waist, in a blue dignity bag, and should not rest on the floor. The floor was dirty, the bag could become contaminated and lead to a urinary tract infection. 2) During an observation and interview on 1/15/2025 at 8:51 AM, the sink in the 2 South B side medication room had a white substance on both handles, rust on the right side of the handle, towels in the sink, and a basin over the towels on each side of the sink. The water was not able to be turned on. Licensed Practical Nurse #21 stated they notified maintenance months ago there was a problem with the sink. They shut the water off and there was no longer running water in the medication room. If you wanted to wash your hands you went to the nearest bathroom. They carried their own hand sanitizer in their pocket because proper hand hygiene was the number one way to prevent an infection. Facility Work Orders dated (MONTH) 2024 to (MONTH) 2025 documented: - on 12/2/2024 a work order was placed for the 2 South Nurse's Station sink for flooding and a broken sink. The work order was closed on 12/4/2024, it was a repeat work order, and there was a temporary fix in place completed by Maintenance Technician # 25. - on 12/6/2024 a work order was placed for the 2 South Nurse's Station medication room leaking sink. It was closed on 12/10/ 2024. There were no visible leaks, and everything was dry, and the lines were checked. Maintenance Technician #25 spoke with the nurses. During an interview on 1/16/2025 at 1:42 PM, Maintenance Director #4 stated their department was responsible for maintaining rooms in the facility. When they received a work order, they looked at the problem, ordered parts if necessary, and fixed any issues, most of them within 24 hours. Faucets were fixed in 24 hours as it was important for staff and residents to have running water to wash their hands. They had not been in the medication room on 2 South B side recently. Maintenance Director #4 observed the sink, and stated there was a significant buildup of calcium along with rust. They were not sure why the sink was turned off. There should be a functioning sink in the medication room to wash hands. During an interview on 1/16/2025 at 3:53 PM, Registered Nurse Unit Manager #22 stated hand washing was the best way to prevent an infection and there was not a functioning sink in the 2 South B side medication room since at least September. They had completed a work order, and it remained broken. Staff could use the sink in the dining room to wash their hands. During an interview on 1/17/2025 at 9:20 AM, Infection Preventionist #23 stated handwashing was the primary way to prevent the spread of infections. They were not aware there was a sink that was not functioning in the medication room of 2 South B side. All sinks should be in working order. 10 NYCRR 415. 19 | Plan of Correction: ApprovedFebruary 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Replace Resident #17 urinary catheter bag and place dignity bag over it, ensuring there is no contact with the ground when hung from the bed or wheelchair - Clean and repair the sink in the medication room on 2 South The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit all urinary catheter bags in the facility and educate Nursing Staff on infection prevention - Audit all sinks in medication rooms to be sanitary and in working order. Educate maintenance department on timely work order responses The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on infection prevention (specifically catheters) to Nursing Staff The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Auditing urinary catheter bags throughout the facility x5/week times 3 months at 100% - Auditing work order system repair timeliness and effectiveness x 5/week at 3 month 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Infection Preventionist |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards for expiration dates for 2 of 5 medication carts (3 North A side and 2 North A side carts) and 1 of 3 medication storage rooms (3 North) reviewed, and 1 medication cart (3 south B side cart) was observed unlocked and unattended. Specifically, the 3 North A Side cart had eye drops, multidose diabetic pens (device used to deliver injectable medication), a multidose insulin vial, and inhalers without opened or discard dates; the 2 North A side cart had multidose diabetic pens without opened dates or discard dates, and a multidose diabetic pen without a resident identifier or an opened or discard date; the 3 North medication refrigerator contained a multidose influenza vaccine vial and a multidose [MEDICATION NAME] vial that were expired; and an additional multidose influenza vaccine vial that did not have an opened date or discard date. Additionally, the 3 South B side cart was observed unlocked and unattended in the common resident hallway. Findings include: The facility policy, Storage of Medications revised 8/2024 documented medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations. The medication supply was accessible only to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies were locked when they were not attended by persons with authorized access. Outdated medications were immediately removed from inventory, disposed of, and reordered from the pharmacy. Certain medications such as multiple dose injectable vials and ophthalmic (eye) medications required an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. The nurse placed a date opened sticker on the medication and recorded the dated opened and the new date of expiration. The expiration date of the vial or container was 30 days from opening unless the manufacturer recommended another date. The nurse checked the expiration date of each medication before administering it. Expired medications were not administered. During an observation on 1/14/2024 at 8:35 AM, the 3 North A side medication cart was observed with Licensed Practical Nurse # 24. Resident #43 had opened [MEDICATION NAME] (antibiotic) 0. 3% eye drops without an opened or expiration/ discard date; Resident #45 had an opened Ozempic (GLP-1 agonist) multidose pen and 2 opened Trelegy Ellipta inhalers (treats [MEDICAL CONDITION]) without an opened or expiration/ discard date; Resident #59 had an opened [MEDICATION NAME] (insulin) multidose pen, an opened Humalog (insulin) multidose vial, and a Trelegy Ellipta inhaler without opened or expiration/ discard dates; Resident #111 had an opened [MEDICATION NAME] multidose pen and 2 opened Anoro Ellipta inhalers without opened or expiration/ discard dates; and Resident #125 had opened [MEDICATION NAME] (steroid) 1% eye drops and [MEDICATION NAME] (treats irritation) 0. 5% eye drops without opened or expired/ discard dates. Licensed Practical Nurse #24 stated without opened dates, they would not know if a medication was good. The nurse that opened the medications was responsible they were dated. Nurses were also responsible to look at the medication dates prior to administration. Insulin was good for 30 days and the eye drops, and the inhalers should also follow the 30 day expiration rule. If expired medications were given, they were not as effective. They did not think they had given any of the undated medications this morning. During an observation on 1/14/2025 at 8:54 AM, the 3 North Medication Storage room was observed with Licensed Practical Nurse # 25. The refrigerator contained an opened box with a multidose vial of influenza vaccines with a date on the box of 11/2024 and an opened box of [MEDICATION NAME] skin test multidose vial with a date on the box of 11/ 2024. There was also an opened box with a multidose vial of influenza vaccines that did not have an opened or expiration/ discard date. Licensed Practical Nurse #24 stated these vials were good for 30 days and if they were not dated it would not be known if they were any good. During an interview on 1/14/2025 at 9:04 AM, Registered Nurse Unit Manager #9 stated all multidose medications were labeled when opened so the nurses knew how long they were good for. The date was checked by the nurse before administering medications to make sure they were not expired. Expired medications could be less effective or there could be adverse reactions. They did audits of the medication carts weekly and ensured medications were dated and not expired. There was a document from the pharmacy the nurses checked if they were unsure how long a medication was good for. Insulins, eye drops, and inhalers all had expiration dates. During an observation on 1/14/2025 at 9:06 AM, the 2 South A side medication cart was observed with Licensed Practical Nurse # 21. Resident #76 had an opened Basaglar (insulin) multidose pen without an opened or expiration/ discard date; Resident #163 had an opened Humalog (insulin) multidose pen without an opened or expiration/ discard date; and there was a Trulicity multidose pen without resident identifiers or an opened or expiration/ discard date. Licensed Practical Nurse #21 stated without opened dates, there was no way of knowing when the medications expired. Expired medications were not as effective, and residents could have higher blood sugars if they received these expired mediations. Insulins were good for 40 days. During an interview on 1/16/2025 at 3:53 PM, Registered Nurse Unit Manager #22 stated medications were labeled when they were opened so the nurses knew how long they were good for. If a medication was not dated it needed to be thrown out because they would not know if the medication was still good. Insulin was good for 28 days and if it was expired, it may not effectively manage blood sugar. During an observation on 1/17/2025 at 8:44 AM, the 3 South B side medication cart was unlocked and unattended in the hallway. Licensed Practical Nurse Unit Manager #5 stated they just stepped away for a moment to put their coffee in the office. They stated residents and other staff should not have access to their medication cart. During an interview on 1/17/2025 at 9:46 AM, the Director of Nursing stated insulins should have been dated when opened or the nurse could not guarantee the effectiveness of the medication and that it was not expired. All medications were only guaranteed effective for certain time. The nurse that opened the medication was responsible it was dated. The night shift was supposed to check the carts and removed items that were expired or not dated as opened. No medications should be administered without an opened date. Expired medications were no longer in their intended form. Medication carts should be locked when not attended. The expectation was nurses hit the lock button on the cart any time they walked away from it. 10NYCRR 415. 18(d) | Plan of Correction: ApprovedMarch 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Dispose of opened and unlabeled medications from Med carts 3 North A and 2 South A, and influenza vaccine vials and tuberclin vial from 3 North Medication Storage Room. The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit all medication carts, rooms and refrigerators The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Educate all nurses on medication labeling and storage - Educate all nurses on locking medication carts when left unattended The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit all medication carts, rooms and refrigerators x1 per unit/week for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals (the 1/14/2025 1st floor lunch meal and the 1/15/2025 3rd floor lunch meal) reviewed. Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/14/2025 and 1/15/ . Additionally, 9 of 9 anonymous residents present at the Resident Council meeting and Resident #103 stated the food was not appetizing. Findings include: The 1/2022 updated facility policy, Food Temperatures, documented all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the portioning, transporting, and delivery process until received by the individual recipient. During an interview on 1/13/2025 at 12:39 PM, Resident #103 stated the food was not hot and was not palatable. During a resident group interview on 1/13/2025 at 2:30 PM, 9 anonymous residents stated the food was not hot and was lukewarm. Their concerns included burnt grilled cheese sandwiches, the meat was tough, noodles were overcooked, and there was not enough variety with ham every week. The cold foods were not served cold. During a 1st floor lunch meal observation on 1/14/2025 at 12:13 PM Resident #7 was served their lunch meal tray and used as a test ray. The resident refused a replacement meal, as they had ordered food from outside the facility. The ham was measured at 121. 1 degrees Fahrenheit, the corn was 113. 9 degrees Fahrenheit, and the orange juice was 52 degrees Fahrenheit. The food temperatures were verified by Licensed Practical Nurse # 12. The ham was very dried out, with a jerky like appearance, and the corn was tough with a plastic texture to the casing. During an interview on 1/15/2025 at 8:19 AM, Certified Nurse Aide #13 stated that residents complained about the food, and some would order out instead of eating the facility food. During a 3rd floor lunch meal observation on 1/15/2025 at 12:39 PM Resident #173 was served their lunch meal tray. A replacement tray was ordered, and Resident #173's original meal tray was tested . The tuna noodle casserole was measure at 133 degrees Fahrenheit, the cooked carrots were 110. 8 degrees Fahrenheit, the mashed potatoes were 126. 9 degrees Fahrenheit, and the gravy was 128. 5 degrees Fahrenheit. The food temperatures were verified by Certified Nurse Aide # 14. During an interview on 1/17/2025 at 9:12 AM, the Director of Activities stated there were recurrent food complaints during the Resident Council meetings. The complaints included cold food, not getting the food they wanted, and waiting too long for their called down second-choice meal to arrive. The Director of Activities stated residents should enjoy their food. If they did not eat it could lead to weight loss, skin problems, and poor quality of life. During an interview on 1/17/2025 at 9:42 AM, Dietary Aide #17 stated hot food should be served at a temperature higher than 140 degrees Fahrenheit, and cold food should be served under 40 degrees Fahrenheit. The temperatures of the tuna noodle casserole, carrots, mashed potatoes, gravy, ham, and the corn were too cold. The orange juice was too warm for a cold beverage. Food should be palatable and served at appropriate temperatures. It should look appetizing as we eat with our eyes first. If it did not look good to the kitchen staff, it would not look good to the residents. It was important for residents to enjoy their food for proper nutrition and healing purposes. During an interview on 1/17/2025 at 10:02 AM, the Corporate Regional Director stated hot food should be served at 135 degrees Fahrenheit or higher, and cold food should be 41 degrees Fahrenheit or below to remain out of the danger zone. Residents should have palatable and enjoyable food. It was important to serve the residents food at appropriate temperatures because bacteria could grow in the danger zone between 41 degrees Fahrenheit and 135 degrees Fahrenheit and could make them sick. The tuna noodle casserole, cooked carrots, mashed potatoes, gravy, ham, and corn temperatures were not acceptable. 10NYCRR 415. 14(d)(1)(2) | Plan of Correction: ApprovedMarch 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - The affected residents were provided with replacement meal trays The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit meals using test trays - when arriving to the dining table check if meal is at temperatures that are appropriate: Hot food 135 degrees F or higher and cold items 41 degrees or lower, and taste if meal is flavorful. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on food temperatures to dietary staff The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit meals arriving to the residents table are at temperatures that are appropriate: Hot food 135 degrees F or higher and cold items 41 degrees or lower. Items to be palatable and adequately appetizing. Audit x3 meals for 1 month then 1 meal per month x3 months until 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services |
Scope: N/A
Severity: N/A
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the recertification survey conducted 1/13/2025 - 1/17/2025, the facility failed to obtain a signed Acknowledgment and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form (Criminal History Record Check form 102) for 2 of 5 employees (Employees #28 and #29) reviewed. Specifically, Employees #28 and #29 did not have Criminal History Record Check form 102. Findings include: The facility policy, Criminal History Record Checks, revised 11/29/18, documented the Director of Human Resources or designee must obtain from the prospective employee a signed authorization for the search and exchange of the records, Form 102. There was no documented evidence Employees #28 and #29 had a completed and signed Acknowledgment and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form (Criminal History Record Check form 102). During an interview on 1/15/2025 at 9:45 AM, Human Resources Director #30 stated Form 102 was part of the application packet received by prospective employees. Human Resources Director #30 confirmed Form 102 for Employees #28 and #29 was not completed. They stated they realized the employees did not have the required Criminal History Record Check form 102 when they pulled the files requested by the surveyor. They stated there were gaps in the policy that required procedures be put in place to ensure this did not happen again. 10NYCRR 402. 5 | Plan of Correction: ApprovedFebruary 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Form 102 Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form completed for employees #28 & #29 The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit employee files for form 102 for CHRC The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education to Human Resources on CHRC regulation/license The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Auditing of new hires and current employees for form 102 to occur x10/month for 3 months at 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Human Resources |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews during the recertification survey conducted 1/13/2025-1/19/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 5 resident units (Units 2 North, 2 South, and 3 South) reviewed. Specifically, Units 2 North, 2 South and 3 South had several walls with missing paint, patched up holes unpainted, resident room doors with missing thresholds where dirt/debris had collected, missing tiles, dirty linen on the resident room floors, and the 2 south dining room that was not decorated or homelike. Findings include: The facility policy, Resident Rights, revised 2/2022, documented the residents had rights to a dignified existence. The facility policy, Quality of Life- Homelike Environment, revised on 2/2022, documented the residents were provided a safe, clean and comfortable and homelike environment. The facility staff and management should to the extent possible, reflect a personalized homelike setting that included clean, sanitary, and orderly environment, inviting colors and d?â?®cor. The undated facility Housekeeper/Room Attendant Job Description documented the housekeepers were responsible for the cleaning and sanitation of the facility daily. All housekeepers must report problems, concerns, and maintenance issues to the supervisor. Review of the facility work orders dated 11/1/2024 to 1/16/2025 there were multiple open work orders that had not been completed. The following were observations on 2 north unit: - On 1/13/2025 at 10:46 AM, room [ROOM NUMBER]-B, there was a large approximately 2 feet tall by 6 inches wide scraped missing painted area on the wall behind the head of bed. - On 1/16/2025 at 7:38 AM, room [ROOM NUMBER]- B, the wall to the right of the head of the bed there was an unpainted 10 x 10-inch spot of plaster. During an interview on 1/17/2025 at 9:36 AM, Registered Nurse Unit Manger #7 stated the staff should use the computer to enter a work order if they noticed something needed to be fixed. For a home-like environment, the walls in the residents' room should be maintained. They were not aware of any issues with the walls in rooms 265-B and 272-B. The following were observations on 2 South unit: - On 1/13/2025 at 10:29 AM, room [ROOM NUMBER], missing floor tiles near the bed and peeling paint around the bathroom sink. - On 1/13/2025 at 11:04 AM, room [ROOM NUMBER], the door threshold was missing and caused an uneven floor surface. - On 1/13/2025 at 12:55 PM, room [ROOM NUMBER] had several empty 2 liter bottles of soda on the floor and at the foot of the resident's bed. The door threshold was missing that caused an uneven floor surface and the area was discolored black and brown. - On 1/14/2025 at 8:46 AM, room [ROOM NUMBER] the door threshold was missing and caused an uneven floor surface. - On 1/14/2025 At 1:09 PM, room [ROOM NUMBER] had a bag of dirty linens on floor, there was a pizza box resting on the trash can, four 2 liter bottles of soda on the floor at the foot of the bed, and the doorway threshold was missing leaving a black and brown surface and uneven floor.- At 1:09 PM, room [ROOM NUMBER] had a bag of dirty linens on floor, there was a pizza box resting on the trash can, four 2-Liter bottles of soda on the floor at the foot of the bed, and the doorway threshold was missing leaving a black and brown surface and uneven floor. - On 1/14/2025 at 1:12 PM, room [ROOM NUMBER] had 3 bags of dirty linens under sink and towel on the floor saturated with yellow colored liquid. - On 1/14/2025 at 2:49 PM, room [ROOM NUMBER] had a grapefruit sized missing paint spot to the right of the door when opened, several areas of scuffed missing paint on the left wall entering the resident's room and a missing floor tile outside the door that was covered with brown debris. - On 1/15/2025 at 11:35 AM, room [ROOM NUMBER] had a sticky yellow fluid on the floor the size of a basketball at the bottom of the bed. - On 1/16/2025 at 10:32 AM, room [ROOM NUMBER] was missing portions of the door threshold causing an uneven floor surface. - On 1/16/2025 at 10:33 AM, room [ROOM NUMBER] was missing the threshold between the door and hallway. The area contained a black and brownish substance and caused an uneven floor surface; and there were 2 bags of dirty linen on the floor at the foot of the bed. - On 1/16/2025 at 10:40 AM, the dining room on 2 South had a hole in the wall near the floor, and the molding was discolored black. There was missing paint on the wall under the left side of the television and on the right side there was a white patched, unpainted area. Other than a blank chalk board and a clock, there were no homelike or personalized items. - On 1/16/2025 at 10:46 AM, room [ROOM NUMBER] had a missing threshold and the area on the floor was discolored and uneven, and on the left side of the wall when entering the room, there was a patched-up section of wall with missing paint. During an interview on 1/16/2025 at 10:47 AM, Certified Nurse Aide #1 stated when something on the unit was broken, they were supposed to put in a work order on the computer and it would go to the appropriate department. They confirmed the threshold in room [ROOM NUMBER] was mostly missing and the area was brown. They stated they would notify maintenance because it was a tripping hazard. They confirmed there was also missing paint in the same room. The one bigger spot was from when there was a hole in the wall that was patched up and it was not repainted. The holes and missing paint were not homelike. They stated the bags of dirty linen should not be left on the floor as it was an infection control issue, and it was not homelike. They were not sure why the walls at the end of the hallway were painted different colors. They stated room [ROOM NUMBER] was missing most of the threshold and was discolored and this was a tripping hazards, they always catch their own shoe on it. During an interview on 1/16/2025 at 10:58 AM, Housekeeper #2 stated they were responsible for cleaning rooms, bathrooms, nurses' station, and dining room and shower rooms. They stated if they saw something broken, they would remove and replace it. If there was something they could not fix they would put in a work order, and which went directly to maintenance. Maintenance was responsible for replacing thresholds in the doorways. Missing thresholds would be a tripping hazard. They stated they have seen dirty linen on the floor in resident rooms. The certified nurse aides were responsible to place dirty linen in the dirty room. Dirty linens and uneven floors were not homelike. The following observations on were made on 3 south: - On 1/15/2025 at 3:27 PM, the door across from the nurses' station was missing the molding on the doorknob side, and the door behind the nurses' station had a large scrape across the middle of the door. - On 1/16/2025 at 10:18 AM, the door jam and framing around room [ROOM NUMBER] had several spots of palm sized chipped and peeling paint. - On 1/17/25 at 8:41 AM, on 3 south room [ROOM NUMBER], the door jam and framing had several palm sized areas of chipped and peeling paint remained. At 8:42 AM, there was a door across from the 3 south nurses station missing molding on the doorknob side and the door behind the nurses' station had a large scrape across the middle. At 8:43 AM, the clean linen room door was still missing paint across middle of door between molding. During an interview on 1/17/2025 at 8:44 AM, License Practical Nurse Unit Manager #5 stated if they noticed an environmental issue they would complete a work order. Typically, the issue was fixed the same day. Any staff member could fill out a work order. They had not noticed the molding across from nurses' station or clean linen door missing paint. It was not homelike for the residents. During an interview on 1/17/2025 at 8:49 AM, Certified Nurse Aide #6 stated if they noticed a maintenance issue, they would notify the charge nurse or fill out a work order. They had not noticed the missing paint or the missing molding. They stated it was an eyesore and not homelike for the residents. During an interview on 1/16/25 at 1:18 PM, the Director of Housekeeping and Laundry stated every day one of the residents' room were assigned to be deep | Plan of Correction: ApprovedFebruary 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - 272B: Paint scrap behind the head of bed - 265B: Paint unpainted plaster - 225: Put in floor tile, paint near bathroom sink, put in door threshold - 220: Put in floor tile outside door, paint wall, put in door threshold - 206: Put in door threshold, pick-up and clean dirty linen and trash in room - 203: Put in door threshold, clean trash - 202: Clean sticky yellow spot at base of bed on the floor - 201: Put in door threshold - 2 South Dining Room: repair hole in wall near floor, paint under television, paint unpatched patch on right side, add personalization to dining room with wall decals and colored paint, and picture frames - 3 South Supply Closet: Add molding to doorknob side - 3 South Nurses Station: Paint door scratch behind nurses station - 305: Paint door jam frame paint chips The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit all units for homelike environment: All resident areas The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on homelike environment to maintenance and housekeeping departments The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit Resident areas on units for homelike environment x1 Month for 3 consistent months at 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **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 1/13/2025 to 1/17/2025, the facility did not ensure electrical equipment was maintained in accordance with National Fire Protection Association 99 for 2 non patient care electrical equipment reviewed (resident room [ROOM NUMBER] electric tree, resident room [ROOM NUMBER] compact disc player). Specifically, the above-mentioned resident rooms had electrical equipment that lacked asset labels. Findings include: The electrical equipment/quality control policy, last revised 3/13/2024, documented that: - non patient care electrical equipment must be tagged with a numbered asset label and another label with the date and signature of inspector; and - non patient care electrical equipment shall be tested on ce every two years. During an observation on 1/13/2025 at 11:15 AM, resident room [ROOM NUMBER] had an electric tree that lacked an asset label. During an observation on 1/13/2025 at 11:50 AM, resident room [ROOM NUMBER] had a compact disc player that lacked an asset label. During an interview on 1/14/2025 at 12:20 PM, the Director of Maintenance was not aware that the resident room [ROOM NUMBER] electric tree and resident room [ROOM NUMBER] compact disc player both lacked asset labels. They stated they could not provide documentation that the electrical equipment had been initially inspected or that they had been inspected every two years. The Director of Maintenance stated that as per policy a label with an asset number would be placed on electrical equipment after having been initially inspected. They stated it was important that all resident owned equipment was maintained for the safety of the residents and staff. 2012 NFPA 99: 10. 5. 3 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - 372 electric tree inspected and tagged with a number asset label and another label with date and signature of inspector - 260 compact disc player inspected and tagged with a number asset label and another label with date and signature of inspector The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit electrical equipment within the facility for proper inspection labels, ensure done every two years The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on Electrical Equipment (NFPA 99) inspection and labeling to maintenance department The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit electrical equipment for inspection and labeling 10x/month for 3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code recertification survey conducted 1/13/2025 to 1/17/2025, the facility did not ensure that hazardous areas were maintained for 1 isolated room (first-floor soiled utility room). Specifically, there were unsealed holes in the first-floor soiled utility room access door. Findings include: During an observation on 1/13/2025 at 10:40 AM, the first-floor soiled utility room had three unsealed small holes through the door. During an interview on 1/14/2025 at 3:50 PM, the Director of Maintenance stated that the existing locking mechanism had broken on the first-floor soiled utility room door approximately two weeks ago and a temporary lock had been installed on the door. They did not realize that the existing holes in the door had not been sealed when the temporary lock was installed. They stated it was important that hazardous area doors were properly sealed to prevent the spread of smoke to other areas. 2012 NFPA 101 19. 3. 2. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1).2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Seal x3 small holes in the 1st floor soiled utility room access door. The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit hazardous area room doors The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on hazardous area enclosure provided to maintenance staff The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit all hazardous doors x3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details **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 1/13/2025 to 1/17/2025, the facility did not ensure the automatic sprinkler system was maintained for 8 areas. Specifically, there were missing ceiling tiles in the third-floor north housekeeping closet, the third-floor north air handler room, and the second-floor south soiled utility room; the second-floor south utility room had a ceiling sprinkler head with a missing escutcheon; the main kitchen had sprinkler heads with unapproved escutcheons; there were damaged sprinkler heads in the main kitchen dish machine area; the oxygen storage room had a side-wall sprinkler head with the safety cover still on it; and improper sprinkler heads had been installed in the main kitchen emergency exit exterior pathway. Findings include: The facility's quarterly sprinkler inspections, dated 9/19/2024 and 12/10/2024, did not document any sprinkler deficiencies. 1. Missing Ceiling Tiles During an observation on 1/13/2025 at 11:05 AM, the third-floor north housekeeping closet was missing a 2-foot by 4-foot ceiling tile. During an observation on 1/13/2025 at 11:31 AM, the third-floor north air handler room was missing an 8-inch by 2-foot ceiling tile. During an observation on 1/13/2025 at 12:25 PM, the second-floor south soiled utility room was missing a 6-inch by 4-foot ceiling tile. During an interview on 1/14/2025 at 2:15 PM, the Director of Maintenance stated the third-floor north air handler room was checked for life safety compliance during the quarterly building inspections. They were not aware of the missing ceiling tile in the third-floor north air handler room and stated there would be no reason for a staff person to remove a ceiling tile from this room. The Director of Maintenance was not aware of the missing ceiling tiles in the third floor north housekeeping closet and the second-floor south soiled utility room. They stated that all staff entering these rooms had been in-serviced initially upon hire and knew how to submit work orders, and no work orders could be found for the missing ceiling tiles in the above-mentioned rooms. The Director of Maintenance stated it was important that there were no missing ceiling tiles because smoke and fire could spread to other areas, and it could prevent the sprinkler system from properly functioning. 2. Missing and Incorrect Sprinkler Escutcheons During an observation on 1/13/2025 at 12:12 PM, the second-floor south utility room had a ceiling sprinkler head that was missing the escutcheon. During an observation on 1/14/2025 at 11:15 AM, the main kitchen had 7 sprinkler heads with pipe backing plates in place of escutcheons. During an interview on 1/14/2025 at 2:25 PM, the Director of Maintenance was not aware of the missing sprinkler escutcheon in the second-floor south utility room and stated that an escutcheon was required. They stated the sprinkler head escutcheons in the main kitchen had not been replaced in [AGE] years. The Director of Maintenance stated it was important that all sprinkler heads had the appropriate escutcheons to prevent smoke and fire from spreading to other areas. 3. Damaged Sprinkler Heads During an observation on 1/14/2025 at 11:00 AM, the main kitchen dish machine area had 3 sprinkler heads with bent deflectors and 1 rusty corroded sprinkler head. During an interview on 1/14/2025 at 2:35 PM, the Director of Maintenance stated the 12/10/2024 quarterly sprinkler system inspection did not document any bent or damaged sprinkler heads in the main kitchen. They stated they assumed the sprinkler vendor who had completed the quarterly inspections was checking every sprinkler head as part of their job. The Director of Maintenance stated the sprinkler heads installed in the main kitchen had been in there since being hired [AGE] years ago. They stated it was important that all sprinklers were maintained so they would function properly when needed. 4. Installed Sprinkler Head with Safety Cover During an observation on 1/14/2025 at 11:08 AM, the oxygen storage room had a side-wall sprinkler head installed with the safety cover still on it. During an interview on 1/14/2025 at 2:48 PM, the Director of Maintenance was not aware the side-wall sprinkler head in the oxygen storage room still had the safety cover still on it. They stated this side-wall sprinkler head had been installed 6 months ago and once installed the safety cover for this sprinkler should have been removed by the vendor. The Director of Maintenance verified the 9/19/2024 and 12/10/2024 quarterly sprinkler system inspections did not document this sprinkler deficiency. 5. Improper Sprinklers During an observation on 1/14/2025 at 3:13 PM, the main kitchen emergency exit exterior pathway had blue high heat sprinklers installed. The location did not contain any heat sources, and it was covered by a metal roof. During an interview on 1/14/2025 at 3:15 PM, the Director of Maintenance was not aware that blue high heat sprinkler heads were only allowed in specific locations associated with high heat production. They stated it was the sprinkler vendors responsibility to install the proper temperature rated sprinkler heads. The Director of Maintenance stated that exterior area behind the main kitchen was not a high heat area. 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 5 2011 NFPA 25: 5. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Put in ceiling tiles in the third-floor north housekeeping closet, the third-floor north air handler room, and the second-floor south soiled utility room - Put in escutcheon for sprinkler head on second-floor south utility room - Fix and replace main kitchen sprinkler heads (7) with unapproved escutcheons; and replace damaged sprinkler heads (3) in the main kitchen dish machine area - oxygen storage room sprinkler head cover removed - improper sprinkler heads removed and replaced in the main kitchen emergency exit exterior pathway The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit ceiling tiles and sprinklers in facility The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education ceiling tiles to maintenance department - Education on sprinklers to maintenance department The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit ceiling tiles x3 months 100% - Audit sprinklers x2/month for 3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 17, 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 1/13/2025 to 1/17/2025, the facility failed to ensure that subsistence needs for residents and staff were maintained. Specifically, the emergency food supply was not properly maintained according to the facility's plan. Findings include: Emergency Pharmaceutical Supplies The facility's undated emergency preparedness policy documented on the Emergency Menu that 3. 2 cases of beef stew and 3. 5 cases of meat ravioli were required to be on hand. The facility's Emergency Menu Review, Quarterly Emergency Menu Review documented by signing below, the facility emergency menu has been reviewed for compliance. The menu was posted appropriately. All items were adequately stocked and within the acceptable use by dates. The form was signed and dated by the Food Service Director most recently on 12/2/ 2024. During an observation and interview on 1/14/2025 at 11:17 AM, the emergency food supply had one case of beef stew on hand. The meat ravioli was not present. The Food Service Director stated the ravioli was not available when they attempted to order that last and they planned to substitute meat sauce and rice instead. They did not realize they were also missing beef stew. The facility did not have any documentation to show beef stew and meat ravioli were not available from their vendor or that they had attempted to order the missing items. 42 CFR: 483. 73(b)(1) | Plan of Correction: ApprovedMay 5, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Update emergency menu to available in house items for emergency preparedness The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit Emergency food stock The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Emergency food stock education to dietary department The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit emergency food audit x1/day for 4 weeks, then 4/month for 3 months, 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey conducted 1/13/2025 to 1/17/2025, the facility did not ensure electrical equipment had approved wiring with NFPA 70, 2011 Edition for 2 rooms. Specifically, the main kitchen milk walk-in cooler light had liquid in the protective glass cover and the main kitchen walk-in freezer had an open junction box with exposed electrical wires. Findings include: During an observation and interview on 1/14/2025 at 11:03 AM, the main kitchen milk walk-in cooler light had liquid in the protective glass cover. The Food Service Director stated the light had been like that for several years and they were not sure how the water got in the light fixture. During an observation on 1/14/2025 at 11:05 AM, the main kitchen walk-in freezer had an open junction box with exposed electrical wires. These wires were in the direct path of the installed side-wall sprinkler head. During an interview on 1/14/2025 at 2:54 PM, the Director of Maintenance stated they were not aware that the main kitchen milk walk-in cooler light fixture was submerged in water. They stated that the water in the light cover could short out the light and this was not acceptable. The Director of Maintenance stated the main kitchen walk-in freezer electrical junction box did have a protective cover installed over it about a year ago, but they were not aware that was missing. They stated without the protective cover there were exposed wires and there were no work orders regarding the missing protective cover. The Director of Maintenance stated that all kitchen staff had been trained to submit work orders and a work order regarding the issues identified in the walk-in cooler and the walk-in freezer. They stated it was important loose electrical wires and electrical lights were kept away from water for the safety of the staff. 2012 NFPA 101: 19. 5. 1, 9. 1. 2 2011 NFPA 70 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Main Kitchen walk-in cooler changed to NFPA 70 2011 Edition approved wiring - Junction box in Main Kitchen walk in freezer exposed wire replaced by covered NFPA 70 2011 Edition approved wiring The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit electric and gas equipment The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on Electrical Equipment (NFPA) to maintenance department The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit electrical and gas equipment 10x/month for 3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 17, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/13/2025 to 1/17/2025, the facility did not ensure that vertical openings were maintained for 8 areas observed. Specifically, the first-floor south emergency exit stairwell, second-floor south emergency exit stairwell, third-floor south emergency exit stairwell, second-floor northwest emergency exit stairwell, third-floor northwest emergency exit stairwell, second-floor northeast emergency exit stairwell, third-floor northeast emergency exit stairwell, and the second-floor center emergency exit stairwell had door frames that lacked fire-rated labels. Findings include: The 2023 and 2024 annual fire door inspection forms did not include a section to document the fire rating of the specific fire door frames. On 1/13/2025, between 10:50 AM and 9:52 AM, the following emergency exit stairwell door frames lacked fire-rated labels: - the first-floor south emergency exit stairwell; - the second-floor south emergency exit stairwell; - the third-floor south emergency exit stairwell; - the second-floor northwest emergency exit stairwell; - the third-floor northwest emergency exit stairwell; - the second-floor northeast emergency exit stairwell; - the third-floor northeast emergency exit stairwell; and - the second-floor center emergency exit stairwell. During an interview on 1/14/2025 at 12:45 PM, the Director of Maintenance was not aware that the door frames for all four of the facility's emergency exit stairwells had lacked fire-rated labels. They stated that these door frames had been annually inspected by a third party in 2023 and 2024 and stated the annual fire door inspection log did not have a spot to document the fire rating of the door frames. The Director of Maintenance was aware that the emergency exit stairwell door frames were required to have 1 hour fire-rated labels. They stated it was important that all door frames were properly fire-rated for the safety of the residents and staff. 2012 NFPA 101: 19. 3. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Ensured vertical openings maintained and fire rating labels placed on; the first-floor south emergency exit stairwell, second-floor south emergency exit stairwell, third-floor south emergency exit stairwell, second-floor northwest emergency exit stairwell, third-floor northwest emergency exit stairwell, second-floor northeast emergency exit stairwell, third-floor northeast emergency exit stairwell, and the second-floor center emergency exit stairwell The facility will identify other residents having the potential to be affected by the same deficient practice and the follwoing corrective action will be taken - Audit vertical openings and fire rated doors for fire rated labels. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education of fire rated doors to have label to door tracking to maintenance staff The corrective action(s) will be monitored to ensure the deficient practice will not recur, - Audit all fire rated doors for vertical opening and fire rated labels x3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance |