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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews conducted during a Recertification survey from 12/02/2024 to 12/09/2024 the facility did not ensure that each section of the Minimum Data Set assessment accurately reflected the residents' status. This was evident for 1 (Resident #37 of 5 residents reviewed for Unnecessary Medication and 1 (Resident #130) of 3 residents reviewed for Behavioral-Emotional out of 37 sampled residents. Specifically, the most recent Minimum Data Set Assessment did not accurately document that Resident #37 and Resident #130 displayed wandering behavior. The findings are: The facility policy and procedure titled Minimum Data Set Comprehensive Assessments revised 09/2024 documented that comprehensive assessments will be conducted to assist in developing person-centered care plans. The policy also documented that comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information and then monitoring results and adjusting interventions. When assessing the individual, relevant information from multiple sources are gathered. The policy did not address accuracy of the assessment. 1. Resident #37 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessments dated 09/04/2024 and 11/27/2024 documented that Resident #37 had severe cognitive impairment. Section E of the assessments documented that Resident #37 did not exhibit wandering behavior. A Comprehensive Care Plan titled Wandering/Elopement dated 01/13/2021 documented as a goal that resident will not wander outside of the facility for 90 days. Interventions included to engage in group activity and place a wander guard. The Evaluation note dated 11/28/2024 documented Resident #37 continues on hourly visual check for safety. Resident #37 observed walking on and off unit carrying their personal items at all times without seeking exits and remains calm in a supervised area. The Elopement and Unsafe Wandering Screen dated 10/10/2024 documented Resident #37 verbalized a desire to leave the facility without proper permission or authorization. Resident #37 was determined to be at risk for elopement and wandering. On 12/03/2024 at 09:54 AM, Resident #37 was observed at the reception desk, at the entrance of the facility. The Quarterly Minimum Data Set Assessment did not accurately document Resident #37's wandering behavior. During an interview on 12/09/2024 at 9:27 AM, Certified Nursing Assistant #7 stated Resident #37 goes to the lobby and tried to leave the facility. Certified Nursing Assistant #7 stated security called them to redirect Resident #37 when they stand by the door. They stated that behavior does not happen daily. 2. Resident #130 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #130 had severe cognitive impairment. Section E documented that Resident #130 did not exhibit wandering behavior. A Comprehensive Care Plan titled Wandering/Elopement dated 04/06/2023 documented as a goal that resident will be redirected to a safer area and wandering episode will decrease for 90 days. Interventions included to engage resident in group activities of their choice and monitor resident' location at regular intervals. The Evaluation note dated 11/10/2024 documented that Resident #130 had made no attempt to leave the facility. Resident #130 required constant redirection. Resident #130 continues on hourly visual check monitoring for safety. A Comprehensive Care Plan titled Therapeutic Recreation dated 11/10/2022 documents as a goal that resident will demonstrate fewer episodes of disruptive behaviors. Interventions included to provide one to one visits to prevent social isolation and respect resident's rights to refuse invites. The Evaluation note dated 06/12/2024 documented Resident #130 is due for quarterly update and within that time frame their care plan have remain the same since the last note. Resident #130 continues to refuse invitation to therapeutic recreation and continues to wander around and off the unit. Resident #130 was very confused and comes off the unit looking for their family and sometimes bangs the walls. The Evaluation note dated 09/04/2024 documented Resident #130 has a quarterly assessment, during this update Resident #130's care plan has remained the same since the last note. Resident #130 continues to wander around and off the unit and that Resident #130 is very confused. Resident #130 comes off the unit and looks for their family and bangs on the walls. Activity Leader provides Resident #130 with tactile and visual sensory stimulations at least twice a week. The Evaluation note dated 11/27/2024 documented Resident #130 is due for annual update within that frame, Resident #130's care plan remained the same. Resident #130 continues to refuse therapeutic reaction, continues to look for their family and roams the halls. Resident #130 is redirected by staff because Resident #130 is looking for an exit to leave. The Elopement and Unsafe Wandering Screen dated 09/07/2024 documented Resident #130 is at risk for wandering and elopement. On 12/02/2024 at 10:50 AM, Resident #130 was observed exiting the dining room, entering the bathroom stall, exiting, and returning to the dining room. On 12/04/2024 at 11:11 AM, Resident #130 exited the unit and staff was observed redirecting Resident #130 back to the unit. On 12/06/2024 at 12:42 PM, Resident #130 walked out of the dining room, went into the bathroom, exited the bathroom from the other entrance and returned to the dining room. On 12/09/2024 at 11:31 AM, Resident #130 exited the unit and staff was observed escorting Resident #130 back to the unit. During an interview on 12/02/2024 at 10:52 AM, Activity Leader #1 stated they were informed by the supervisor that Resident #130 will wander into other resident's room. Activity Leader #1 also stated that Resident #130 exits the dining room and staff would have to redirect them back into the dining room. During an interview on 12/06/2024 at 12:35 PM, Certified Nursing Assistant #5 stated that Resident #130 wanders on and off the units and goes into other resident's room. Certified Nursing Assistant #5 also stated that Resident #130 does not like to sit, and they redirect Resident #130 by providing coloring activity to distract them from wandering. During an interview on 12/06/2024 at 12:38 PM, Licensed Practical Nurse #3 stated Resident #130 wanders on the unit. Licensed Practical Nurse #3 also stated they try to engage Resident #130 in activity. During an interview on 12/06/2024 at 4:03 PM, the Minimum Data Set Coordinator stated they are responsible for completing all sections of the Minimum Data Set Assessment. The Minimum Data Set Coordinator also stated that 7 days prior to the Quarterly review, they conduct interviews with staff and residents, and observe the residents' behavior. The Minimum Data Set Coordinator further stated that during that time if the residents do not present any wandering behavior they will not document in section E of the Minimum Data Set Assessment. The Minimum Data Set Coordinator stated Resident #37 did not have any recent wandering or elopement behavior, so they did not document it in the Minimum Data Set Assessment. The Minimum Data Set Coordinator stated Resident #37 ambulates at liberty on and off the unit and does not wander. During an interview on 12/09/2024 at 9:39 AM, Licensed Practical Nurse #2 stated Resident #130 wanders daily to the North Unit and was observed knocking on other residents' door looking for their family. During an interview on 12/09/2024 at 1:33 PM, Certified Nursing Assistant #6 stated Resident #130 walks around and sometimes tries to go into the kitchen. 10 NYCRR 415. 11(b) | Plan of Correction: ApprovedJanuary 3, 2025 Immediate Correction 1) On 12/30/24, The Minimum Data Set (MDS) Coordinator reviewed and updated the Quarterly MDS assessment to accurately document Resident #37s wandering behavior. 2) On 12/30/24, The Comprehensive Care Plan for Resident #37 was reviewed and revised by the MDS Coordinator to ensure interventions accurately reflect their current wandering status, including additional monitoring and activities to reduce wandering episodes. 3) On 12/30/24, The Quarterly MDS assessment for Resident #130 was reviewed and updated to reflect their wandering behavior accurately. 4) On 12/30/24, The Comprehensive Care Plan was updated by the MDS Coordinator to ensure alignment with observed behaviors, including enhanced monitoring and interventions to address wandering tendencies. 5) On 12/30/24, Education Counseling was conducted and completed on Accuracy of Assessments for the MDS Coordinator, DON, ADON, DSW, and DOR. Identification of Others 1) An audit of the last 30 days of MDS assessments will be conducted by the MDS Coordinator to identify any inaccuracies related to wandering or other behaviors. 2) Residents identified with discrepancies will have their MDS assessments updated, and care plans revised accordingly. Systemic Changes 1) The facility policy on Minimum Data Set Comprehensive Assessments has been revised by the Administrator to include explicit guidelines emphasizing the importance of accurate documentation of residents behaviors, including wandering. 2) All MDS Coordinators, Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) will be re-educated on: - A review of the regulatory requirement of F 641. - The importance of accurate MDS documentation. - Observing, reporting, and documenting wandering and other behavioral patterns. - Utilizing interdisciplinary team input to ensure MDS accuracy. 3) A daily communication audit tool will be developed and implemented to ensure all wandering behaviors are documented and considered during MDS assessments. Quality Assurance (QA) 1) An interdisciplinary team meeting will be held bi-weekly to review residents with identified wandering behaviors and ensure care plans and interventions are appropriate and effective. 2) Monthly in-service training sessions on MDS accuracy and behavioral documentation will be conducted to ensure ongoing compliance x 6 months. 3) Audits will be completed by the MDS Coordinator weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The MDS Coordinator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a Recertification survey and Abbreviated survey (NY 169, NY 202) from 12/02/2024 to 12/09/2024, the facility did not ensure that care plans were reviewed and revised by the interdisciplinary team after each assessment. This was evident in 1 (Resident #17) out of 1 resident reviewed for Dental out of 37 sampled residents. Specifically, the care plan related to Oral/Dental Care was not revised quarterly. The findings include: The facility's policy and procedure titled Comprehensive Care Planning with a revised date of 09/24, documented review as necessary and at intervals not to exceed 92 resident days after the last assessment reference date, response to current plan of care and the establishment treatment of [REDACTED]. Quarterly team reviews must be completed within the 92 days of Minimum Data Set 3. 0 Quarterly time frame. Resident #17 (NY 169, NY 202) was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) dated 10/02/2024 documented Resident #17 had a Brief Interview of Mental Status score of 12, indicating moderately impaired cognition. A Comprehensive Care Plan for Dental dated 08/11/2023, documented interventions to provide adequate oral hygiene daily, dental consult annually/as needed, and inspect mouth for any abscesses, sores, and/or signs of infection to physician as necessary. The Care Plan for Oral/Dental Care was created on 08/11/2023 and the last evaluation note was dated 04/18/ 2024. There was no documented evidence that the Oral/Dental Care plan had been reviewed and revised after the Quarterly assessment on 04/18/2024, 07/10/2024, and 10/02/ 2024. During an interview on 12/9/2024 at 03:26 PM, the Director of Nursing stated they try their best to review and revise care plans but sometimes it does not get done. The Director of Nursing also stated that it is the responsibility of the Minimum Data Set Coordinator and the Registered Nurse supervisors to develop and update the care plans. Where is the interview with the MDS Coordinator or Nurse Supervisor who was responsible for creating this care plan? They should be interviewed before the Director of Nursing as they oversee all operations and are responsible for supervision of nursing staff and not the actual creation of the care plan. I did not interview the MDS Coordinator. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedJanuary 2, 2025 Immediate Correction 1) On 12/30/24, Resident #17 was assessed by MD. 2) Dental Consult was done on 12/19/24 at the hospital. 3) On 12/10/24, The comprehensive care plan for Resident #17 related to oral/dental care was reviewed and revised by the interdisciplinary team (IDT) to reflect the current assessment and oral health status. 4) The care plan now includes measurable goals, updated interventions, and a schedule for follow-up evaluations. 5) On 12/30/24, The Minimum Data Set (MDS) Coordinator and the registered nurse supervisor responsible for Resident #17s care plan were counseled and re-educated on care plan timing and revision requirements. Identification of Others 1) A facility-wide audit in the last 30 days will be conducted to identify residents whose care plans had not been reviewed or revised within the required timeframes. 2) Care plans for all residents identified in the audit will be reviewed and revised as needed. Systemic Changes 1) The facility's policy on Comprehensive Care Planning was reviewed and revised by the Facility Administrator to explicitly include: - Care plan reviews and updates must occur after every comprehensive and quarterly assessment. - A checklist for MDS Coordinators and the IDT to ensure compliance with the 92-day review requirement. - Documentation requirements for resident and/or representative participation in care plan meetings or reasons for their absence. 2) MDS Coordinator, RN's and LPN's were re-educated on care plan timing and revision regulations by the Director of Nursing (DON). 3) Training emphasized the importance of timely care plan updates, interdisciplinary collaboration, and accurate documentation. 4) IDT meetings were restructured to include a dedicated review of residents due for care plan updates within the next 30 days. 5) The MDS Coordinator will send reminders to IDT members seven days prior to quarterly care plan review deadlines. 6) A care plan audit tool was developed and implemented to ensure that all care plans are reviewed, revised, and updated as required. 7) The tool will track care plan creation, review dates, and changes made during assessments. Quality Assurance (QA) 1) The DON or designee will complete random care plan audits quarterly for one year to monitor ongoing compliance. 2) Resident council meetings will include a discussion on care plan updates to ensure resident participation and satisfaction with their care plans. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that a Comprehensive Care Plan was developed and implemented to meet a resident's needs. This was evident for 1 (Resident # 111) of 2 residents reviewed for Skin Conditions out of 37 sampled residents. Specifically, a care plan was not developed for Resident #111 who complained of itchy skin and had ongoing skin issues. The findings are: The facility's policy and procedure titled Comprehensive Care Planning with a revised date of 09/24, did not specifically referenced how Comprehensive Care Plans would be created. The policy states that a Comprehensive Care Committee would be created which consists of each healthcare discipline involved in providing health care services. The policy also states that an objective of the Comprehensive Care Committee is discussion and assessment of all acute, subacute, or chronic management problems that interfere with the ability of any one discipline to manage resident care effectively. Resident #111 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented Resident that #111 was cognitively intact. On 12/09/24 at 09:20 AM, Resident #111 was interviewed and stated they had skin problems that started when they came into the facility on e year ago. Resident #111 also stated that the facility was supposed to provide cream, but they did not. The Dermatology consult dated 1/3/2024 documented Resident #111 was examined for [MEDICAL CONDITION] and rashes to lower legs and arms with little improvement with topicals. The Dermatology consult also documented that Resident #111 skin is described as [DIAGNOSES REDACTED]tous papules widespread to bilateral lower extremities and few scattered on upper arms and diagnosed as having [DIAGNOSES REDACTED] (a skin condition that causes itchy bumps on your skin). Resident #111's medical record revealed there was no comprehensive care plan related to skin condition was developed and implemented for Resident #111 since their admission to the facility. On 12/09/24 at 11:08 AM during an interview with Medical Doctor stated that Resident #111 has a history of chronic [MEDICAL CONDITION] with elevated liver enzymes and the itchiness is possible related to that. The Medical Doctor also stated that they discontinued the statin medications, that can play a role in liver functions and did not renew the Cortisone creams because it causes the skin to thin out and the resident does not complain of being itchy every day. The Medical Doctor further stated that Resident #111 has flare ups from time to time and when there is a flair up, they will reorder the Cortisone cream, but currently, they do not believe that Resident #111 requires the Cortisone cream. On 12/9/2024 at 12:35 PM, the Director of Nursing was interviewed and stated that the Minimum Data Set Coordinator and nurse supervisors are responsible for initiating and revising the care plans quarterly. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedJanuary 2, 2025 Immediate Correction 1) On 12/30/24, An MD assessment was completed on Resident #111 who addressed the itchy skin condition by giving the resident a cream. 2) On 12/10/24, A comprehensive care plan was developed and implemented to address Resident #111s ongoing skin condition. 3) On 12/26/24, Education was completed for the staff responsible for initiating clinical care plans. Identification of Others 1) A facility-wide audit tool will be developed to identify all residents with skin conditions or similar complaints who may not have a comprehensive care plan in place. 2) All identified residents will have their care plans reviewed, developed, or updated to address their individual needs. Systemic Changes 1) The facility policy on Comprehensive Care Planning was reviewed and revised by Facility Administrator to include specific guidelines for the development and implementation of care plans addressing chronic conditions, including skin conditions. 2) Clear timelines for initiating care plans upon admission and updating them quarterly or as conditions change were added to the policy. 3) Minimum Data Set (MDS) Coordinator, RN's and LPN's were re-educated on: - The process of developing, implementing, and updating comprehensive care plans. - Identifying resident needs through assessments, observations, and interdisciplinary collaboration. - Incorporating physician recommendations, specialist input, and resident preferences into care plans. 4) A checklist audit tool was introduced to ensure care plans address all identified medical, nursing, psychosocial, and other resident needs. 5) The care plan includes measurable objectives and specific interventions, such as: - Monitoring the skin condition for changes or flare-ups. - Ensuring availability and application of prescribed topical creams or other dermatologic treatments as needed. - Coordinating with dermatology for follow-up consultations and recommendations. - Educating staff on proper skin care techniques and resident preferences. Quality Assurance (QA) 1) The Director of Nursing (DON) or designee will review care plans weekly to ensure all identified conditions are addressed in comprehensive care plans. 2) Random audits of care plans will continue quarterly for one year, ensuring compliance with federal regulations and timely updates to care plans as resident needs change. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
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 from 12/02/2024 to 12/09/2024, the facility did not ensure that a resident who used [MEDICAL CONDITION] drugs received gradual dose reductions unless clinically contraindicated, to discontinue the drug. This was evident for 1 (Resident #153) of 5 residents reviewed for Unnecessary Medications out of 37 sampled residents. Specifically, Resident #153 had a Dementia [DIAGNOSES REDACTED]. There was no evidence that a gradual dose reduction had been attempted and there was no documented evidence that Resident #153 displayed any mood or behavioral symptoms that warranted continued use of the medication. The finding is: Resident #153 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 Assessments dated 06/26/2024 and 09/19/2024 documented that Resident #153 was severely cognitively impaired with long and short-term memory problems and had no potential indicator for [MEDICAL CONDITION]. The Minimum Data Set further documented that Resident #153 had [DIAGNOSES REDACTED]. physician's orders [REDACTED].#153 had been prescribed [MEDICATION NAME] 125mg by mouth in the evening and [MEDICATION NAME] 50mg by mouth daily for Unspecified Mood Disorder effective 03/22/2024, and [MEDICATION NAME] Acid 250mg twice daily for Unspecified Mood Disorder. On 12/04/24 at 10:50 AM, Resident #153 was observed sitting in activity in the day room, no psychotic behavior noted. On 12/05/24 at 11:16 AM, Resident #153 was observed in the main dining room during music activity, no psychotic behavior was noted. Review of progress notes from (MONTH) 2024 to 12/09/2024 revealed no documented psychotic behaviors for Resident # 153. The Medication Administration Records dated (MONTH) 2024 to present documented that Resident #153 received [MEDICATION NAME] 125mg in the evening and [MEDICATION NAME] 50mg in the morning as ordered by the Physician. The Psychiatric Consultation dated 4/10/24 and 7/15/2024 documented that the Psychiatrist wants to try a gradual dose reduction on the [MEDICATION NAME], but son keeps on refusing the gradual dose reduction. On 12/5/24 at 11:42 AM, the Psychiatric Nurse Practitioner was interviewed and stated that Resident #153 was admitted to the facility from the hospital with the [MEDICATION NAME] order. The Psychiatric Nurse Practitioner also stated that they wanted to attempt a gradual dose reduction on several occasion however the Resident #153's son did not agree to it, so it was never attempted. The Psychiatric Nurse Practitioner further stated that the only behavior that Resident #153 has was repeatedly saying oh my God. On 12/9/24 at 1:49 PM, the Director of Nursing was interviewed and stated that the child of Resident #153 kept on refusing the gradual dose reduction and so they could not it. 10 NYCRR 415. 12(l)(2)(ii) | Plan of Correction: ApprovedJanuary 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Correction 1) On 12/24/24, A care conference was held with Resident #153s son, the psychiatric nurse practitioner, and the attending physician to discuss the necessity of a gradual dose reduction (GDR) and behavioral interventions. 2) On 12/14/24, The psychiatrist/psychiatric nurse practitioner documented the clinical justification for attempting the GDR. 3) On 12/24/24, All [MEDICAL CONDITION] medications and CCP were updated by the IDT team for Resident #153 to ensure compliance with requirements, and any necessary changes were documented in the clinical record. Identification of Others 1) Develop an audit tool of all residents currently prescribed [MEDICAL CONDITION] medications to identify those who: - Have not undergone a GDR, if clinically appropriate. - Lack documentation of behavioral symptoms or a specific [DIAGNOSES REDACTED]. - Have PRN orders for [MEDICAL CONDITION] medications exceeding 14 days without proper evaluation and documentation. 2) Immediate corrective actions will be implemented for identified residents, including care plan updates, medication reviews, and staff education. Systemic Changes 1) Review and revise the facility's policy on [MEDICAL CONDITION] medication use to include: - Guidelines for initiating and documenting GDRs. - Processes for handling refusals by family or residents, including obtaining written refusal documentation. 2) Provide training to RN's. LPN's, Psychiatrist and Dr's on the following: - Regulatory requirements for [MEDICAL CONDITION] medications and PRN orders. - Documentation standards, including behavioral monitoring and physician rationales. - Effective communication strategies for engaging families in care decisions. 2) Develop standardized communication audit to educate families about the benefits of GDRs and the risks of long-term [MEDICAL CONDITION] medication use. 3) The facilitys medical director will review the case to ensure adherence to regulations and provide oversight for future interventions. Quality Assurance 1) The pharmacy consultant will conduct monthly reviews of [MEDICAL CONDITION] medication use for all residents, including compliance with GDRs and PRN order limits. 2) The interdisciplinary team (IDT) will review [MEDICAL CONDITION] medication cases during quarterly care plan meetings. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a recertification and complaint survey (NY 667, and NY 814, from 12/02/2024 to 12/09/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made. This was evident for 2 (Resident # 139 and Resident #103) of 6 residents reviewed for Abuse and 1 (Resident #71) of 6 residents reviewed for Accidents out of 37 sampled residents. Specifically, and allegation of sexual Abuse for Resident #139 and an injury of unknown origin for Resident #103 was not reported in a timely manner and an injury of unknown origin for Resident #71 was not reported to the Department of Health. The findings are: 1. The facility policy and procedure titled Abuse Prevention Program dated revised 9/2024 stated that all individuals (Employees, Managers, Operators, Agents, and Contractors) have personal responsibility to report any suspicion of abuse/neglect. The policy also stated that if suspected abuse/neglect involved serious body injury it must be reported not more than two real time hours after forming suspension. The policy further stated serious body injury defined as extreme pain, substantial risk for death and injury that required medical intervention. Resident #139 ((NY 667) was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #139 had intact cognition. The facility Accident and Incident report dated 10/27/24 documented that Resident #139 reported to Registered Nurse #1 that at around 4:30 AM a resident walked into their room and touched them on their penis. The resident called 911 and was transported to the emergency room for evaluation. The resident returned to the facility on [DATE] with no apparent injury at 7:45 PM. The Nursing Home Facility Incident Report revealed that the New York State Department of Health was notified of the alleged sexual abuse on 10/27/24 at 12:27 PM. This was reported greater than 2 hours from the time the allegation was first made. On 12/06/24 at 9:33 AM, Registered Nurse #3 was interviewed and stated that they responded to the residents allegation on 10/27/24 in the early morning about having been inappropriately touched by another resident who wandered into their room. Registered Nurse #3 also stated that they notified the medical doctor. Registered Nurse #3 further stated that they did not believe the allegation that was being made and did not notify the Director of Nursing. Nurse #3 stated that it was several hours later when they did notify the Assistant Director of Nursing when they arrived at the facility. On 12/06/24 at 07:50 AM, the Assistant Director of Nursing was interviewed and stated that while they were on their way to the facility Registered Nurse #3 notified them of the alleged sexual abuse by phone at around 10:30 AM or 11:00 AM. The Assistant Director of Nursing also stated that they immediately reported this allegation once they arrived at the facility and gathered some information. The Assistant Director of Nursing further stated that the reporting time to the Department of Health is 2 hours once an allegation of abuse is made. On 12/06/24 at 9:39 AM, the Director of Nursing was interviewed and stated that the required reporting time for reporting any allegations of abuse to the Department of Health is 2 hours. The Director of Nursing also stated that they were made aware of the incident around 11:30 AM or 12:00 PM by the Assistant Director of Nursing, and the night shift Registered Nurse should have notified it immediately once the allegation was made. 2. Resident #103 was last admitted Non-Alzheimer's Dementia, Hypertension, and [MEDICAL CONDITION]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #103 was moderately cognitively impaired, required dependent care for all Activities of Daily Living, is non-ambulatory, and had impairment on one side of the upper extremities and both sides of the lower extremities. The Physician order [REDACTED]. The Nursing progress note dated 6/16/2024 at 9:39 PM documented that resident was alert and responsive was called by Certified Nursing Assistant who was doing care and noted bluish discoloration to the left elbow swollen which was tender to touch. Registered Nurse supervisor was called and notified safety-maintained ice pack applied left in no apparent distress. The Nursing progress noted dated 6/17/2024 at 5:24 AM documented resident remains alert and responsive. Discoloration and swelling persist to left elbow. Site tender to touch, unable to extend upper extremity, x ray ordered by Registered Nurse. Due nursing care rendered; anticipated needs met without incident. As needed Tylenol given with good effect. Resident is currently resting comfortable. Plan of care continues. The Nursing progress note dated 6/18/2024 at 11:40 AM documented writer called by Certified Nursing Assistant to see the resident who is holding the left elbow by chest, upon arrival resident observed in Geri Chair, left elbow blue and yellow discoloration, resident guarding the arm, unable to extend the arm as resident crying. Tylenol given as ordered. Doctor Chowdhury made aware. New order x ray STAT left elbow ordered. Will continue to monitor for any further signs and symptoms of pain. The Nursing progress notes dated 6/18/2024 at 2:52 pm documented x ray done; result received Acute fracture at the base of olecranon with intra articular extension into the anterior sigmoid cavity cortex. Joint diffusion with elevation of the anterior distal humeral fat pad. [MEDICAL CONDITION]. Diffuse soft tissue swelling. Doctor made aware. Xray results dated 6/18/2024 from Precision Health Incorporated Med Fax documented Findings Acute Fracture at the base of the Olecranon with Intra-articular extension into the anterior sigmoid cavity cortex. Joint effusion with elevation of the anterior distal humeral fat pad. [MEDICAL CONDITION]. Diffuse soft tissue swelling. The facility Investigation of Incident/Accident Form dated 6/18/2024 documented Resident is an [AGE] year-old with [DIAGNOSES REDACTED]. The resident was alert and responsive to all stimuli, not able to make needs known and all needs are met by staff. On 6/16/24 at 9:39 PM Certified Nursing Assistant reported bluish discoloration to left elbow and tender to touch with swelling, Tylenol was given for pain with good effect. On 6/18/2024 at about 11:40 am, resident was holding the elbow with blue, yellow discoloration and x ray was ordered by medical doctor, which was done with result fracture left elbow. Resident was transferred to Hospital for evaluation, returned with negative for fracture. Hospital records show x ray of the right elbow was done instead of the left elbow. Resident was transferred back to the hospital on [DATE] and returned with soft cast on left upper arm with sling. Evaluated by medical doctor completed on 6/20/2024 and Therapy evaluation and follow up with orthopedics. Pain management as needed. Facility concluded no abuse neglect, mistreatment regarding this resident and resident had a nondisplaced fracture of last elbow. No history of Trauma/Fall. History of [MEDICAL CONDITION]. Patient transfer to Hospital emergency room for treatment. The document titled Nursing Home Facility Incident Report stated submitted successfully on 6/18/2024 at 17: 33. There was no documented evidence that the injury of unknown origin for Resident #103 was reported to the Department of Health as required when first observed on 6/16/ 2024. On 12/09/24 at 10:30 AM, an interview was conducted with the Administrator for the facility who stated that multiple things such as injury of unknown origin, or abuse must be reported timely based on injury to the Department of Health. | Plan of Correction: ApprovedJanuary 3, 2025 Immediate Correction: 1) On 12/31/24, The facility implemented a 24-hour shift check to ensure that all staff are familiar with and adhere to reporting guidelines for abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. 2) On 12/31/24, training was provided to all staff on the importance of timely reporting of any alleged violations, specifically the 2-hour reporting requirement for abuse or serious bodily injury and the 24-hour reporting requirement for non-serious events that dont result in major injury. 3) There were no adverse effects to Resident #139 as a result of reporting the incident late to the DOH. 4) There were no adverse effects to Resident #103 as a result of reporting the incident late to the DOH. 5) There were no adverse effects to Resident #71 as a result of not reporting the incident to the DOH. Identification of Others: 1) Conduct a facility-wide audit of all incidents reported over the past 6 months to identify if any other incidents were not timely reported. This will include any allegations of abuse, neglect, injuries of unknown origin, or accidents requiring reporting to the DOH. 2) The audit will be conducted by the Director of Nursing, Assistant Director of Nursing, and Administrator. Systemic Changes: 1) The facilitys Abuse Prevention Program and Incident Reporting policies will be reviewed and revised to: - Clarify the specific timeframes for reporting to the Department of Health and other relevant authorities. - Emphasize the need for immediate notification of the Administrator, Director of Nursing, and Department of Health within 2 hours of any abuse allegations or incidents involving serious bodily injury. - Include a clear statement that all incidents which dont result in serious bodily injury must be reported to the Department of Health within 24 hours. 2) The reviewed policies will be distributed to all staff and reviewed in staff meetings. 3) Ensure that all nurses, nursing assistants, and supervisory staff are trained on the timely reporting of incidents, particularly those related to abuse, neglect, and injury of unknown origin. Training will emphasize: - Definition and identification of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. - The 2-hour and 24-hour reporting timeframes, as well as appropriate escalation procedures. - Use of the facilitys reporting forms, including how to promptly notify the Administrator, Director of Nursing, and Department of Health. 4) The facility will implement a tracking system audit tool for all reported incidents. This will allow for better tracking of timely reporting, including automated reminders and alerts for the 2-hour and 24-hour reporting requirements. 5) A daily log audit tool of incidents will be maintained, with a designated team to review and ensure compliance with reporting timeframes. 6) The Director of Nursing and Assistant Director of Nursing will implement a daily audit tool review of all reported incidents to ensure they are reported timely and accurately to the Department of Health. Any discrepancies in reporting will be addressed with immediate corrective action. Quality Assurance: 1) The Quality Assurance (QA) Committee will meet weekly to review the status of incident reporting and ensure that all allegations of abuse, neglect, and injury are reported in a timely manner. 2) The Director of Nursing (DON) and Assistant Director of Nursing (ADON) will review all current/future incidents and ensure all required reporting to the Department of Health (DOH) and State Survey Agency are submitted immediately where necessary. 3) A monthly audit of all incident reports will be conducted by the QA Committee to ensure that no incidents are missed and that all reporting requirements are followed. 4) The monthly audit will be completed by the Director of Nursing, Assistant Director of Nursing and Administrator, weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews conducted during the Recertification survey from 12/2/2024 to 12/9/2024, the facility did not ensure the resident's right to participate in the development and implementation of their person-centered plan of care. This was evident for 2 (Resident #111 and Resident #13) of 3 residents reviewed for Care Planning out of 37 total sampled residents. Specifically, Resident #111 and Resident #13 were not invited to attend their scheduled Comprehensive Care Plan and quarterly meetings. The findings are: The facility policy titled Comprehensive Care Planning revised 09/24 documented each capable resident will receive a written and/or verbal invitation to attend the initial, quarterly, annual, and significant change care plan meetings. The policy also stated that their response to written/verbal invitations will be documented on the Comprehensive Care Plan meeting schedule sheet. 1. Resident #111 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 assessment dated [DATE] documented that Resident #111 was cognitively intact. On 12/9/2024 at 09:30 AM, Resident #111 was interviewed and stated that they have not been invited to a care plan meeting since being admitted into the facility on e year ago. Resident #111 also stated that they did not recall anyone ever coming to discuss their care with them. The Care Plan Meeting Sign In sheets dated 3/12/2024 6/4/2024, 8/7/2024 and 11/12/2024 were signed by members of the interdisciplinary team and did include a signature for Resident # 111. Progress Notes dated 03/12/2024, 06/04/2024, 08/07/2024 and 11/12/2024 documented that Resident #111's child attended the meeting via teleconference. There was no documented evidence Resident #111 was invited to or attended their scheduled care plan meetings. On 12/09/24 at 09:41 AM, an interview was conducted with the Director of Social Worker who stated Resident #111 does and has participated in their care plan meetings along with their adult child. The Director of Social Worker also stated that there is no documentation that Resident #111 was present or was invited to the care plan meetings. The Director of Social Worker further stated that residents are notified of the care plan meetings verbally and there is a sign in sheet that all attendees must sign. The Director of Social Worker stated they were told by the Department of Health that residents do not have to be invited to the quarterly meetings only the annual, significant change, and by request. On 12/09/24 at 12:30 PM, an interview was conducted with Social Worker #1 who stated that they schedule the care plan meetings, and they verbally invite cognitively intact residents to attend meetings the day before and the day of the meeting. Social Worker #1 also stated that the families are called and invited to attend the care plan meeting for residents that are not cognitively intact. For residents who cannot come down to the conference room or if the resident refuses to come out of their rooms to attend the care plan meeting, the interdisciplinary team will go to the resident's room to conduct the care plan meeting. Social Worker #1 further stated that there should be documentation in the progress notes if the resident and/or family members attended or refused to attend the meeting and there is a sign in sheet that the residents sign to document that they attended the care plan meetings. Social Worker #1 stated that they do not know if it is always documented in the system when residents attend the meetings. 2. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented that Resident #13 had moderately impaired cognition. Section Q of the Minimum Data Set Assessment documented that Resident #13 participated in assessment and goal setting. On 12/02/2024 at 10:50 AM, Resident #13 was interviewed, and they stated they do not participate in their care plan meetings. The Annual Care Plan meeting note dated 05/16/2024 documented Resident #13's family was contacted and continues to be highly involved in Resident #13's plan of care. The Quarterly Comprehensive Care Plan meeting note dated 10/29/2024 documented family were contacted and participated in the meeting with the interdisciplinary team via telephone conference. Resident #13's care, current conditions, well-being, and possible discharge plans in the future were discussed. Social Worker will continue to provide support to resident and responsible party as needed. There was no documented evidence that Resident #13 was invited to or participated in the care plan meeting. During an interview on 12/06/2024 at 10:41 AM, the Director of Social Work stated that alert residents, Certified Nursing Assistants, next of kin, Social Worker, Nursing Supervisor, Dietary, and Minimum Data Set Coordinator are in attendance for the care plan meetings. The Director of Social Work also stated that Resident #13 was asked if they wanted to participate and refused and requested that their family be called. The Director of Social Work further stated that they did not document that Resident #13 refused to participate in the care plan meeting and they should have. During an interview on 12/06/2024 at 3:47 PM, the Assistant Director of Nursing stated Nursing, Dietary, Activity, Rehabilitation, Minimum Data Set Coordinator, and the Resident are present during the care plan meetings. The Assistant Director of Nursing also stated that the Social Worker is responsible for inviting the resident to the care plan meeting. 10 NYCRR 415. 3(f)(1)(v) | Plan of Correction: ApprovedJanuary 2, 2025 Immediate Correction: 1) On 12/30/24, Immediate written and/or verbal invitations were sent to Resident #111 for all upcoming care plan meetings, including quarterly, significant change, and annual care plan meetings. 2) On 12/30/24, The Social Worker visited Resident #111 to explain the right to participate and assist in identifying a preferred time and manner for involvement in care planning meetings. 3) On 12/30/24, Documentation was completed by the Director of Social Services in the care plan and progress notes to indicate Resident #111's participation or refusal to attend each meeting. 4) On 12/30/24, Resident #13 was provided with written and/or verbal invitations for all upcoming care plan meetings, including quarterly, significant change, and annual meetings. 5) On 12/30/24, The Social Worker visited Resident #13 to assess their preference for participation and offer the option of attending the next care plan meeting. 6) If Resident #13 continues to refuse participation, the refusal will be documented in the progress notes, and the family will be invited to participate, with proper documentation of their involvement. Identification of Others: 1) The facility will review all other residents who have been cognitively assessed as capable of participating in care planning to ensure that all eligible residents and resident representatives have been appropriately invited and given the opportunity to engage in their care plan development. 2) A full audit by the DSW of residents who are cognitively intact and those with partial or full impairments will be conducted to ensure that invitations for care plan meetings are consistently extended, and participation is documented. Systemic Changes: 1) The facility's policy on Comprehensive Care Planning, revised 09/24, will be reviewed to clearly specify that residents must be invited to all care plan meetings, including quarterly, annual, and significant change meetings. Invitations must be extended in writing and/or verbally to all residents deemed cognitively intact. 2) The policy will include instructions for the Social Worker and interdisciplinary team on the documentation requirements, including invitations, attendance, refusals, and family involvement, to be included in the progress notes and sign-in sheets. 3) The Social Work department will receive additional training on the facility's policy regarding resident participation in the care planning process, including the requirement for documented invitations, participation, and refusals. 4) The Social Workers will be in serviced and training will focus on the importance of inviting all residents who are cognitively intact and resident representatives accurately documenting attendance, and ensuring all communications with residents and family members are clear and complete. 5) The care planning meeting schedule and process will be revised to include a checklist that confirms each resident's participation, the invitation status, and any family involvement. This checklist will be reviewed by the Director of Social Services before each meeting to ensure compliance. 6) The Director of Social Worker will ensure documentation is accurately recorded for future meetings, including whether the resident was invited and/or participated by documented efforts in progress notes and having the resident sign the care plan meeting sheets. Quality Assurance: 1) The Director of Social Services will implement a monthly audit of care plan meeting invitations, participation, and refusal documentation for the next three months to ensure compliance with the facility policy. 2) The facility administration will establish a process for residents and families to provide feedback regarding the care planning process and whether they felt adequately invited or involved by surveying residents and families on an ongoing basis. 3) The Care Plan Meeting Invitation Audits will be completed by the Director of Social Services weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Social Services. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of resident room walls with mismatched paint patches, discolored blinds, worn window treatments, torn wall paper, damage furniture and dirty, dusty areas. This was observed during the Environment task and was evident on 4 (1 North, 1 East, 2nd floor and 1 West) of 5 units. The findings include but are not limited to: The facility policy and procedure revised 09/01/24 titled Safe, Clean, Comfortable and Homelike Environment documented that it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible. The policy also documented that this includes providing housekeeping and maintenance services necessary to maintain a sanitary environment. 1. On unit 1 North the following was observed: a. The baseboard and door corners in male and female shower room/bathroom were in disrepair. b. In room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] there were large unpainted areas near the radiator. 2. On unit 1 East the following was observed: a The hallway wall between rooms [ROOM NUMBERS] had patches of unpainted areas. b. Ceiling above the double door had patches of unpainted areas. c In room [ROOM NUMBER], and in the sitting area across from room [ROOM NUMBER] and 17 the windows were visibly dirty with whitish smudges on the window panes. d. In room [ROOM NUMBER] the plaster surrounding the light fixture on the ceiling and the wall across from the bed was cracked. e. In room [ROOM NUMBER] hooks on the privacy curtain were missing, walls were damaged, and the windowsill was cracked. During an interview on 12/09/2024 at 12:03 PM, Maintenance Worker #1 stated when repairing a damaged area, the area is supposed to be compounded then painted. Maintenance Worker #1 also stated that if the repair is light then the compound takes a day to dry and then is painted the following day. If the damage is large it would be three days before the area is painted. Maintenance #1 further stated that they are responsible for ensuring the hooks for the privacy curtains are in place. During an interview on 12/09/2024 at 12:19 PM, Housekeeper #2 stated they are responsible for cleaning every room on the unit, including the nurse's station. Housekeeper #2 also stated that they wipe the windows daily. Housekeeper #2 further stated they did not clean the windows in room [ROOM NUMBER] because the residents were in there. During an interview on 12/09/2024 at 12:22 PM, Maintenance Worker #2 stated they are responsible for fixing the holes, cracks and/or any damages to the ceilings on the units. Maintenance Worker #2 stated after patching the damage they have to wait for the plaster to dry and then paint it later. Maintenance #2 stated there was a water leak in room [ROOM NUMBER] and they repaired the wall and cemented it but have not returned to paint the wall because other priority assignments were called in and had to be done. 3. On the 2nd Floor the following was observed: a. In room [ROOM NUMBER] there were multiple areas of mismatched paint on the walls in the room. b. Above the window in room [ROOM NUMBER] there were mismatched patches of white paint over yellow paint and the entrance door had peeling brown paint. c. In room [ROOM NUMBER] there were unpainted white patches above bed A, and three large unpainted areas around the head of Bed B. There were large unpainted areas on the wall at the foot of bed, and the window treatments were tattered with pieces of fabric hanging. d. In room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] the window treatments were tattered with pieces of fabric hanging, and the white window blinds was discolored with brownish stains. e. The air conditioner unit located in the hallway just outside the Patio door was loose, and the base board under air conditioner unit was loose and split at the sides. On 12/09/24 at 12:20 PM, an interview was completed with a Housekeeper #1 who stated that they did observe the mismatched paint and blinds that are in disrepair and the maintenance department was aware and stated they will change all the blinds soon. Housekeeper #1 also stated that they attempted to clean the blinds several times, but they cannot be cleaned, and they were told they will change all the blinds soon, but they are not sure when this would be done. Housekeeper #1 further stated maintenance is working on fixing all the mismatched paint in the rooms and some rooms had already been taken care of. Housekeeper #1 stated they always report to the Maintenance Director if they see something that needs to be fixed. 4. On unit 1 West the following was observed: a. In Room W 49 b, an unmade bed was heavily stained and there was a worn blue colored mattress cover, the wooden bed frame was heavily worn and stained, and a wooden closet was missing a door handle and the bottom drawer was broken and placed on the floor. In addition, the top area of the room air conditioner located below the window was dusty and dirty. b. In Room W 65 the wall by the radiator had white unpainted plaster, broken window blinds, and the window sill was dusty and dirty with crumbed broken plaster. In addition, the bathroom wall tiles were dirty and stained. c. In Room W 47 b, the air conditioner was missing the front panel which was observed on the floor, and broken plaster was observed on the room walls. d. Torn wall paper on the walls in the corridor across from room W 50. e. In Room W 52 dried food and splatters were on the room walls. Review of the Maintenance Log Books for (MONTH) and (MONTH) revealed no written concerns as identified by the State Surveyors. On 12/09/24 at 08:20 AM, an interview was conducted with Housekeeper #3 who stated that they are responsible for cleaning the 1st floor West Wing and part of the 1st floor North Wing. Housekeeper #3 also stated that they perform daily routine cleaning of rooms and bathrooms and that there is a Maintenance log Book located on each unit for anyone to report issues that the Maintenance Department needs to address. Housekeeper #3 further stated that they can verbally inform the Maintenance Director of any issues and had not reported any issues recently. Housekeeper #3 stated that they do the best they can to keep the facility clean. On 12/09/24 at 12:04 PM, the Director of Housekeeping and Maintenance was interviewed and stated that their role is to maintain and ensure the environmental safety and cleanliness of the facility for residents, visitors, and staff. The Director of Housekeeping and Maintenance also stated that they make daily morning rounds on every unit to ensure that life safety concerns are identified and addressed, and they also see if staff are maintaining a clean environment. The Director of Housekeeping and Maintenance further stated that they have a lot of challenges and try to meet the demands, and recently hired a painter whose role is to paint and fix the walls and they have completed all the hallways on the 1st floor. On 12/09/24 at 01:23 PM, the Administrator was interviewed and stated that their Environmental policy means that the residents have a right to an environment that is clean, that their furniture is in good condition and that a homelike appearance is maintained, for not only the residents, but for staff and visitors as well. The Administrator also stated that they hired a painter approximately 3 months ago to address the concerns of torn wall paper, broken plaster and chipped paint. All units hallways and common areas were plastered and painted and completed a month ago. The painter has begun to plaster and paint the 3rd floor resident rooms. All rooms on the 3rd floor were completed for plaster and painting approximately 2 weeks ago. The 2nd floor resident rooms began approximately 2 weeks ago to plaster and paint and is ongoing. The Administrator also stated that they make daily environmental rounds together with my Assistant Administrator and when they come across identified environme | Plan of Correction: ApprovedJanuary 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Correction: 1) As of 12/31/24, The Maintenance Department will prioritize the immediate repair of all areas identified in the survey, including the unpainted walls, mismatched paint patches, cracks, and damaged areas in Rooms 40, 38, 37 (Unit 1 North), Rooms 25, 28, 18, 16/17 (Unit 1 East), Rooms 206, 210, 203, 211, 215, 217 (2nd Floor), and Rooms W49, W65, W47b, W52 (Unit 1 West). 2) As of 12/31/24, All areas observed with visible dirt, dust, or staining (e.g., air conditioner units, windowsills, walls, and bathroom tiles) were thoroughly cleaned and sanitized by the Maintenance/Housekeeping team. 3) As of 12/31/24, the windows in room [ROOM NUMBER], the air conditioners in multiple rooms (e.g., W49b, W65), and the bathrooms with stained tiles were cleaned by the Maintenance/Housekeeping team. 4) As of 12/31/24, The Housekeeping staff performed a detailed cleaning of the affected areas and provided documentation of completion. 5) As of 12/31/24, In Room W49b, the stained and worn mattress, broken bed frame, and broken closet were repaired. 6) As of 12/31/24, The missing door handle in Room W49b was replaced by the Maintenance team. Identification of Others: 1) Units 1 North, 1 East, 2nd Floor, and 1 West will have their rooms assessed for cleanliness and safety, and corrective actions will be taken as needed. All affected rooms will be given priority for repairs and cleaning. 2) The Director of Housekeeping and Maintenance will oversee that the rooms are returned to a safe, clean, and comfortable environment. 3) A facility-wide audit will be conducted to identify any additional rooms or common areas that may require repair, cleaning, or redecoration. This includes assessing all floors, any unpainted walls, damaged window treatments, and necessary repairs to ensure that all areas meet the facilitys safety and comfort standards. Systemic Changes: 1) The facilitys Safe, Clean, Comfortable and Homelike Environment policy will be revised to include clearer guidelines on maintaining rooms, common areas, and the timely reporting of repairs or maintenance concerns. 2) The updated policy will also specify the roles and responsibilities of the Housekeeping and Maintenance departments in ensuring a safe and homelike environment. 3) The Director of Maintenance and Maintenance and housekeeping workers will undergo additional training to understand the updated standards and expectations for maintaining a safe, clean, and homelike environment. 4) A clear protocol will be implemented for housekeeping staff to immediately report issues to the Maintenance Director, including a system for tracking repairs and ensuring all issues are addressed in a timely manner. 5) The facility will implement daily environmental rounds with the Administrator, Assistant Administrator, Director of Housekeeping, and Maintenance Director to assess the cleanliness, safety, and comfort of resident rooms and common areas. 6) A formal audit checklist will be developed to ensure the environment meets the facility's standards for cleanliness, maintenance, and homelike qualities. 7) Any issues identified during the rounds will be documented, and corrective actions will be taken immediately. Any issues that cannot be resolved during the rounds will be logged and addressed within a defined timeframe (e.g., 24-72 hours). 8) A Maintenance Log will be implemented, where maintenance and housekeeping staff will be required to record and report any issues they notice during cleaning. This log will be reviewed daily by the Maintenance Director to ensure timely action is taken. 9) The facility will ensure all maintenance issues reported in the log are tracked through completion, with clear timelines for resolution and documentation. 10) Staff will be instructed to immediately report any areas of concern in resident rooms or common areas, ensuring that all repairs and cleanliness issues are promptly addressed. Quality Assurance: 1) The Director of Maintenance/Housekeeping will conduct weekly audits for the next 3 months to ensure that all repairs, cleaning, and updates have been completed as per the standards outlined in this plan. The audits will also assess whether the facility is maintaining a safe, clean, comfortable, and homelike environment for residents. 2) The facility administration will establish a feedback mechanism for residents and their families to provide input on the condition of the environment. A survey or comment box will be placed in common areas to allow for anonymous feedback on cleanliness, safety, and comfort. 3) Feedback will be reviewed by the Administrator and the QAPI team, and corrective actions will be taken based on the feedback received. 4) Weekly audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details Based on observations, interviews, and record review conducted during the recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the Lobby area, hallways, and nursing station. The facility policy and procedure revised 09/01/24 titled Safe, Clean, Comfortable and Home-Like Environment documented, it is the policy of the facility to provide a safe, clean, comfortable homelike environment in such a manner to acknowledge and respect residents rights to the extent possible. The findings are: During multiple observations in the facility from 12/02/2024 at 9:30 PM and 12/09/2024 at 3:00 PM the following was observed: 1. In the Lobby Area, the bathroom near Main Dining Room area had holes in the wall, rusty call bell panel and broken molding. 2. in 1 West Nurse Station cable wires were layered with dirt and dust. 3. In the 2nd floor Nurses station 2 black swivel chairs had torn vinyl armrests, and there was a desk with broken and rough-edged Formica paneling. 4. In the 3rd Floor Nurses Station there was peeling and torn wall paper underneath the nurse station desk area, a desk with rough bottom edges and broken Formica panels, the bottom desk drawer did not close properly and was in disrepair, and the staff bathroom had a leaking, loose faucet. 5. In the 1 North Nursing station dusty areas were noted and there were unpainted patches in the ceiling. On 12/09/24 at 01:23 PM, the Administrator was interviewed and stated that their Environmental policy means that the residents have a right to an environment that is clean, that their furniture is in good condition and that a homelike appearance is maintained, for not only the residents, but for staff and visitors as well. The Administrator also stated that when we come across identified environmental concerns we notify the Maintenance Director to ensure corrective action is immediately taken. The Administrator further stated that their plan is to replace the furniture and retain furniture that is in good condition, however they did not have a current proposal or receipts of purchased furniture to show at this time. 10 NYCRR 415. 29 | Plan of Correction: ApprovedJanuary 2, 2025 Immediate Correction 1) As of 12/31/24, the facility repaired the holes in the wall of the bathroom near the Main Dining Room, repainted as needed and replaced the rusty call bell panel and broken molding. 2) As of 12/31/24, the West unit nurse station was thoroughly cleaned specifically all cable wires to remove accumulated dirt and dust. 3) As of 12/31/24, On the 2nd Floor nursing station, Maintenance/Housekeeping department replaced the two black swivel chairs with torn vinyl armrests and repaired the desk with broken and rough-edged Formica paneling. 4) As of 12/31/24, On the 3rd floor nursing station, Maintenance/Housekeeping department replaced the peeling and torn wallpaper underneath the desk area, repaired the desk with rough bottom edges and broken Formica panels, repaired the bottom desk drawer to ensure proper closure and fixed the leaking and loose faucet in the staff bathroom. 5) As of 12/31/24, On the North unit nursing station, the Maintenance/Housekeeping department cleaned the dusty areas thoroughly and patch/painted the unpainted ceiling areas. 6) The above Immediate repairs and replacements were documented in the maintenance log and overseen by the Maintenance Director to ensure timely completion. Identification of Others 1) The Director of Maintenance and Housekeeping will conduct a facility-wide environmental audit to identify other areas that may not meet the standards of a safe, functional, sanitary, and comfortable environment. 2) Include all common areas, resident rooms, nursing stations, and staff areas in the audit. 3) Document all findings and create a prioritized corrective action plan for each identified issue. Systemic Changes 1) Review and revision of the facility's Environmental Policy to include: - Detailed cleaning schedules for all areas, including nursing stations and common spaces. - Timelines for routine inspections of furniture, fixtures, and equipment to ensure functionality and safety. - Clear procedures for promptly addressing and documenting maintenance requests. 2) Provide in-service training to Housekeepers, Maintenance Workers, RN's, LPN's and CNA's on the importance of maintaining a safe, clean, and homelike environment. 3) Emphasize protocols for reporting environmental concerns promptly to the Maintenance Director through in servicing and education. 4) Establish an annual budget and timeline for replacing worn or damaged furniture and equipment. 5) Maintain a vendor proposal log and receipts to ensure accountability for all purchases and replacements. Quality Assurance 1) The Maintenance Director or designee will develop and conduct a weekly environmental rounds audit tool focusing on areas cited in the deficiency and other high-traffic locations. 2) Conduct monthly audit of common areas, resident rooms, and nursing stations to ensure ongoing compliance. 3) Solicit feedback from residents, families, and staff through surveys and suggestion boxes to identify additional environmental concerns or improvements. 4) Audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details Based on record review and interviews conducted during the Recertification Survey from 12/02/2024 to 12/09/2024 , the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing Guidelines reviewed 9/2024 stated that the facility will promote resident quality care and safety by ensuring adequate and competent staffing levels are based on the Facility Assessment. The facility staffing physiology is designed to support professional Nursing practice in accordance with our mission and vision. The policy further stated that on a regular basis, a minimum of annually and upon changes in the facility population and care needs, the facility will evaluate the overall number of staff needed to ensure sufficient qualified staff are available to meet each resident needs. The Payroll Based Journal Staffing Data Report for the 3rd quarter of 2024 (04/01/2024 - 06/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment last updated 8/7/2024 documented facility capacity of 180 residents with a weekend staffing plan by shift distributed as follows: Day shift by units: Unit 3: 1 Registered Nurse, 1 Licensed Practical Nurses and 5 Certified Nursing Assistants Unit 2: 1 Registered Nurse, 1 Licensed Practical Nurses and 6 Certified Nursing Assistants Unit East: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit North: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit West: 1 Registered Nurse, 1 Licensed Practical Nurses and 4 Certified Nursing Assistants Total = 5 Registered Nurses, 5 Licensed Practical Nurses, and 20 Certified Nursing Assistants. Evening Shift: Registered Nurse Supervisor: 1 Unit 3: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit 2: 1 Registered Nurse, 1 Licensed Practical Nurses and 4 Certified Nursing Assistants Unit East: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit North: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit West: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Total= 5 Registered Nurses, 5 Licensed Practical Nurses, and 15 Certified Nursing Assistants. Night Shift: Unit 3: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit 2: 1 Registered Nurse, 1 Licensed Practical Nurses and 3 Certified Nursing Assistants Unit East: 1 Registered Nurse, 1/2 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit North: 1 Registered Nurse, 1/2 Licensed Practical Nurses and 2 Certified Nursing Assistants Unit West: 1 Registered Nurse, 1 Licensed Practical Nurses and 2 Certified Nursing Assistants Total=5 Registered Nurses, 4 Licensed Practical Nurses, and 11 Certified Nursing Assistants 1 Nurse cover East and North units on the Night shifts. Review of the actual weekend facility staffing schedule from 04/06/2024 to 04/28/2024 documented the following: On 04/06/2024 on the 7 AM-3 PM shift there was a shortage of 4 Registered Nurses for 3rd, 2nd, East, North and Units and 1 Certified Nursing Assistant on the 3rd and East unit, 2 Certified Nursing Assistants for the 2nd unit. On 04/06/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West Units and 1 Certified Nursing Assistants for the 2nd and East unit. On 04/06/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West Units, and 1 Certified Nursing Assistant for the 3rd, East, North and west Units, 2 Certified Nursing Assistant on the 2nd unit. Total staff shortage in a 24-hour period was 14 Registered Nurse, and 11 Certified Nursing Assistants with no replacement of staff. On 04/07/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West Units and 1 Certified Nursing Assistants for the 2nd and 3rd floor. On 04/07/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 2nd, East, North and West units, 1 Licensed Practical Nurse on 3rd Floor, and 1 Certified Nursing Assistant for the East and North units. On 04/07/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, and 1 Licensed Practical Nurse for the North unit, and 1 Certified Nursing Assistant for the 2nd, East, North and West units. Total staff shortage in a 24-hour period was 14 Registered Nurse for 3rd, 2nd, East, North and West units, 2 Licensed Practical Nurses, and 8 Certified Nursing Assistants with no replacement of staff. On 04/13/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, and 1 Certified Nursing Assistant for the 2nd and West units. On 04/13/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, 1 Licensed Practical Nurse for the East Unit and 1 Certified Nursing Assistant for the 2nd unit. On 04/13/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for 3rd, 2nd, East, North and West units, and 1 Certified Nursing Assistant on the 2nd unit. Total staff shortage in a 24-hour period 15 registered Nurse, 1 Licensed Practical Nurse, and 4 Certified Nursing Assistants with no replacement of staff. On 04/14/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurses for the 3rd, 2nd, East, North and West units and 1 Certified Nursing Assistant for the 3rd, 2nd, and North units. On 04/14/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for 3rd, 2nd, East, North and West units, 1 Licensed Practical Nurse for East unit, and 1 Certified Nursing Assistant for the 2nd and East units. On 04/14/2024 on the 11 PM-7 AM shift there was a shortage of 4 Registered Nurse for 3rd, 2nd, East, North and West units, and 1 Certified Nursing Assistant on the 2nd and North units. Total staff shortage in a 24-hour period 14 Registered Nurses, 1 Licensed Practical Nurse and 8 Certified Nursing Assistants with no replacement of staff. On 04/20/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for 3rd, 2nd, East, North and West units, 1 Certified Nursing Assistant on the 2nd, East and North units. On 04/20/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, and 1 Certified Nursing Assistant for the 2nd and East unit. On 04/20/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, and 1 Certified Nursing Assistant for the 2nd, North, and West units. Total staff shortage in a 24-hour period 15 Registered Nurses and 8 Certified Nursing Assistants with no replacement of staff. On 04/21/2024 on the 7 AM-3 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, 2 Certified Nursing Assistants for 2nd unit, and 1 Certified Nursing Assistant for the 3rd unit. On 04/21/2024 on the 3 PM-11 PM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North and West units, and 1 Certified Nursing Assistant for 2nd, North, and West units. On 04/21/2024 on the 11 PM-7 AM shift there was a shortage of 1 Registered Nurse for the 3rd, 2nd, East, North, and West units, and 1 Certified Nursing Assistant for the North unit. Total staff shortage in a 24-hour period 15 Registered Nurses and 7 Certified Nursing Assistants with no replacement of staff. On 04/27/2024 on | Plan of Correction: ApprovedJanuary 3, 2025 Immediate Correction 1) On 12/30/24, The Administrator, DON and HR Director furthered Facility recruitment efforts including: 2) On 12/30/24 contacted CNA School Training program 3) On 12/30/24 contacted 1199 SEIU Hiring division 4) On 12/30/24 contacted additional Staffing agencies like Meridian and Towne. 5) Reviewed the potential to add/hire HHA Hall Monitors to assist in responding to call bells and non-clinical needs informing Charge Nurse of resident needs as indicated. 6) The facility continues to post and promote ads for recruitment for all open positions in the facility with the Apploi platform on job sites like Indeed and Zip Recruiter. 7) On 12/31/24 The Administrator, DON and Staffing Coordinator met with the Resident Council to discuss Facility plan for improving staffing numbers and ensuring care needs are met. Residents expressed satisfaction. 8) Incentives to recruit staff, including the use of sign-on bonuses, job fairs, tuition coverage, shift pickup bonuses and staffing agencies, will continuously be used to increase the facilitys staffing levels. Identification of Others 1) Resident Safety Assessment: The Administrator will conduct a comprehensive review of all residents by 12/31/2024 to identify any who may have been negatively impacted by staffing shortages. This will include checking for delays in care, unmet needs, or changes in physical, mental, or psychosocial well-being. Any identified issues will be addressed by the interdisciplinary team. Systemic Changes 1) The interdisciplinary team revised the staffing policy and Facility Assessment to accurately reflect current staffing needs based on resident acuity, census, and care plans. 2) The DNS and Administrator will review and revise 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. - 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) Implementing a weekend staffing strategy that includes a dedicated pool of on-call staff, incentives for weekend shifts, and pre-scheduled backup coverage. 4) Reviewing and revising licensed nurses and CNA Assignments for each Unit to ensure any staffing adjustments needed based on resident needs and acuity 5) Developing an audit tool to identify the number of open positions based on par levels to ensure that safe sufficient staffing would be maintained. 6) The DNS will provide RN's, LPN's and CNA's 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 is 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. Quality Assurance 1) The QAPI committee will conduct weekly audits of staffing patterns and compliance with the updated Facility Assessment. 2) Initiate resident and family satisfaction survey audit tools to identify concerns related to staffing or care delivery. 3) Review all incidents and complaints quarterly to identify any trends or correlations with staffing levels. 4) Include staffing as a standing agenda item during quarterly QAPI meetings to ensure continuous monitoring and improvement. 5) Audits will be completed by the Director of Human Resources weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 6) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 2. 3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 96: 10. 2. 6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable: (1) NFPA 12 (2) NFPA 13 (3) NFPA 17 (4) NFPA 17A 2009 NFPA 17A 7. 3 Maintenance. 7. 3. 1* A service technician who performs maintenance on an extinguishing system shall be trained and shall have passed a written or online test that is acceptable to the authority having jurisdiction. 7. 3. 1. 1 The service technician shall possess a certification document confirming the requirements in 7. 3. 1 and issued by the manufacturer or testing organization that is acceptable to the authority having jurisdiction. 7. 3. 2* A service technician who has the applicable manufacturer's listed installation and maintenance manual and service bulletins shall service the wet chemical fire-extinguishing system at intervals no more than 6 months apart as outlined in 7. 3. 3. 7. 3. 3* At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual. Based on staff interview and document review, the facility did not ensure that the kitchen 's automatic extinguishing system was maintained according to 2009 NFPA 17A. This occurred in the kitchen located on the 1st floor. The findings include: During the document review on 12/4/24, at approximately 11:00 am, it was noted that the last vendor's inspection and maintenance report for the Ansul extinguishing system in the kitchen was dated 1/24/ 24. This was greater than the required 6-month interval for maintenance of this system. The report, by Fire Command Co., stated that on 1/24/24 unable to do inspection. Cheese Melter no protection. Need to legalize (sic) system. Customer changed equipment. Upon interview at the time of this finding, the Facilities Director stated that they had replaced the Ansul equipment and also contracted with a new vendor to do the maintenance and inspections. It was unclear if the local fire department had done an inspection to certify the new equipment, and a vendor report for a more recent inspection was not available. At the exit conference on 12/4/24, at approximately 1:30 pm, the Administrator stated that the vendor had been to the facility recently but they dis not yet have the report. 2012 NFPPA 101 2011 NFPA 96 2009 NFPA 17A 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedDecember 19, 2024 Immediate Correction: 1) Upon discovering the missed 6-month maintenance interval for the Ansul automatic extinguishing system, the facility immediately contacted a licensed and certified vendor to perform a full inspection and servicing of the system. 2) The facility will ensure the new kitchen equipment (including the Cheese Melter) is properly integrated into the Ansul system. Following the inspection, a report and work quote from the Fire Command Co. vendor was obtained and approved. Identification of Others: 1) The facility will conduct a comprehensive review of all cooking equipment in the kitchen, including checking for proper installation, fire extinguishing system coverage, and compliance with NFPA 96 and NFPA 17A. 2) The Director of Maintenance will ensure that a list of all equipment and associated fire suppression systems is updated. Additionally, the facility will maintain regular communication with the vendor and the local fire department to ensure that all future inspections are performed in a timely manner and that the equipment is certified according to the latest standards. Systemic Changes: 1) The Director of Maintenance will implement a new automated maintenance tracking system audit tool to ensure that all fire suppression and extinguishing systems are inspected at the required intervals. 2) The Director of Maintenance and all relevant maintenance staff will undergo training on the NFPA 96 and NFPA 17A standards, specifically focusing on the requirements for maintaining automatic extinguishing systems in kitchens. Quality Assurance (QA): 1) The facility will implement monthly audits of all fire safety equipment in the kitchen, including automatic extinguishing systems, fire suppression systems, and related equipment. These audits will verify that all equipment is functional and maintained according to NFPA standards, and that service reports are up to date. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 2. 8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7. 8. 7. 8 Illumination of Means of Egress. 7. 8. 1 General. 7. 8. 1. 1* Illumination of means of egress shall be provided in accordance with Section 7. 8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7. 8. 1. 2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7. 8. 1. 2. 2. 7. 8. 1. 4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0. 2 ft-candle ( 2. 2 lux) in any designated area. 7. 8. 1. 2. 3* Energy-saving sensors, switches, timers, or controllers shall be approved and shall not compromise the continuity of illumination of the means of egress required by 7. 8. 1. 2 Based on observation and interview, the facility did not ensure that egress lighting was provided continuously, and that all lights were operable without the use of a timer. This occurred at and near the first -floor exit discharge at the West stair. The findings include: During the life safety survey of 12/3/24, at approximately 10:00 am, it was noted that the lights at the exit discharge at the W stair and the lights at the discharge from the adjacent dining room, were controlled by a timer. At the time of this finding, the Facilities Director stated that the timers would be replaced with photocells which would not interfere with the continuous illumination at the egress. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedDecember 19, 2024 Immediate Correction: 1) On 12/4/2024, the timers that controlled the lighting at the West stairs were immediately deactivated and replaced with photocell sensors. 2) The new photocell sensors now ensure that the lighting remains continuously operational, without the need for manual intervention, and fully meets the requirements. 3) The newly installed photocell sensors were tested on -site to confirm that the egress lighting now operates continuously during hours of occupancy, in compliance with the required illumination standards. The lighting was inspected to ensure that no failure of any single lighting unit resulted in an illumination level of less than 0. 2 ft-candle in any designated area. 4) The Director of Maintenance documented the replacement of the timers and the installation of photocells, confirming that all lighting in the means of egress is now continuously illuminated. Identification of Others: 1) A comprehensive review of all lighting systems controlling means of egress throughout the facility was conducted to identify any additional instances where timers or other manual control systems might be in place. This included all exit access areas such as corridors, stairs, aisles, and exits. Systemic Changes: 1) As a systemic change, the facility will ensure that all areas requiring illumination of egress pathways are equipped with photocell sensors to guarantee that lighting will remain continuously on, even if power is lost or if there is a failure of an individual lighting unit. 2) The Facility Director will ensure that all maintenance and operations staff are trained in the requirements, specifically regarding continuous illumination for means of egress. This training will emphasize the proper installation and maintenance of lighting systems and photocell sensors. Quality Assurance (QA): 1) The Director of Maintenance will implement a monthly audit tool to verify that all means of egress lighting remain continuously operational and is in compliance. The audits will include checking that photocell sensors and lighting units function properly without any timers or manual switches. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x3months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan. |