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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: December 17, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 10/21/2024 to 10/28/2024, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 1 (Resident #287) of 6 residents reviewed for Activities out of 38 sampled residents. Specifically, Resident #287 was not provided with activities that met their cultural preferences and were in their preferred language. The findings are: The facility policy titled Therapeutic Recreation programs Scope of Services dated 6/17/2024 documented the activities program reflects the cultural interests of resident population and provides opportunities for continual enjoyment in areas of former leisure interests. The policy also documented that leisure programs were to enhance the social, emotional, intellectual, physical, creative, and spiritual wellbeing of the resident population. Resident #287 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set assessment dated [DATE] documented Resident # 287 was severely impaired in cognition and their preferred language was Cantonese. The Annual Minimum Data Set assessment also documented it was very important for Resident #287 to do their favorite activities. The Annual Minimum Data Set assessment further documented only Resident #287's representative participated in the assessment. On 10/21/2024 at 10:47 AM, Resident #287's Representative was interviewed and stated Resident #287 was Taishanese and Cantonese speaking only and liked to watch Cantonese television channels when they were in the community. Resident #287's Representative also stated they were not aware if the facility had Cantonese television channels available for Resident #287. Resident #287's Representative further stated there was no television set in Resident #287's room and they did not observe that Resident #287 had been provided with any other device to watch television programs in their preferred language. Resident #287's Representative stated they participated in the care plan meeting for Resident #287 and told the staff that Resident #287 liked to watch television programs in Cantonese language. During an observation of Resident #287's room on 10/21/2024 at 11:01 AM, no television set or other device was observed. From 10/21/2024 at 10:13 AM to 10/28/2024 at 09:23 AM, multiple observations were made of Resident #287 sitting in their wheelchair in the dining room with no ongoing activities and the television in the dining room was playing an English-language station. Resident #287 was also not provided or offered alternate activities in their preferred language. The Comprehensive Care Plan titled Activities: Activities/Socialization initiated on 05/15/2023 and last updated 8/13/2024 documented one of the goals for Resident #287 was to spend their leisure time watching television. The Quarterly/Annual/Significant Change Assessments - IDT (Interdisciplinary Team) dated 8/13/2024 documented Resident #287 enjoyed watching TV/DVDs/Videos. The facility document titled Complimentary Television Channels listed that the facility provided 50 television channels. Two channels (46 and 49) broadcasted in Spanish, three channels (4, 5, 6) broadcasted in Russian, and the remaining channels broadcasted in English. There was no documented evidence that a resident centered activity program that incorporated Resident #287's interests, hobbies, and cultural preferences, which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence, was implemented. On 10/25/2024 at 09:46 AM, Certified Nursing Assistant #11 was interviewed and stated Resident #287 was alert with episodes of confusion and did not speak English. Certified Nursing Assistant #11 also stated that Resident #287 had breakfast in the dining room every day and stayed there until going back to bed in the evening. Certified Nursing Assistant #11 further stated that the television in the dining room played English-language programs all the time and there were no Asian television channels at the facility. Certified Nursing Assistant #11 stated that Resident #287 did not watch the television in the dining room and there was no television set in Resident #287's room. On 10/25/2024 at 10:50 AM, Recreation Therapist #2 was interviewed and stated they did the admission, quarterly, and annual recreation assessment for Resident #287. Recreation Therapist #2 also stated that Resident #287's Representative was interviewed regarding Resident #287's activity preferences during the assessment and they were aware that Resident #287's preference was to watch Cantonese language television. Recreation Therapist #2 further stated that the facility only provided English and Spanish language television channels for residents, and Resident #287 did not understand English or Spanish. Recreation Therapist #2 stated that there was no television set in Resident #287's room and the television in dining room played English channels all day and they were not able to explain how Resident #287 might view programs in their preferred language. On 10/25/2024 at 11:08 AM, the Director of Recreation was interviewed and stated that the facility only had English and Spanish language television channels. The Director of Recreation also stated they had devices like iPad for residents to watch video programs in their preferred language. The Director of Recreation further stated that they were not sure if any such device had been provided to Resident #287 so they could watch television programs in their preferred language or if Resident # 287 was able to navigate these alternative devices. The Director of Recreation stated they were not aware that Resident #287's was not being provided activities in their preferred language. 10 NYCRR 415.5(f)(1) | Plan of Correction: ApprovedNovember 19, 2024 I. Immediate Corrective Actions: 1)On 11/18/24 The IDT Team reviewed and revised Resident # 287 CCP to ensure meaningful activity programs meet the resident?ÇÖs interests and support his physical, mental and psychosocial needs. 2) On 11/13/24 the Facility provided Resident # 287 with an IPAD/digital device with Cantonese programming installed. 3) On 11/18/24 the Resident was provided with a communication board with simple words phrases in Cantonese/English 4)On 11/18/24 Recreational Leader assigned to resident # 287 was provided with educational counseling by the Administrator regarding the need to ensure that all residents are provided with meaningful activities that incorporate language, cultural and personal preferences 5) On 11/18/24 the Director of Recreation was provided with educational counseling by the Administrator to ensure that all residents are provided with meaningful activities that incorporate language, cultural and personal preferences II. Identification of Others: 1). The facility respectfully states that all residents were potentially affected. 2) The Director of Recreation in conjunction with the DON and MDS Coordinator developed a list of all residents whose primary language is not English. This list was utilized by the Director of Recreation to ensure all residents that do not speak English as primary language are provided with meaningful activities and this is reflected in CCP. III. Systemic Changes: 1) The Policy and Procedure for Recreational Programming was reviewed and revised by the Director of Recreation and Social Worker to ensure: All residents whose primary language is not English are identified and provided with culturally appropriate and meaningful activities Residents?ÇÖ preferences regarding activities are reviewed and revised as needed during CCP review Individualized and group activities for each resident will be implemented based on customary routines, preferences and ADL activities 2) All recreational staff received in-service education on the revised Policy Highlights of the lesson plan include: The responsibility of the IDT Team to incorporate residents?ÇÖ preferences for activities into daily routines. The need for the Recreation leader to communicate to the Director of Recreation the resident?ÇÖs response to Recreational Activities The procedure for logging resident participation including 1:1 activity and Programmed/Group Activities IV. Quality Assurance: The Recreation Director and Social Worker developed an audit tool to ensure all residents receive activity programs that meet their needs and preferences as identified in their comprehensive assessment and plan of care. 10 randomly selected residents will be audited by the Recreation Director weekly x 1 month, followed by monthly x 5 months to ensure they are being provided with meaningful, culturally appropriate activities. Any findings that require interventions will be discussed that the Morning QA Meeting All findings will be reported quarterly to the QA Committee to track compliance and monitor sustainability V. Person Responsible Director of Recreation |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: December 17, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during the Recertification and Complaint Survey (NY 830 & NY 223) from [DATE] to [DATE], the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported low weekend staffing and 1 star staffing rating for Fiscal Quarter 3, 2024 as confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report. This was evident for 2 of 2 residents reviewed for Sufficient and Competent Nurse Staffing out of a sample of 38 residents. The findings include but are not limited to: The facility Staffing policy and procedure dated [DATE], last reviewed [DATE] documented that the facility maintains adequate staffing on each shift to ensure that resident's needs and services are met; licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services; Certified Nursing Assistants are available on each shift to provide the needed care services of each resident as outlined on the resident's comprehensive care plan. The New York State Department of Health Intake #NY 830 dated [DATE] with the Addendum dated [DATE] documented that Resident #97 complained of unsafe staffing in the facility, most of the time, it is throughout the building during the day, with ,[DATE] Certified Nursing Assistants on each unit instead of 5; Residents are not getting the care they deserve; residents who are bed bound or can't ring the call bell are not changed frequently and left soiled. The complainant also stated that their unit does not consistently have a nurse, when the regular evening shift nurse takes vacation or has a day off, they would have no nurse, and they have to wait up to two hours for a nurse to come from another unit to give them medication. The New York State Department of Health Intake #NY 830 dated [DATE] documented that the Representative for Resident #443 complained that residents were left sitting in the hallway in wheelchairs throughout the day, and there was a distinct smell of urine which led them to believe that residents were not being changed. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 3, 2024 ([DATE]- (MONTH) 30) documented the facility triggered for low weekend staffing and 1 star staffing rating. The Facility assessment dated [DATE] documented that the facility capacity was 360 beds and average daily census was 353 residents. The Facility Assessment also documented that the overall facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs were: 6AM-2PM: Certified Nursing Assistants ,[DATE], Licensed Practical Nurses 10, and Registered Nurses 5, and Unit Managers 5. 2PM-10PM: Certified Nursing Assistants ,[DATE], Licensed Practical Nurses/Registered Nurses 10, and Registered Nurse Supervisors 2. 10PM -6AM: Certified Nursing Assistants 22, Licensed Practical Nurses/Registered Nurses 10, and Registered Nurse Supervisors 1. The Daily Staffing Sheet reviewed for the weekends dated from (MONTH) 16, 2024, to (MONTH) 27, 2024, documented that the day and evening shifts were short of one Certified Nursing Assistant per unit on multiple occasions. Resident #163 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #163 had intact cognition. On [DATE] at 09:50 AM, Resident #163 was interviewed and stated that they are not getting adequate care because of the shortage of staff. Resident #163 also stated that there are only 3 Certified Nursing Assistants every day instead of 5, and they are not able to respond to the residents' needs in a timely manner. Resident #97 (NY 830) was admitted to the facility with [DIAGNOSES REDACTED]. The Annual Minimum (MDS) data set [DATE] documented that Resident #97 had intact cognition. On [DATE] at 10:31 AM, Resident #97 was interviewed and stated that residents on the unit require a lot of care, but there are not enough staff to take care of the resident's needs. Resident #97 also stated that most of the time, especially on weekends and on the evening shift they do not have enough staff to take care of them, and sometimes there was no nurse to give them their medications on time, especially when the regular evening nurse was not working. On [DATE] at 09:30 AM, Resident #443's Representative (NY 223) was interviewed and stated that their parent had since died , however Resident #443 had multiple pressure ulcers, could not verbalize their needs, and they felt that Resident #443 had not received proper care and was not being changed regularly. On [DATE] at 02:34 PM, an interview was conducted with Certified Nursing Assistant #1 who stated that they work the 2 PM to 10 PM shift and had not seen the charge nurse for their shift since they arrived on the floor at 2 PM and did not meet the outgoing nurse so was not given an update on the residents before beginning their shift. Certified Nursing Assistant #1 also stated that this happens all the time and sometimes when there is no nurse the supervisor comes to cover the floor. Certified Nursing Assistant #1 further stated that they work every other weekend, and there are supposed to be 4 Certified Nursing Assistants but most of the time there are only 3 Certified Nursing Assistants to work on the unit. On [DATE] at 02:39 PM, Certified Nursing Assistant #2 was interviewed and stated that they reported to the unit at 2:00 PM today, but they have not seen a nurse on the unit yet, and this happens frequently when their regular nurse is off, and a charge nurse will be sent to the unit later in the shift. Certified Nursing Assistant #2 also stated that they work every other weekend and most of the time 3 Certified Nursing Assistants work instead of 4. Certified Nursing Assistant #2 further stated that if the residents are asking for their medication, they will call on the evening supervisor to come and help. On [DATE] at 02:44 PM, Certified Nursing Assistant #3 was interviewed and stated that they have not seen any nurse to cover the unit for today. Certified Nursing Assistant #3 also stated that they work every weekend and many times they are short staffed on the evening and night shifts where they only get 3 Certified Nursing Assistants instead of 4, and on the night shift when there should be 2 Certified Nursing Assistants to work they sometimes only have 1 Certified Nursing Assistant. Certified Nursing Assistant #3 further stated that if multiple residents need help at the same time, they try to pay attention to the resident that needs the most help first and then they would assist the other residents. On [DATE] at 02:49 PM, an interview was conducted with Certified Nursing Assistant #4 who stated that they worked the 6 AM to 2 PM today and will be staying for the 2 PM to 10 PM shift to make the 4th Certified Nursing Assistant on the evening shift. Certified Nursing Assistant #4 also stated that they work every other weekend on the day shift, and most of the time when any of the regular Certified Nursing Assistants called out, they always work with 4 staff instead of 5. On [DATE] at 11:08 AM, an interview was conducted with Licensed Practical Nurse #1 who stated that they work the 6 AM to 2 PM shift every other weekend, and there are always 4 Certified Nursing Assistants instead of 5 on most weekends. Licensed Practical Nurse #1 also that the residents suffer a little bit as there are a lot of totally dependent residents on the floor that need assistance to be fed which can take a long time so often some residents are fed late because they cannot all be fed at the same time. Licensed Practical Nurse #1 further stated that sometimes there is no nurse relieve them at the end of their shift, so they either have to wait an extra 15 to 30 minutes, have the evening supervisor relieve them and take the keys or just wait until another nurse is sent to relieve them if the supervisor is not available to collect the keys. On [DATE] at 11:26 AM an interview was conducted with Registered Nurse #1 that works the 6 AM to 2 PM shift on the unit. Registered Nurse #1 stated that 5 Certified Nursing Assistants are scheduled to work, but sometimes 4 will work if 1 was pulled out for escort, or if 1 calls out. Registered Nurse #1 also stated that it will take the staff a lot of time to give care to the resident when they work short, and some residents will have to wait a longer for care to be provided. Registered Nurse #1 further stated that most of the residents require total care, but they always encourage the staff to do their best to meet the residents' needs. On [DATE] at 12:31 PM, the Corporate Staffing Manager was interviewed and stated that the facility has a par level which is consistent all the time and they always meet with the Administrator and the Director of Nursing to review staffing based on the resident's census and residents' acuity level. The Corporate Staffing Manager also stated that for the evening and weekends call outs, the supervisor on duty will reach out to staff to try to get someone to come in. The Corporate Staffing Manager further stated that there is a staffing agency that the facility works with, and if there are any problems with staffing the supervisor can reach out, in addition there are per-diem staff that can be called if needed. On [DATE] at 01:13 PM, an interview was conducted with the Director of Nursing who stated that they meet daily with the Administrator, Staffing Coordinator, and Human Resources staff to review staffing, discuss the needs of the building, review the schedule, and if any shortage is noted they try to fill in the staff. The Director of Nursing also stated that the facility does sometimes have staff call outs and they recently did a job fair as they are trying their best to have adequate staffing. Director of Nursing further stated that there was a supervisor to cover the unit that was reported by the surveyor without a nurse on [DATE], they were told that the supervisor just stepped out to attend to another urgent issue when the surveyor was there. Director of Nursing stated that they are not sure what happened to the nurse on the unit that day, but they were told that a supervisor went to the unit to take over the unit until the nurse was around. On [DATE] at 2:39 PM, the Administrator was interviewed and stated that when staff, residents, or residents' family member bring workload concerns to them they try to review the staffing for that day and make sure that their complaints are addressed properly. The Administrator also stated that the facility is trying to ensure that resident's care is not negatively affected due to shortage of staff. The Administrator stated that their labor relations committee and Quality Assurance Agency committee discuss the staffing problem regularly to ensure there is adequate staffing for the residents' care. The Administrator further stated that they make sure that they do not start the shift without adequate staffing, and never go below critical levels. 10 NYCRR 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedNovember 19, 2024 I. Immediate Corrective Action: On 11/18/24 The Administrator, DON and Corporate HR Coordinator furthered Facility recruitment efforts including: 1) contacted CNA Training program(s) LIST 2) contacted 1199 SEIU Hiring division 3) contacted additional Staffing agency- LIST 4) The facility posted ads for recruitment for all open positions in the facility with Apploy and Indeed. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The Social Service Department conducted an audit with randomly selected alert residents on each unit to identify any issues related to staffing concerns and resident care issues. Any identified issues will be addressed by the IDT Team. No other identified. III. Systemic Changes: 1) The DNS and Administrator reviewed and revised the Facility Assessment to document sufficient staffing needs for each unit based on: Acuity level and Census including special care needs of residents on individual units, and any other pertinent information about the resident needs. 2) An evaluation of diseases, conditions, physical, functional, or cognitive limitations of the resident population Specific skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. The number of Nursing staff to provide services to residents and assist and monitor aides. 3)The DON and RN Unit Managers reviewed and revised the CNA Nursing Assignments for each on Unit to ensure any staffing adjustments needed based on resident needs and acuity 4) The Corporate HR Director determined the number of open positions based on par levels to ensure that that safe sufficient staffing would be maintained. 5). The DNS provided all Nurse manager staff with education on measures to be taken when staffing is below par levels. Highlights of the Inservice include: The responsibility of the RNS to check staff at the beginning of each shift. The need to have a contact list of available staff and agencies to be called in as needed. The responsibility of the Charge Nurse on each unit to complete an assignment sheet and update as needed for any staffing changes The responsibility of all Nursing Staff to report to Charge Nurse/RNS when any care or services cannot be provided to residents during the shift. The responsibility of the RNS to ensure resident medications, treatments and care are provided in accordance with resident plan of care. The need for ancillary staff to assist with responding to call bells and informing direct caregivers of resident needs/requests. The responsibility of the DON/Designee to contact the NYSDOH Surge and Flex if the facility implements crisis staffing plan. IV. Quality Assurance: 1) The Administrator, in conjunction with the DNS developed an audit tool to ensure that staffing levels are monitored, and all residents receive required services in accordance with resident plan of care. This audit will be done by the RNS for each unit weekly x 3 months followed by monthly x 6 months. 2) The HR designee will audit the Staffing Dailies to identify date, shift and unit that that had less than sufficient staffing weekly x 4 weeks followed by monthly x 11 months 3) All findings will be reported at the Morning QA meeting for follow-up with residents on affected units. 4) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Person Responsible: Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: December 24, 2024
Citation Details 2012 NFPA 99: 6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning Table 6.4.1.1.16.2 Safety Indications and Shutdowns Level 1 Indicator Function (at Battery Voltage) CV S RA (a) Overcrank X X X (b) Low water temperature X - X (c) High engine temperature pre-alarm X - X (d) High engine temperature X X X (e) Low lube oil pressure pre-alarm X - X (f) Low lube oil pressure X X X (g) Overspeed X X X (h) Low fuel main tank X - X (i) Low coolant level X O X (j) EPS supplying load X - - (k) Control switch not in automatic position X - X (l) High battery voltage X - - (m) Low cranking voltage X - X (n) Low voltage in battery X - - (o) Battery charger ac failure X - - (p) Lamp test X - - (q) Contacts for local and remote common alarm X - X (r) Audible alarm-silencing switch - - X (s) Low starting air pressure X - - (t) Low starting hydraulic pressure X - - (u) Air shutdown damper when used X X X (v) Remote emergency stop - X - Based on observation, and staff interview it was determined that facility did not ensure that the emergency generator was provided with a remote annunciator in a readily observed location. The Finding is: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, during Life Safety Survey following concerns observed: - Remote annunciator panel for the generator observed in Fire Alarm Control Panel (FACP) room near the front lobby desk area. At the time of the observation, staff stated its not visually observed and they have to rely on an audio signal emitting from the room. On 10/24/24 at approximately 09:46 am, this concern was shared with the Director of Engineering and theystated it will be corrected. 2012 NFPA 99 2010 NFPA 110 NYCRR 711.2(a) 10 NYCRR 415.29 | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions The emergency generator annunciator panel will be relocated so that staff at the font lobby desk can visually observe it. Completion 12/17/24 II. Identification of Others Potentially Affected The facility only has one emergency generator annunciator panel so no further evaluation is needed. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes The Maintenance Director, or designee, will perform documented monthly inspections to ensure the emergency generator annunciator panel is visible and functioning properly on an ongoing basis as part of the facility?ÇÖs life safety program. IV. Quality Assurance The director of maintenance will audit the location and visuality of the enunciator X 2 months and quarterly x12 V. Responsible Party and Date of Correction Director of maintenance. 12/27/2024 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: November 24, 2024
Citation Details Based on observation and interview it was determined that the facility did not ensure that hazardous areas are protected with doors that are self closing and latching. The Findings are: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, during Life Safety Survey the following concerns were observed: - On 10/22/24 at approximately 10:39 am, motor room (mechanical area) on the roof, the fire doorwas kept open by a concrete brick. In an interview with Director of Engineering, stated this concern would be corrected. NFPA 101 2012: 19.3.2.1, 8.4, 8.4.1*, 8.4.2 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions The concrete brick holding open the roof?ÇÖs mechanical room door was removed on 11/10/24 II. Identification of Others No other mechanical room doors were identified. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes 1. Maintenance staff was in-service regarding regulations regarding keeping the roof mechanical closed and unobstructed. 2. Visual checks of said area have been added to their daily rounding log. Any identified discrepancies will be immediately corrected. IV. Quality Assurance 1. Audits of the roof mechanical room door will be conducted weekly X4 weeks, Monthly X2 months and quarterly X9 months. 2.Results of the audit inspections will be brought to the QA meetings for one year. V. Responsible Party and Date of Correction The director of maintenance is responsible for overseeing this process. 12/27/2024 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: December 23, 2024
Citation Details Based on observation and interview it was determined that the facility did not ensure that means of egress was continuously illuminated. Reference is made to the 'B' stairwell on second floor. This was observed on 1 out of 7 units. The Findings are: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, during the Life Safety Survey, the following concerns observed: - On 10/24/24 at approximately 10:31 am, in stairwell 'B' tube in light fixture was not luminated. In an interview with Director of Engineering at approximately 10:35 am, stated it will be corrected. 2012 NFPA 101: 19.2.8, 7.8.1.2, 7.8.1.3, 7.8.1.4* 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions 1. The light bulb was replaced in stairwell ?ÇÿB?ÇÖ on 11/14/24 II. Identification of Others 1. The Maintenance Director, performed a facility wide assessment of the other egress stairwells to ensure the lights are functioning properly. No other malfunctioning lights were identified. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes 1. Maintenance staff was in-service regarding regulations regarding keeping stairwell free of any non-working light bulbs. 2. Visual checks of said areas have been added to their daily rounding log. Any burnt out light bulbs will be immediately cleared. IV. Quality Assurance 1. Audits of all stairwell areas will be conducted weekly X4 weeks, Monthly X2 months and quarterly X9 months. 2. Results of the audit inspections will be brought to the QA meetings for one year. V. Responsible Party and Date of Correction Director of Maintenance. 12/27/2024 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: December 27, 2024
Citation Details Based on observation and interview it was determined that the facility did not ensure that fire doors not maintained in accordance with NFPA 80. This was observed on 1 out of 7 floors. The Findings are: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, during Life Safety Survey following concerns observed: - Fire door rating labels for doors to the linen chute and dry pump room (kitchen) were not visible at the time of survey. This was observed on the first floor. In an interview with Director of Engineering on 10/24/24 at approximately 9:48 am, stated these concerns will be corrected. 2012 NFPA 101 2010 NFPA 80: 5.2.1, 5.2.4.2 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions The following fire door labels will have their labels evaluated and made visible by 12/27/24: A. First floor linen chute room. B. Kitchen dry pump room. II. Identification of Others 1. The Maintenance Director will performed a facility wide assessment of the other required fire rated doors to ensure they have visible labels and are maintained properly. 2. The following doors were identified and will be corrected by 12/27/24 5 north B wing staircase door 5 south d wing staircase door. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes 1. Maintenance staff was in service regarding regulations of keeping all fire rated door labels visible and maintained properly. 2. Visual checks of said fire-rated doors have been added to their daily rounding log. Any identified discrepancies will be immediately corrected. IV. Quality Assurance 1. Audits of the fire rated doors will be conducted weekly X4 weeks, Monthly X2 months and quarterly X9 months. 2. Results of the audit inspections will be brought to the QA meetings for one year. V. Responsible Party and Date of Correction The director of maintenance is responsible for overseeing this process. 12/27/2024 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: November 24, 2024
Citation Details Based on observation and interview it was determined that the facility did not ensure that all means of egress were free of obstructions or impediments. This was observed in 1 out of 7 units. The Findings are: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, during Life Safety Survey following concerns observed: - Multiple chairs (5) and tables were observed stored in close proximity to 'B' stairwell egress area on the second floor. This reduced the width of the corridors and had the potential of impeding the use of the corridor in the event of fire or other emergency. On 10/24/24, at approximately 10:53 a.m, in an interview with the Director of Maintenance, advised staff to correct this concern and ensured all egress areas be free of any impediments. 2000 NFPA 101 7.1.10, 19.2.1 711.2(a)(1) | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions The items stored in close proximity to stairwell ?ÇÿB?ÇÖ egress were removed on 11/14/24 II. Identification of Others The Maintenance Director performed a facility-wide assessment of all other egress stairwells to ensure that they were clear. No other areas were identified. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes 1) Maintenance staff was in-service regarding regulations regarding keeping stairwell egress clear. 2) Visual checks of said areas have been added to their daily rounding log. Any obstructions will be immediately cleared. IV. Quality Assurance 1) Audits of all stairwell egress areas will be conducted weekly X4 weeks, Monthly X2 months and quarterly X9 months. 2) Results of the audit inspections will be brought to the QA meetings for one year. V. Responsible Party and Date of Correction Person responsible, Director of maintenance. 12/27/2024 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: December 24, 2024
Citation Details 10 NYCRR 415.29 Physical Enviornment The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. Based on observations and interview it was determined that facility did not ensure the physical environment wasmaintained. Refrences are made to the ventilation on the 7th floor and egress area on 1st floor. The Findings are: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, duringthe Life Safety Survey the following concerns were observed: - A heavy accumulation of dust was observed on the return air grill in the oxygen room located on 7th floor. On 10/22/24 at approximately 10:29 am, the Director of Engineering stated all ventilation grills will be maintained. - Egress area on 1st floor 'C' stairwell observed with flaking paint. On 10/24/24 at approximately 09:45 am, director of engineering stated this was caused by excess humidity and it will be corrected. | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions The return air grill in the oxygen room on the 7th floor was removed, cleaned and put back in place on 11/13/24 II. Identification of Others The Maintenance Director will perform a facility wide assessment of all return air grills to ensure they are not dusty. No other dusty grills identified. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes 1. Maintenance staff was in serviced regarding keeping all return air grills clean. 2. Visual checks of said return air grills have been added to their daily rounding log. Any identified discrepancies will be immediately corrected. IV. Quality Assurance Audits of the return air grills will be conducted weekly X4 weeks, Monthly X2 months and quarterly X9 months. Results of the audit inspections will be brought to the QA meetings for one year. Responsible Party and date of completion The director of maintenance is responsible for overseeing this process. 12/27/2024 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 28, 2024
Corrected date: November 24, 2024
Citation Details Based on observation and interview it was determined that the facility did not ensure that smoke barrier doors on first floor blocked by linen carts. This was observed on 1 out of 7 floors. The Findings are: From 10/22/24 - 10/25/24 between hours of 09:30 am - 02:30 pm, during Life Safety Survey following concerns observed: - The smoke barrier double doors between the two smoke compartments on the main floor of the facility were observed with linen carts that prevented the closing of the doors. On 10/25/24 at approximately 10:05 am, Director of Engineering advised staff to remove the carts, and stated all smoke compartments will be maintained. 2012 NFPA 101 10 NYCRR 711.2 (a) | Plan of Correction: ApprovedNovember 15, 2024 I. Corrective Actions The linen carts holding open the main floor?ÇÖs smoke barrier double doors were removed on 11/13/24 II. Identification of Others The Maintenance Director checked all of the other smoke barrier double doors to ensure their doors are not being propped open. No other areas were identified. The facility acknowledges all residents could be potentially affected by this condition, but respectfully submits that no residents were affected. III. Systemic Changes 1. Maintenance staff was in-service regarding regulations regarding keeping smoke barrier doors free of obstructions. 2. Visual checks of said area smoke barrier doors have been added to the maintenance daily rounding log. Any identified discrepancies will be immediately corrected. IV. Quality Assurance 1. Audits of the smoke barrier doors will be conducted weekly X4 weeks, Monthly X2 months and quarterly X9 months. 2. Results of the audit inspections will be brought to the QA meetings for one year. V. Responsible Party and Date of Correction The director of maintenance is responsible for the oversight of this process. 12/27/2024 |