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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations and staff interviews conducted during the Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure garbage and refuse were disposed properly. This was evident during kitchen observation. Specifically, the facility garbage bins did not have a lid or cover to prevent the harborage and potential feeding of pests. The findings: The facility's policy and procedure titled Disposal of Garbage and Refuse revised 1/2025 documented all garbage and refuse will be disposed of in a safe and efficient manner throughout the day. The exterior dumpster area shall be maintained and free of rubbish and other debris. All waste shell be kept in lined containers that are covered with lids, leak-proof and non-absorbent prior to disposal. On 2/10/2025 at 1:02PM, an observation was made of the garbage disposal room. The garbage bins all containing garbage were observed without a lid or cover. On 2/10/2025 at 1:13 PM and 2/11/2025 at 3:40PM, the garbage bin located in the garbage pickup area was observed without lid or cover, exposing garbage piled high in the bin. On 2/11/2025 at 12:04PM, Director of Food Service stated garbage bins are not equipped with a lid so they are not able to keep waste covered at this time. On 2/11/2025 at 3:27PM, Housekeeping Director stated they have been working in the facility for [AGE] years and the waste company has never provided garbage bins equipped with lids. Therefore, the garbage taken out to the pick-up area are always left exposed in the bin. On 2/12/2025 at 11:31 AM, Administrator was interviewed and stated they contacted the vendor to address the issue. 10 NYCRR 415. 14(h) | Plan of Correction: ApprovedMarch 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The vendor was contacted on 02/12/2025 to supply the facility with 10 new metal garbage bins with covers. New metal garbage bins have been delivered to the facility on [DATE] & 2/27/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The facility Policy and Procedure was titled Disposal of Garbage and refuse, was reviewed and dated; no revision needed. All Housekeeping and kitchen staff are in-serviced on the above policy New metal garbage bins with covers are being implemented An audit tool is being created to ensure compliance with garbage disposal 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? On a weekly for one quarter, the Director of Housekeeping or designee will conduct environmental audits of the compactor room and loading dock to ensure garbage bins are covered and in good condition. Any outstanding issues will be corrected and reported to the Administrator immediately and in good condition. On a monthly for one quarter, the Director of Housekeeping or designee will report audit findings to the Administrator. On a quarterly basis, the Director of Housekeeping or designee will present audit findings to the QAPI Committee. The QAPI Committee will review the findings and determine if further action is necessary. 5. The title of the person responsible for correction of each deficiency Director of Housekeeping |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY# 998) and Recertification survey from 2/5/2025 to 2/12/2025, the facility did not ensure a resident with limited range of motion received treatment and services to maintain and/or to prevent further decrease in range of motion. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with range of motion exercises in accordance with a physician's orders [REDACTED]. The findings are: The facility's policy and procedure titled Rehabilitative Nursing Care undated documented rehabilitative nursing care is performed daily for those residents who require such service include assisting residents with their routine range of motion exercises, floor ambulation, standing and transfer. Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #66 is cognitively intact and requires partial/moderate assistance for upper body dressing, personal hygiene and dependent for lower body dressing, putting footwear. The New York State Department of Health Complaint Intake received 7/12/2024 documented that Resident #66 no longer receives physical therapy and was ordered to receive stretches in bed. However, staff are not providing any exercises. On 2/6/2025 9:59 AM, Resident #66 was interviewed who stated they are ordered to receive upper/lower extremity exercises in bed after therapy was discontinued. Initially, the nursing staff were doing the exercises daily for Resident # 66. It later stopped completely and has not been getting any exercise for few months already. The Physician order [REDACTED].#66 to receive Active Range of Motion to both upper extremities and Active/Passive Range of Motion to both lower extremities 3 sets x 10 reps daily as tolerated. The Comprehensive Care Plan for Resident #66 placed on Range of Motion initiated 11/6/2024 and last reviewed 1/23/2025 documented resident will maintain to participate in range of motion during care and will not develop any contracture or limitation in movements during care until next review date. The interventions included active range of motion to both upper extremities and active/passive range of motion to both lower extremities 3 sets x 10 reps in all available planes of motion daily as tolerated. The Certified Nursing Assistant Documentation Record for Resident #66 dated 1/1/2025 to 2/6/2025 documented Resident #66 to receive range of motion to both upper/lower extremities 3 sets x 10 reps once daily for 15 minutes during 7:30AM to 3:30PM shift. The review of the record revealed that the AROM/PROM exercises were being provided/was tolerated. On 2/7/2025 at 10:14 AM, Certified Nursing Assistant #9 stated they are currently regular assigned staff during the day shift for Resident # 66. Certified Nursing Assistant #9 stated Resident #66 is cognitively intact, requiring total care for most of ADLs except for eating. Resident #66 is also limited in their mobility/functional level so resident utilizes the call bell when help is needed. Certified Nursing Assistant #9 stated Resident #66 prefers to stay in their room, mostly in bed. Certified Nursing Assistant #9 recalled Resident #66 on range of motion some time last year, but stated resident is not currently on any program. Therefore, Certified Nursing Assistant #9 stated they are not performing any range of motion exercises for Resident # 66. Certified Nursing Assistant #9 stated nursing instructions/therapy binder were checked to confirm that Resident #66 was not on any restorative nursing program. Certified Nursing Assistant #9 stated they don't remember completing any documentation related to range of motion in the electronic medical record for Resident # 66. Therefore, they could not explain why there is documentation indicating Resident #66 was provided with range of motion exercises. On 2/11/2025 at 11:43 AM, Certified Nursing Assistant #11 stated they are per diem who worked during the day shift on 2/6/ 2025. Certified Nursing Assistant #11 recalled that Resident #66 was added to their assignment because staff had called out on that day. Certified Nursing Assistant #11 stated they didn't provide any range of motion exercises for any residents including Resident #66 on that day. Certified Nursing Assistant #11 stated they did not know why documentation reflected that resident was provided with range of motion exercises. It was an error and should have not been documented as completion. On 2/11/2025 at 11:22 AM, Physical Therapist stated Resident #66 last received therapy from 10/17/2024 to 11/6/2024 and was placed on maintenance restorative nursing program. Resident #66 is provided with daily range of motion exercises for 15 minutes by nursing staff. Range of motion can be incorporated/performed during ADL care but it requires time to complete 10 reps x 3 sets for both upper/lower extremities. On 2/10/2025 at 8:25 AM, Registered Nurse #3 stated certified nursing assistant during the day shift is responsible to provide range of motion during ADL care daily. Nursing staff is rotated monthly, so they are responsible to check resident's individual plan of care in the electronic medical record. Registered Nurse #3 stated they were not aware that Resident #66 was not getting their range of motion exercises daily. On 2/12/2025 at 12:05 PM, Director of Nursing Service stated that unit nurse supervisor is responsible to review resident's individualized plan of care with assigned nursing staff and to conduct rounding on the unit to ensure the care is being provided. Director of Nursing Service stated the staff will need more training about performing range of motion and documenting accurately in the electronic medical record. 10 NYCRR 415. 12(e)(2) | Plan of Correction: ApprovedFebruary 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 66 was assessed by OT on (2/27/2025) and had no negative outcomes from the deficient practice Task in CNA Accountability (Point Of Care) was revised to provide clear instructions pertinent to Range of Motion exercises on 2/27/ 2025. Certified Nursing Assistant # 9 was re-educated on the following plan of care listed in electronic Kardex on 2/27/2025 Certified Nursing Assistant # 11 was re-educated on the accuracy of documentation on 2/27/2025 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on restorative nursing care have the potential to be affected by this practice. An audit is being conducted on all residents on the Restorative Nursing Care to ensure the tasks are documented accurately based on actual provision of care. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility Policy and Procedure titled ?ôRehabilitative Nursing Care?Ø was reviewed and revised to ensure restorative nursing care provided and accurately documented All nursing staff are being in-serviced on the above policy and procedure with an emphasis on the importance of the completion of the restorative care and accurate documentation of such All RNs and therapists are being re-educated on proper entry of restorative nursing tasks into EHR Weekly restorative nursing care meetings are being initiated to ensure the ordered restorative care is provided and documented The audit tool was created to ensure compliance 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis for the first quarter, the Director of Nursing, or designee, will randomly observe and audit 3-5 residents on the restorative nursing care for the completion of task and accurate documentation. Any outstanding issues will be addressed immediately and reported to the Administrator On a monthly basis, Director of Nursing will report the findings to the Administrator On a quarterly basis Director of Nursing will report findings to QAPI Committee QAPI Committee to determine if further action is required 5. The title of the person responsible for correction of each deficiency Director of Nursing & Assistant Dir. of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
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 the Recertification Survey from 02/05/2025 - 02/12/2025, the facility did not ensure that infection control practices and procedures were maintained. This was evident for 2 Residents (Resident # 389 and Resident #63) of 12 residents observed for medication administration and 1 Resident (Resident #389) observed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, 1. ) Licensed Practical Nurse #2 failed to follow Enhanced Barrier Precautions by not donning a gown while administering intravenous medications for a Resident with a Peripherally Inserted Central Catheter. 2. ) Licensed Practical Nurse #3 failed to follow Enhanced Barrier Precautions by not donning a gown while administering medications for a Resident with a Gastrostomy tube. 3. ) Licensed Practical Nurse #1 did not establish a clean field for the placement of wound supplies while performing a dressing change and did not perform hand hygiene after removing the soiled dressings. The findings are: The facility policy titled Enhanced Barrier Precautions reviewed/revised 02/2025, documented that Enhanced Barrier Precautions are implemented for residents who are at high risk of both acquisition of and colonization with multi-drug-resistant organisms. Enhanced Barrier Precautions expands the risk of personal protective equipment and refers to the use of gowns and gloves during high contact resident care activities. Enhanced Barrier Precautions should be applied to the residents with wounds, indwelling medical devices and infection or colonization with a multi-drug-resistant organisms. The facility policy titled Wound Care reviewed/revised 02/2025, documented steps in the wound care procedure: Establishment of a clean field on the resident's over the bed table for the placement of the clean items used while performing the dressing change. Hands should be washed and dried thoroughly after tape is loosened and the dressing is removed. 1) On 02/06/25 at 9:06AM, during observation of medication administration for Resident #389, Licensed Practical Nurse # 2 was observed a) Administering 5 milliliters of 0. 9% Sodium Chloride Flush Solution into the Peripherally Inserted Central Catheter b) Preparing and Administering the antibiotic solution of [MEDICATION NAME] Sodium Chloride 350- 0. 9 milligrams/50mililiters to be administered at a rate of 100ml/hr. into the Peripherally Inserted Central Catheter without wearing a gown. On 02/06/25 at 9:30AM, Licensed Practical Nurse #2 was Interviewed and stated that they were not sure if the Intravenous Line for administration of medication for Resident #389 was a Central Catheter. Licensed Practical Nurse #2 was then observed looking in the Electronic Medical Record and stated that they then determined that the Resident's intravenous line is a Peripherally Inserted Central Catheter. Licensed Practical Nurse #2 further stated that they did not wear a gown because the resident is not on contact precautions. After reading the signage that was posted for Enhanced Barrier Precautions, Licensed Practical Nurse #2 stated that they were not knowledgeable on the topic because they have not received any education on Enhanced Barrier Precautions. 2. ) On 02/10/25 at 9:33AM, during observation of medication administration for Resident #63, Licensed Practical Nurse # 3 was observed administering medications into the Gastrostomy tube without wearing a gown. Resident #63 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE], documented that Resident #63 had severely impaired cognition and required 51% or more of the total caloric intake to be administered through a feeding tube On 02/10/25 at 9:45AM, Licensed Practical Nurse #3 was interviewed and stated that they did not wear a gown during medication administration because the Resident is not on contact precautions. Enhanced Barrier Precautions signage was posted on the resident's door. Licensed Practical Nurse #3 was observed reading the signage and afterwards stated they did not wear a gown for medication administration through the Gastrostomy tube because they did not see the signage. The signage was also posted on the personal protective equipment cart. 3. ) On 02/07/25 at 11:47AM during wound care observation for Resident #389, Licensed Practical Nurse # 1 was performing wound treatments to the left foot and bilateral hips and was observed placing wound care supplies and gauze dressings on an over the bed table that was not cleaned nor covered with a barrier to establish a clean field. After removal of the soiled dressings from the 3 wounds, it was observed that Licensed Practical Nurse # 1 did not perform hand washing or change gloves. Resident #389 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], documented Resident # 389 had severely impaired cognition, the presence of 2 venous and arterial ulcers, skin and ulcer/injuries and required medication administration intravenously A Readmission Nursing assessment dated [DATE], documented that the readmitting [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A Physician order [REDACTED]. On 02/07/25 at 12:20, Licensed Practical Nurse #1 was Interviewed on the wound procedure related to infection control measures. Licensed Practical Nurse #1 stated that they were nervous during the wound observation and that is why they omitted critical steps including establishing a clean field for placement of the wound supplies and hand washing and change of gloves after removal of the soiled dressings. On 02/07/25 at 12:30, Registered Nurse #1 was interviewed and stated that Licensed Practical Nurse #1 should not have omitted any infection control steps or processes while performing the wound treatment as they were educated, and they will be reeducated on the procedures. On 02/07/25 at 9:06 AM, The Assistant Director of Nursing/ Infection Control Preventionist, was interviewed and stated that all the nurses have been oriented on Enhanced Barrier Precautions and infection control procedures, medication administration and treatments. Inservice agendas and attendance sheets were received. The Assistant Director of Nursing/ Infection Control Preventionist also stated that they round daily, to ensure that the correct infection control signage is posted, and that the staff is administering medications correctly and following infection control and enhanced barrier precautions. On 02/07/25 at 09:47 AM The Director of Nursing was interviewed and stated that when a resident is admitted they are notified by email of those with indwelling devices, and they advise the staff on postings for Precautions and PPE to ensure compliance. The Director of Nursing further stated that walking Rounds with the Registered Nurses and the Licensed Practical Nurses for accountability has been initiated daily and for every shift and the Assistant Director of Nursing will report on the findings. 10 NYCRR 415. 19 (a) (1-3) | Plan of Correction: ApprovedMarch 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #389 has no negative outcome as evidenced by no signs and symptoms of infection of IV site and wound Resident #63 has no negative outcome as evidenced by no signs and symptoms of infection of [DEVICE] site LPN # 2 & LPN # 3 were in serviced on enhanced barrier precaution policy and procedure on 2/6/ 2025. LPN #1 was in serviced on dressing dry clean policy and procedure on 2/27/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this practice. All residents with wounds and EBP are being reassessed to ensure no deficient practice occurs. Any outstanding issues will be addressed immediately 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The facility Policy on enhanced barrier precautions was reviewed and no revision needed. - All staff is being re-educated on enhance barrier precaution. - EBP competency test is being administered to clinical staff and implemented as part of orientation and annual training - All nurses are being re-educated on dressing change policy and procedure with emphasis on establishing a clean field for placement of wound supplies and hand hygiene. - Wound Dressing Change observation is being implemented to the orientation and thereafter annually -Audit tools are being developed for enhanced barrier precaution and wound dressing dry clean. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis for the first quarter, the director of nursing or designee, will conduct an audit of 2 to 4 employees caring for residents on enhanced barrier precaution for compliance. Any outstanding issues will be correct immediately and reported to the administrator. On a weekly basis for the first quarter, the director of nursing or designee will conduct treatment observation on 1 nurse for proper dressing change including surface preparation and hand hygiene. On a monthly basis, the Director of Nursing will report the findings to the Administrator On a quarterly basis Director of Nursing will report findings to QAPI Committee QAPI Committee to determine if further action is required 5. The title of the person responsible for correction of each deficiency Director of Nursing & Asst. Dir of Nursing |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details Based on observations, record reviews, and interviews conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure the daily nurse staffing was posted. Specifically, there was no indication of the daily nurse staffing information with the total number of staff and total number of hours posted. This was evident during the review of the Staffing task. The findings include: The facility policy and procedure titled Posting Daily Nurse Staffing Information, last revised 01/02/2025, documented that the facility's policy is to ensure that nurse staffing information is always readily available in a readable format to residents and visitors. The facility will post daily nurse staffing information in a prominent place in each unit and in common areas that are readily accessible to residents and visitors. During multiple observations conducted on 02/05/2025 through 02/11/2025, there was no indication of the daily nurse staffing information being posted in the lobby or the nursing unit. The daily schedule was posted in the lobby inside a bulletin board. On 02/11/2025 at 9:39 AM, the Staffing Coordinator was interviewed and stated that the daily staffing schedule with the staff names and units assigned is posted on the bulletin board in the lobby. The daily nurse staffing with the total number of staff and total number of hours is not posted; it is attached to the schedule at the end of the day. On 02/11/2025 at 9:55 AM, the Director of Nursing was interviewed and stated that the staffing schedule is posted daily in the lobby. It contains where the staff are assigned to work. The daily staffing with the total number of staff and hours is supposed to be posted. I am not aware that it is not being posted. I do not check to see if it is posted; the director of nursing is responsible for ensuring that daily staffing is posted. On 02/11/2025 at 10:17 AM, the Administrator was interviewed and stated that staffing is posted in the lobby on the bulletin board. The schedule and the daily staffing are supposed to be posted. I usually check every morning but have not looked at it since the survey. I did not know that the daily staffing with the total number of staff and hours was not posted. 10 NYCRR 415. 13 | Plan of Correction: ApprovedFebruary 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The daily nurse staffing data was posted in a prominent place for residents and visitors to see in the facilitys lobby by front desk on 2/11/2025 and daily thereafter. Facility Staffing Coordinator and Director of Nursing were educated on a policy ?ôPosted Nurse Staffing Information?Ø with an emphasis on posting in a prominent place readily accessible to residents and visitors on 2/11/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Policy and Procedure titles ?ôPosted Nurse Staffing Information?Ø was reviewed and no revision is required Nursing Administration, Staffing Coordinator, RN Supervisors and RNs are being in-serviced on the above policy Director of Nursing is going to oversee daily nurse staffing data posting The audit tool was developed for monitoring compliance 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? Twice a week for one quarter, Director of Nursing or designee, will randomly check 2 prominent locations to ensure the nurse staffing data is posted and is accurate. Any outstanding findings will be addressed immediately and reported to the Administrator. On a weekly basis Director of Nursing or designee, Will report the findings to the Administrator. On a monthly basis Director of Nursing or designee will report findings to Administrator On a quarterly basis Director of Nursing or designee will report findings to QAPI Committee QAPI Committee to determine if further action is required 5. The title of the person responsible for correction of each deficiency Director of Nursing & Administrator |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the Recertification Survey from 02/05/2025 to 02/12/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended quarterly meetings. Specifically, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 4 out of the four meetings as required. The findings are: The facility Quality Assurance and Performance Improvement (QAPI) policy, last revised on (MONTH) 31, 2022, documented that the Quality Assessment and Assurance Committee consists of, at minimum, the director of nursing services, the medical director or designee, and at least one other member of the facility staff. One of them must be the administrator, the owner, a board member, or another individual in a leadership role. Meetings will be held quarterly. The facility policy and procedure titled Medical Director, with the last revised date of (MONTH) 2025, documented that the Medical Director will be responsible for improving the performance of medical services as an integral part of performance improvement activities. A review of the Quarterly Meeting Attendance Sheets entitled Quality Assurance and Performance Improvement revealed that the Medical Director did not sign the attendance sheets for the following meetings: 01/31/2024, 04/08/2024, 08/29/2024, and 12/19/ 2024. There is no documented evidence that the Medical Director attended the Quality Assurance & Performance Improvement meeting via Microsoft Teams or in person for 4 of the four quarterly meetings. On 02/12/2025 at 1:59 PM, the Director of Nursing was interviewed and stated that the Quality Assessment and Assurance Committee comprises the director of nursing, the administrator, the medical director, and all the department heads. They meet quarterly, but we have been meeting every week since (MONTH) on different topics. The Medical Director only comes to the quarterly meetings. The department heads attend the weekly meeting. On 02/12/2025 at 2:53 PM, the Medical Director was interviewed and stated that the protocol of the Quality Assurance and Performance Improvement meeting is to discuss different topics requiring improvement. The Administrator shares the meeting, and it covers everything that is a potential risk. I attend some of the meetings. The Administrator informs me on the phone that they are having a meeting. I do attend the meeting, and my name might be in the minutes. I do not sign the attendance record. On 02/12/2025 at 3:00 PM, the Administrator was interviewed and stated that they meet every quarter. All the department heads and corporate representatives attend the meeting. We hold a medical board meeting for the physicians. The Medical Director does not physically attend the quality assurance meeting. After the meeting, I would have a one-on-one meeting with the Medical Director to explain what we discussed and any new performance improvement plan. 10 NYCRR 415. 15(a) | Plan of Correction: ApprovedMarch 5, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Medical Director was in-serviced on 2/13/25 on the requirement to attend the QAPI meetings quarterly or designate a qualified representative in their absence. The Medical Director was instructed to sign the attendance sheet for all QAPI meetings to ensure proper documentation of participation on 2/13/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The facility Policy and Procedure was titled QAPI, was reviewed and dated, no revision needed. An Audit tool is being developed to monitor the attendance of all QAPI committee members. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a quarterly basis for the one quarter, the Administrator, or designee, will monitor the attendance of all QAPI committee members to ensure compliance. Quarterly, the Administrator or designee will formally invite the Medical Director to the QAPI meetings. Quarterly for on The Administrator or designee will ensure the Medical Director attends each quarterly QAPI meeting, either in person or via Zoom. The Administrator or designee will verify and document the Medical Directors attendance at each QAPI meeting. 5. The title of the person responsible for correction of each deficiency Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Complaint (NY# 998) and Recertification Survey from 2/5/2025 to 2/12/2025, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. This was evident for 1 (Resident #66) of 2 residents reviewed for Limited Range of Motion out of 37 total sampled residents. Specifically, Resident #66 was not provided with Range of Motion exercises, but documentation reflected that resident was provided with Range of Motion exercises. The findings are: The facility's policy and procedure titled Charting and Documentation undated documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #66 is cognitively intact and requires partial/moderate assistance for upper body dressing, personal hygiene and dependent for lower body dressing, putting footwear. The New York State Department of Health Complaint Intake received 7/12/2024 documented that Resident #66 no longer receives physical therapy and was ordered to receive stretches in bed. However, staff are not providing any exercises. On 2/6/2025 9:59AM, Resident #66 was interviewed who stated they are ordered to receive upper/lower extremity exercises in bed after therapy was discontinued. Initially, the nursing staff were doing the exercises daily for Resident # 66. It later stopped completely and has not been getting any exercise for few months already. The Physician order [REDACTED].#66 to receive Active Range of Motion to both upper extremities and Active/Passive Range of Motion to both lower extremities 3 sets x 10 reps daily as tolerated. The Comprehensive Care Plan for Resident #66 placed on Range of Motion initiated 11/6/2024 and last reviewed 1/23/2025 documented resident will maintain to participate in range of motion during care and will not develop any contracture or limitation in movements during care until next review date. The interventions included active range of motion to both upper extremities and active/passive range of motion to both lower extremities 3 sets x 10 reps in all available planes of motion daily as tolerated. The Certified Nursing Assistant Documentation Record for Resident #66 dated 1/1/2025 to 2/6/2025 documented Resident #66 to receive range of motion to both upper/lower extremities 3 sets x 10 reps once daily for 15 minutes during 7:30AM to 3:30PM shift. The review of the record revealed that the AROM/PROM exercises were being provided/was tolerated. On 2/7/2025 at 10:14 AM, Certified Nursing Assistant #9 stated they are currently regular assigned staff during the day shift for Resident # 66. Certified Nursing Assistant #9 stated Resident #66 is cognitively intact, requiring total care for most of ADLs except for eating. Resident #66 is also limited in their mobility/functional level so resident utilizes the call bell when help is needed. Certified Nursing Assistant #9 stated Resident #66 prefers to stay in their room, mostly in bed. Certified Nursing Assistant #9 recalled Resident #66 on range of motion some time last year, but stated resident is not currently on any program. Therefore, Certified Nursing Assistant #9 stated they are not performing any range of motion exercises for Resident # 66. Certified Nursing Assistant #9 stated nursing instructions/therapy binder were checked to confirm that Resident #66 was not on any restorative nursing program. Certified Nursing Assistant #9 stated they don't remember completing any documentation related to range of motion in the electronic medical record for Resident # 66. Therefore, they could not explain why there is documentation indicating Resident #66 was provided with range of motion exercises. On 2/11/2025 at 11:43 AM, Certified Nursing Assistant #11 stated they are per diem who worked during the day shift on 2/6/ 2025. Certified Nursing Assistant #11 recalled that Resident #66 was added to their assignment because staff had called out on that day. Certified Nursing Assistant stated they didn't provide any range of motion exercises for any residents including Resident #66 on that day. Certified Nursing Assistant #11 stated they did not know why documentation reflected that resident was provided with range of motion exercises. It was an error and should have not been documented as completion. On 2/11/2025 at 11:22 AM, Physical Therapist stated Resident #66 last received therapy from 10/17/2024 to 11/6/2024 and was placed on maintenance restorative nursing program. Resident #66 is provided with daily range of motion exercises for 15 minutes by nursing staff. Range of motion can be incorporated/performed during ADL care but it requires time to complete 10 reps x 3 sets for both upper/lower extremities. On 2/10/2025 at 8:25 AM, Registered Nurse #3 stated certified nursing assistant during the day shift is responsible to provide range of motion during ADL care daily. Nursing staff is rotated monthly, so they are responsible to check resident's individual plan of care in the electronic medical record. Registered Nurse #3 stated they were not aware that Resident #66 was not getting their range of motion exercises daily. On 2/12/2025 at 12:05 PM, Director of Nursing Service stated that unit nurse supervisor is responsible to review resident's individualized plan of care with assigned nursing staff and to conduct rounding on the unit to ensure the care is being provided. Director of Nursing Service stated the staff will need more training about performing range of motion and documenting accurately in the electronic medical record. 10 NYCRR 415. 22(a)(1-4) | Plan of Correction: ApprovedFebruary 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 66 was assessed by OT on (2/27/2025) and had no negative outcomes from the deficient practice Task in CNA Accountability (Point of Care) was revised to provide clear instructions pertinent to Range of Motion exercises on 2/27/2025 Certified Nursing Assistant # 9 was re-educated on the following plan of care listed in electronic Kardex on 2/27/2025 Certified Nursing Assistant # 11 was re-educated on the accuracy of documentation on 2/27/2025 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents on restorative nursing care have the potential to be affected by this practice. An audit is being conducted on all residents on the Restorative Nursing Care to ensure the tasks are documented accurately based on actual provision of care. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The facility Policy and Procedure titled ?ôCharting and Documentation?Ø was reviewed, dated and no revision was required All interdisciplinary teams are being in-serviced on the above policy and procedure with an emphasis on the importance of documentation accuracy Thorough training on proper documentation practices was added to the orientation and thereafter annual education New process is being implemented to ensure compliance with documentation by interviewing 2-3 employee on monthly basis proper documentation policy and procedure The audit tool was created to ensure compliance 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis for the first quarter, the Director of Nursing, or designee, will randomly check and audit 3-5 residents medical records for accurate documentation of care provided. Any outstanding issues will be addressed immediately and reported to the Administrator On a monthly basis, the Director of Nursing will report the findings to the Administrator On a quarterly basis the Director of Nursing will report the findings to QAPI Committee QAPI Committee to determine if further action is required 5. The title of the person responsible for correction of each deficiency Director of Nursing & Asst. Dir of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews conducted during the Recertification survey from 02/05/2025 to 02/12/2025, the facility did not ensure that care and services were provided according to accepted standards of clinical quality and practice. This was evident for 1 (Resident #389) of 2 residents reviewed for Intravenous medication administration out of a total of 35 sampled residents. Specifically, Intravenous antibiotics for Resident #389 were administered through a Peripherally Inserted Central Catheter by a Licensed Practical Nurse. The findings are: The facility Policy and Procedure titled Administering Medication by Central Line Access, reviewed and or revised 01/02/2025, documented guidelines for safe administration of medications intravenously through a central line access: 1) An LPN may Not Flush any venous central line for patency including a Peripherally Inserted Central Catheter. 2) An LPN may Not administer any intravenous solutions through a central venous line including a Peripherally Inserted Central Catheter. Resident #389 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE] documented Resident #389 with severely impaired cognition and they required medication administration intravenously. On 02/06/25 at 9:06AM, during observation of medication administration of Resident #389, Licensed Practical Nurse #2 was observed 1) Administering 5 milliliters of 0. 9% Sodium Chloride Flush Solution into the Peripherally Inserted Central Catheter 2) Preparing and Administering the antibiotic solution of [MEDICATION NAME] Sodium Chloride 350- 0. 9 milligrams/50mililiters to be administered at a rate of 100ml/hr. into the Peripherally Inserted Central Catheter. A Hospital Surgical Progress Note/discharge summary dated 01/21/2025, documented that Resident #389 is undergoing antibiotic treatment for [REDACTED]. A Facility Physician order [REDACTED].#389 had a left arm Central Venous Peripherally Inserted Central Catheter Line to be observed every shift for signs and symptoms of infection. A Facility Physician order [REDACTED]. 0. 9 milligrams/50mililiters. 360 milligrams to be administered intravenously once daily for 14 days. A Facility Physician order [REDACTED]. 0. 9% 5 milliliters to be administered for Central Venous / Peripherally Inserted Central Catheter Line maintenance before and after antibiotic administration. A Facility Medication Administration Record [REDACTED] 5. On 02/06/25 at 9:30AM, Licensed Practical Nurse #2 was Interviewed and stated, that they were not sure if the Intravenous Line for administration of medication for Resident #389 was a Central Catheter. Licensed Practical Nurse #2 was then observed looking in the Electronic Medical Record and stated that they then determined that the Resident's intravenous line is a Peripherally Inserted Central Catheter. Licensed Practical Nurse #2 further stated that they have been employed by the facility for 1 month and has not yet been in-serviced on intravenous administration. On 02/06/25 at 12:34PM, Registered Nurse #1, the unit supervisor, was Interviewed and stated that Licensed Practical Nurses do not give medications through a central line. Medication administration is monitored as new medication orders are reviewed. If an antibiotic is to be given through a Peripherally Inserted Central Catheter, the Licensed Practical Nurses are reminded not to give the medication as the Registered Nurse on duty will. Registered Nurse #1 further stated that it will take some investigation to determine how the Licensed Practical Nurse has been administering medications through the Peripherally Inserted Central Catheter and that they will have to speak with the Assistant Director of Nursing regarding this and additional education for Licensed Practical Nurses. On 02/07/25 at 09:06AM, The Assistant Director of Nursing was interviewed and stated that Licensed Practical Nurse #2 was hired on 12/17/2025 as a new nurse who has been assigned to work the night shift and has passed orientation education on infusion therapy. An agenda and attendance sheet were provided. The Assistant Director of Nursing also stated that the facility admission nurse reviews the medication orders, enters the details into the Medication Administration Record, [REDACTED]. The Assistant Director of Nursing then stated that the Licensed Practical Nurse who is administering the medications should contact the Registered Nurse if the Medication Administration Record [REDACTED]. The Assistant Director of Nursing further stated that they can also administer the medications as they round daily and communicate with the staff to ensure that the nurses are administering medications correctly but they did not check the medication administration for Resident # 389. They don't audit the Medication Admission Records for signatures of nurses who are performing intravenous medication administration but will start. On 02/07/25 at 09:47 AM, The Director of Nursing was interviewed and stated that when a resident is admitted they are notified by email of residents with indwelling devices, and they advise the staff on postings for Precautions and Personal Protective Equipment to ensure compliance. The Director of Nursing also stated that the Licensed Practical Nurse should look at the Medication Administration Record [REDACTED]. The Director of Nursing further stated that the Registered Nurse should be rounding and that's how they would know there is a central line medication administration. Walking Rounds with the Registered Nurses and the Licensed Practical Nurses for accountability has been initiated daily and for every shift and the Assistant Director of Nursing will report on the findings. 415. 11(c)(3)(i) | Plan of Correction: ApprovedFebruary 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 389 had no negative outcomes from the deficient practice. IV medication via Central line was administered by RN after 2/6/2025 Licensed Practical Nurse # 2 was in-serviced on the ?ôAdministering Medications by Central Line Access?Ø policy and procedure on 2/6/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents receiving intravenous medications have the potential to be affected by this practice. All residents medication administration records who are currently receiving intravenous medications/ Fluids/Flush were reviewed, no outstanding issues were found 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility Policy and Procedure titled ?ôAdministering medications by Central Line Access?Ø was reviewed, no revision required All nurses are being in-serviced on the above policy and procedure with an emphasis on the professional scope of practice of LPN Education on administration of medications by central line access was added to the orientation and to the annual in-services New process of marking administration by RN only for medications administered via central lines is being implemented to ensure the scope of practice is being maintained The audit tool was created to ensure compliance 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis for the first quarter, the Director of Nursing, or designee, will audit the intravenous medication(s) order and Medication Administration Record [REDACTED]. Any outstanding issues will be addressed immediately and reported to the Administrator On a monthly basis, Director of Nursing will report the findings to the Administrator On a quarterly basis Director of Nursing will report findings to QAPI Committee QAPI Committee to determine if further action is required 5. The title of the person responsible for correction of each deficiency Director of Nursing & Assistant Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Recertification survey from 02/5/2025 to 02/12/2025, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing. This was evident for 1 of 4 residents (Resident #389) reviewed for Pressure Ulcer Injury out of a total of 35 sampled residents. Specifically, Resident #389 did not receive pressure relieving devices and preventative measures to promote wound healing. . The findings are: The Facility Policy titled Prevention of Pressure Ulcers reviewed/revised 01/02/025, documented the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors, interventions for specific risk factors, and preventative measures. General preventive measures include 1) Identify risk factors for pressure ulcer development 2) For a person in bed: Change position at least every two hours or more frequently if needed, determine if resident needs a special mattress, if a special mattress is needed, use one that contains foam, air, gel, or water, as indicated. Use pillows or wedges to keep bony prominences such as knees or ankles from touching each other. When in bed, every attempt should be made to float heels (keep heels off the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. Resident #389 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], documented Resident # 389 had severely impaired cognition, the presence of 2 venous and arterial ulcers, and skin and ulcer/injury treatments that included pressure reducing devices for the chair, the bed, and a turning and positioning program. Resident #389 was dependent for all bed mobility and transfers. On 02/06/25 at 8:47 AM, Resident #389 was observed out of bed sitting. No heel booties were applied to cover the left foot surgical site and there was no pressure reducing device present in the wheelchair. On 02/06/2024 at 9:06 AM, During medication administration observation, Resident #389 was observed in bed. There was no heel booties applied, no offloading of the heels and there was no pressure reducing mattress present. On 02/07/25 at 11:47 AM, During wound observation, Resident #389 was observed in bed. There was no heel booties applied, no offloading of the heels and there was no pressure reducing mattress present. A Readmission Nursing assessment dated [DATE], documented that the readmitting [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Sore Risk dated 01/03/2025 and 01/22/2025, documented that Resident #389 was at a moderate risk of developing pressure ulcers. A Physician order [REDACTED]. A Physician order [REDACTED]. A Wound Assessment Progress Note dated 01/28/2025, documented that Resident #389 has significant contributors for increased risk of wound incidence and/or impede healing including impaired mobility. Education was provided regarding pressure relief, general offloading and frequent repositioning with offloading orders to avoid direct pressure to wound sites. A Wound Assessment Progress Note dated 01/30/2025, documented recommendations for nursing to continue to monitor skin integrity/wound progression and provide preventative measures. The Certified Nursing Assistant Accountability Record for (MONTH) 2025 documented the intervention/task to turn and reposition Resident # 389. There was no intervention/task for turning and repositioning on the Certified Nursing Assistant Accountability Record for February 2025. There was no documented evidence that measures were implemented to promote wound healing and prevent additional skin breakdown. On 02/12/25 at 9:24 AM, An Observation was performed with Registered Nurse #1 that Resident #389 did not have any pressure ulcer preventative measures in place including an air mattress, a seat cushion, heel booties, nor were his heels/surgical site off loaded. Registered Nurse #1 was interviewed and stated that the Protocol for residents prone to pressure ulcers and or who currently have a wound is that a Braden scale risk assessment is performed at admission and the admission nurse should report the at-risk residents findings to the Assistant Director of Nursing and or the Director of Nursing and they will arrange with maintenance for the resident to get an air mattress. Registered Nurse #1 also stated that a care plan should be entered for turning and positioning every 2 hours and entered in the CNA Accountability. Registered Nurse #1 further stated that foam dressings and heel booties are also used for prevention of skin breakdown and for the promotion of wound healing and all these measures should have been entered in orders. The Electronic Medical Record was reviewed by Registered Nurse #1 who stated that there were no orders entered for pressure relieving measures or devices. On 02/12/25 at 12:56 PM, the Director of Nursing was interviewed and stated that Corporate wants new forms implemented so the turning and positioning has been performed but not documented in the record. the Director of Nursing also stated that the unit manager who rounds daily should have picked up on the fact that there was no preventative measures or equipment in place for pressure ulcers prevention and wound healing and the admission nurse should have also documented to have these measures put in place. 10 NYCRR 415. 12(c)(1-2) | Plan of Correction: ApprovedFebruary 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? For Resident # 389: - Pressure reduction mattress was provided on 2/12/2025 - Heel bootie for left foot was provided on 2/12/2025 - Turning and Positioning task was added to the CNA accountability on 2/26/2025 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents at risk for developing pressure ulcers have the potential to be affected by this practice. A facility wide audit is being conducted to ensure all residents at risk for pressure ulcers or with pressure ulcers receive necessary services (preventative measures) to prevent skin breakdown and to promote wound healing Any outstanding issues will be addressed immediately. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Policy and Procedure ?ôPrevention of Pressure Ulcers?Ø was reviewed, and no revision needed All nursing staff is being re-educated on the ?ôPrevention of Pressure Ulcers?Ø policy, with emphasis on implementation and documentation of preventative interventions being done All unit managers are being in-serviced on review of new admissions/re-admissions for initiation of preventative skin care/interventions on person-centered care plan and for activation of tasks in EHR (PCC) for documentation of care The audit tool was developed for monitoring compliance with implementation of preventative skin care/interventions and tasks activation in EHR 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis for one quarter, ADNS or designee will audit newly admitted and readmitted residents charts to ensure compliance with preventative skin care is initiated and documentation of such; and residents with newly developed skin breakdown charts for appropriate interventions. Any outstanding issues will be addressed immediately and reported to DNS On a weekly basis for one quarter, MDS Director or designee, will audit 2-4 newly admitted /readmitted residents and residents with new skin breakdown to ensure skin care tasks activation in PCC and report the findings to DNS On a monthly basis DNS or designee will report findings to Administrator On a quarterly basis DNS or designee will report findings to QAPI Committee QAPI Committee to determine if further action is required 5. The title of the person responsible for correction of each deficiency Director of Nursing & Assistant Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA . 3. 6. 3* Corridor Doors. 19. 3. 6. 3. 1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following: (1) 1 ?é¾ in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes. 19. 3. 6. 3. 5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19. 3. 5. 7. Based on observation and staff interviews, the facility did not ensure that all corridor doors were designed to resist the passage of smoke. This occurred on four of six floors. The findings include: During the life safety survey on (MONTH) 6, 2025, and (MONTH) 7, 2025, between 9:30 am and 3:00 pm, one panel of the double doors to the Electrical Closet had a manual bolt, thus preventing the doors from latching and resisting the passage of smoke. This occurred on five of five resident floors. At the time of the findings, the Director of Maintenance stated the manual bolts would be replaced with automatic flush bolts. 2012 NFPA 101 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The facility contacted the construction vendor on 2/27/25 to remove the manual flush bolt from the inactive leaf on the identified room doors and will permanently install automatic flush mount bolts on the inactive corridor doors to provide positive latching. Automatic flush mounts bolts has been ordered on 2/27/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of maintenance inspected all areas throughout the facility for the same deficiency. No deficiencies found. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility reviewed the Fire and Smoke Door policy and procedure. The policy was updated to include Corridor doors shall comply with 2012 NFPA 101: 19. 3. 6. 3. 5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. Double doors shall be equipped with auto flush mount bolts. Manual flush mount bolts are prohibited. The Maintenance staff will receive education on the Fire and Smoke Door policy and procedures. An audit tool was developed to check corridor doors equipped with auto flush mount bolts. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all Double doors to for auto flush mount bolts to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 6. 2 Construction of Corridor Walls. 2012 NFPA 101: 19. 3. 6. 2. 1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19. 3. 6. 2. 4 through 19. 3. 6. 2. 8. 2012 NFPA 101: 19. 3. 6. 2. 3* Corridor walls shall form a barrier to limit the transfer of smoke. 2012 NFPA 101: 19. 3. 6. 2. 8 There shall be no restrictions in area and fire resistance of glass and frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19. 3. 5. 7. Based on observation and staff interviews, the facility did not ensure that corridor walls were constructed in accordance with NFPA 101. Specifically, a door assembly in the corridor wall did not form a barrier to limit the transfer of smoke. This was observed in one out of six floors. The findings are: On (MONTH) 6, 2025, at 9:30 AM, during the Life Safety Code recertification survey, the Electrical Closet on the Lobby Floor, had an opening of approximately 3 inches by 4 inches, in the corridor wall just above the corner of the door frame. The opening was covered by wallpaper on the corridor side, held down with a screw. At the time of the finding, the Director of Maintenance stated that the door assembly was new, the opening occurred when it was installed, but it would be sealed. On (MONTH) 6, 2025, at approximately 10 AM, the Administrator stated the door and door frame were installed about a year ago. 2012 NFPA 101: 19. 3. 6. 2, 19. 3. 6. 2. 1, 19. 3. 6. 2. 3*, 19. 3. 6. 2. 8. 10NYCRR 711. 2(a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff permanently sealed the opening in the identified corridor wall above the Electrical Closet door on the Lobby Floor on 2/7/ 2025. The corridor wall resists the passage of smoke. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No negative outcome. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues identified, with the proper construction of corridor walls in compliance with 2012 NFPA 101 19. 3. 6. 2. An audit tool was developed to inspect the corridor walls for penetration. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all corridor walls for penetration to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 1. 2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70: 400. 8 Uses Not Permitted. Unless specifically permitted in 400. 7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368. 56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 10. 2. 3. 6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart mounted, provided that all of the following conditions are met: (1) The receptacles are permanently attached to the equipment assembly. (2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. (3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. (4)*The electrical and mechanical integrity of the assembly is regularly verified and documented. (5)*Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. 10. 2. 4 Adapters and Extension Cords. 10. 2. 4. 1 Three-prong to two-prong adapters shall not be permitted. 10. 2. 4. 2 Adapters and extension cords meeting the requirements of 10. 2. 4. 2. 1 through 10. 2. 4. 2. 3 shall be permitted. 10. 2. 4. 2. 1 All adapters shall be listed for the purpose. 10. 2. 4. 2. 2 Attachment plugs and fittings shall be listed for the purpose. 10. 2. 4. 2. 3 The cabling shall comply with 10. 2. 3. 10. 3 Testing Requirements - Fixed and Portable. 10. 3. 1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. Based on observation and staff interviews, during the Life Safety Recertification survey on (MONTH) 6, 2025, through (MONTH) 7, 2025, the facility did not ensure that extension cords and power strips were used in accordance with NFPA 70. Specifically, power strips and an extension cord were observed in use. The findings include but are not limited to: 1) Two unmounted power strips were observed in use in the Dietary office in the Kitchen 2) The Dietician's office in the basement had two extension cords plugged into a power strip powering computer equipment. At the time of the findings, the Director of Maintenance stated that the extension cords would be removed, the power strips mounted or removed and an electrician would install more outlets where needed. The Director of Maintenance further stated that an audit of the facility would be done, and staff would be in-serviced. 2012 NFPA 101: 9. 1. 2 2011 NFPA 70: 400. 8 10 NYCRR 711. 2(a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff removed the two unmounted power strips in the Dietary office in the Kitchen on 3/7/ 2025. The maintenance staff removed the two extension cords plugged into a power strip powering computer equipment in the Dietician's office in the basement on 3/7/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents, visitors and staff have the potential to be affected by this practice. The facility checked all areas for the same deficiency. Any power strips or extension cord deficiencies were immediately corrected. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility reviewed and updated the Electrical Safety Policy and Procedures. All staff will receive additional education, and all participants will understand the life safety issues identified during the facilitys survey and the importance of ensuring compliance with the Electrical Safety Policy and Procedures with particular emphasis on power strips and extension cord prohibitions. An audit tool was developed to check for the improper use of power strips and extension cords monthly. The Director of Maintenance will utilize an audit tool to document any findings. Any issue identified. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all areas for improper use of power strips and extension cords to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details NFPA 99: 6. 3. 4. 1. 3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. Based on observation and document review, there was no evidence that receptacles in resident areas were inspected annually. The findings include: During the life safety recertification survey of (MONTH) 6, 2025, through (MONTH) 7, 2025, between 9:00 AM and 3:00 PM, no documentation was provided to show that receptacles in resident rooms on the 6th Floor had the necessary inspections. On a tour of the 6th Floor, it was noted that resident rooms 601, 603, 605, and throughout the 6th Floor had inspection stickers dated 1/ 2023. An additional outlet in the outdoor area outside of the Physical Therapy Room, part of the path of egress, had signs of damage. At the time of these findings, the Director of Maintenance stated that annual inspections would be done, that the outdoor outlet had been damaged before his time at the facility, and it would be replaced. 2012 NFPA 99 6. 3. 4, 6. 3. 4. 1. 3 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff completed the annual electrical receptacle inspection and testing on the 6th floor on 3/5/ 2025. The director of maintenace replaced the identified damaged outside electrical receptacle on the patio on 3/3/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents, visitors and staff have the potential to be affected by this practice. The Director of maintenance inspected all areas throughout the facility for the same deficiency. No other deficiencies were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with the inspection and testing of electrical receptacles in compliance with NFPA 99: 6. 3. 4. 1. 3. An audit tool has been developed to inspect the electrical receptacle for damage and inspection. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all electrical receptacles for damage and inspection stickers if needed to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99: 6. 3. 2. 1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. 2011 NFPA 70: 700. 10 Wiring, Emergency System. (A) Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as components of an emergency circuit or system. (A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy. Based on observation and staff interviews, the facility did not ensure that all electrical panels were provided with identification. The findings include: During the life safety code recertification survey on (MONTH) 6, 2025, through (MONTH) 7, 2025, between 9 am and 3 pm, the Electrical Closet on the 1st Floor contained three electrical panels. Three of the three panels were missing identification. The Electrical Closet on the 2nd Floor, adjacent to Stairwell A, contained three electrical panels, none had identification. Electrical panels throughout the facility lacked identification. At the time of these findings, the Director of Maintenance stated that an audit of all panels would be done and would ensure all panels would be identified. 2012 NFPA 99 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The facility contacted the electrician vendor on 3/3/2025 to come in and permanently mark all electrical panels with the proper identification. Visit is set for 3/13/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The Director of maintenance shall inspect all areas throughout the facility for the same deficiency. All electrical panels will be marked permanently with proper identification. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with the identification of electrical panels in compliance with 2011 NFPA 70: 700. 10. An audit tool was developed to check all electrical panels for proper identification. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter The Director of Maintenance or Designee will audit all electrical panels to make sure proper identification. Any outstanding findings will be reported to the administrator. On a quarterly basis, the QAPI committee will review the facility risk assessment. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 7. 1. 4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 19. 7. 1. 6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. 4. 7* Fire Drills. 4. 7. 4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. 4. 7. 6* A written record of each drill shall be completed by the person responsible for conducting the drill and maintained in an approved manner. Based on document review and staff interviews, the facility did not ensure that fire drills were held quarterly on each shift and at unexpected times in accordance with NFPA 101. This occurred for one of three shifts The findings are: On (MONTH) 6, 2025, at approximately 2 PM, during the Life Safety Code Survey, a review of the facility fire drill logs for the past 12 months revealed that the night shift (11 PM - 7 AM) did not have a fire drill in the 4th quarter of 2024. Fire drills were held on 3/20/24, 6/20/24, and 8/22/ 24. The drills were conducted at similar times 6:00 AM, 6:30 AM, and 6:50 AM, respectively. On (MONTH) 6, 2025, at 2:30 PM, the Director of Maintenance stated that all the drills had been provided. On (MONTH) 7, 2025, at approximately 2:45 PM, during the exit interview, the Administrator acknowledged the finding. 2012 NFPA 101: 19. 7. 1. 4*, 19. 7. 1. 6, 4. 7. 4*, 4. 7. 6* 42CFR 483. 90(a)(i) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Director of Maintenance will complete the fire drills at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. All fire drills will be a minimum of 1 hour apart on each shift and not duplicated in the same 12 month period. Fire drills conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. All Fire Drills are conducted by the Director of Maintenance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Director of Maintenance was re-educated on how to properly conduct fire drills to ensure the facility meets standards established by the National Fire Protection Association (NFPA). The Director of Maintenance developed a Fire Drill spreadsheet to document varied times and conditions of each monthly drill to maintain compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter, The Director of Maintenance or Designee will review the fire drill spreadsheet to ensure compliance and report any outstanding findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 99: 4. 1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code. 4. 1. 1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code. 4. 1. 2* Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code. 4. 1. 3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code. 4. 1. 4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code. 4. 2* Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure. Based on documentation review and staff interviews during the Life Safety Code recertification survey, the facility did not ensure that a documented NFPA 99 risk assessment was conducted. The findings are: During a record review on 02/07/2025 between 9:00 am and 2:30 pm a completed NFPA 99 Risk Assessment was not found in the folders with the maintenance documentation. The NFPA 99 Risk Assessment was not provided at the time of the survey. During the exit conference on 2/7/25 at 2:00 pm the Director of Engineering and Administrator were informed about the issue. 2012 NFPA 101 10NYCRR 711. 2(a)(1) 10 NYCRR 415. 29 | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Administrator met with the multidisciplinary team which included the Director of Nursing, the Director of Physical Therapy and the Director of Maintenance. The team reviewed the risk category definitions in NFPA 99 and completed the annual assessment on 3/5/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The worksheet is used to record the risk level for listed systems in a given area. Any changes in systems will generate a review of the worksheet 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Administrator reviewed and updated the Facilities Risk Assessment Procedure Policy. Any changes in systems will generate a review of the worksheet. The multidisciplinary team will also conduct an annual review and update the NFPA 99 worksheet. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter The Director of Maintenance or Designee will review the risk assessment to identify any changes. Any outstanding findings will be reported to the administrator. On a quarterly basis, the QAPI committee will review the facility risk assessment. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 3. 5 Extinguishment Requirements. 19. 3. 5. 1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9. 7, unless otherwise permitted by 19. 3. 5. 5. 19. 3. 5. 4* The sprinkler system required by 19. 3. 5. 1 or 19. 3. 5. 3 shall be installed in accordance with 9. 7. 1. 1(1). 9. 7. 1. 1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13: 8. 1* Basic Requirements. 8. 1. 1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles: (1) Sprinklers shall be installed throughout the premises. (2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler. (3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. (4) Sprinklers shall be permitted to be omitted from areas specifically allowed by this standard. (5) When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted. (6) Clearance between sprinklers and ceilings exceeding the maximums specified in this standard shall be permitted, provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections. (7) Furniture, such as portable wardrobe units, cabinets, trophy cases, and similar features not intended for occupancy, does not require sprinklers to be installed in them. This type of feature shall be permitted to be attached to the finished structure. Based on observations, staff interviews, and document review, during the Life Safety portion of the recertification survey, the facility did not ensure it was protected throughout by an approved, supervised automatic sprinkler system in accordance with 2012 NFPA 101. Specifically, there were observations of areas without sprinkler coverage and sprinklers installed without escutcheons or caps. The findings are: On (MONTH) 6, 2025, from 9 AM to 2 PM, observations of missing escutcheons, concealed caps, and ill-fitting or missing ceiling tiles around sprinklers were seen in the Telecommunications Room, Recreation Storage room, Men's Locker Room, Staff bathroom on the 4th Floor, Oxygen Storage room on the 4th Floor, Janitor's Closets on 2nd and 4th Floors, and in resident room 315. On (MONTH) 7, 2025, at approximately 11:45 AM, a tour of the 5th Floor, in the corridor in front of resident rooms 518 through 521, revealed that the sprinklers were 30 feet apart, exceeding the coverage provided by each sprinkler. The Director of Maintenance, who was present at the time of observations, stated that additional sprinklers would be installed that the ceiling tiles were recently upgraded, and the sprinkler pipes may be above the tiles. The Director of Maintenance further stated the missing ceiling tiles, escutcheons, and concealed caps would be installed. 2012 NFPA 101: 19. 3. 5, 19. 3. 5, 9. 7. 1. 1 2010 NFPA 13: 8. 1. 1* 10 NYCRR, 711. 2 (a) (1) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25 The facility engaged our Sprinkler company to install the identified missing, escutcheons, and concealed caps in the Telecommunications Room, Recreation Storage room, Men's Locker Room, Staff bathroom on the 4th Floor, Oxygen Storage room on the 4th Floor, Janitor's Closets on 2nd and 4th Floors, and in resident room 315. Visit scheduled for 3/17/ 2025. On 3/3/25 The facility engaged our Sprinkler company to adjust the sprinkler pendants in the corridor in front of resident rooms 518 through 521 to provide complete coverage in the corridor. The visit is scheduled for 3/17/ 2025. The maintenance staff replaced the identified missing ceiling tiles and the ceiling tiles that were not smoked tight on 2/27/ 25. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be corrected. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with installations of sprinklers in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. An audit tool has been developed to monitor the installation of the sprinkler system, escutcheons and missing tiles. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all ceiling tiles, and sprinklers to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI committee 5. The title of the person responsible for correction of each deficiency Administrator, Dir. Of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25 5. 2* Inspection. .2011 NFPA 25: Table 6. 1. 1. 2 Summary of Standpipe and Hose Systems Inspection, Testing, and Maintenance. Test Item Frequency Reference Hose 5 years/ 3 years NFPA 1962 Based on observation, document review, and staff interviews, the facility did not ensure that all components of the building's extinguishing system were tested and maintained in accordance with NFPA 101. Specifically, the fire hoses were not maintained. The finding is: During the life safety code recertification survey on (MONTH) 6, 2025, and (MONTH) 7, 2025, between 9:00 am and 3:30 pm, it was noted that the fire hoses installed in Stairwell B on the basement level and 1st Floor, were stamped with a date of 4/ 2015. There was no documentation of the hoses having been tested or replaced within the five years prior to the survey. At the time of this finding, the Director of Maintenance stated that the hoses would be replaced or capped. 2012 NFPA 101 2011 NFPA 25 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/5/25, the facility contacted the sprinkler vendor to install all new standpipe hoses throughout the building. The vendor will conduct a visit on 3/15/2025 to prepare a proposal. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The maintenance will survey the entire building for standpipe hoses. All standpipe hoses will be replaced. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All Maintenance staff will receive additional education, and all participants will understand the life safety issues identified during the facilitys survey and the importance of ensuring compliance with the requirements of inspection and testing requirements of Standpipe hoses 2011 NFPA 25 5. 2* Inspection and 2011 NFPA 25: A Preventive Maintenance & Scheduling system will be developed to reflect the inspection and testing of the standpipe system as required by all codes, rules, and regulations. All inspection results will be recorded in the building Records & Logs and available for inspection by the Authority having jurisdiction at all times. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit the standpipe system ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI committee . 5. The title of the person responsible for correction of each deficiency Administrator, Dir. Of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 19. 3. 7. 3 Any required smoke barrier shall be constructed in accordance with Section 8. 5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8. 6. 7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. 8. 5. 6 Penetrations. 8. 5. 6. 1 The provisions of 8. 5. 6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. 8. 5. 6. 2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke. 8. 5. 6. 3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8. 3. 5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8. 5. 6 to restrict the transfer of smoke, unless the requirements of 8. 5. 6. 4 are met. 8. 3. 5. 6 Membrane Penetrations. 8. 3. 5. 6. 1 Membrane penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a membrane of a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device and shall comply with 8. 3. 5. 1 through 8. 3. 5. 5. 2. Based on observation and staff interviews, the facility did not ensure that smoke barrier walls were constructed to provide at least a ?é½-hour fire resistance rating in accordance with NFPA 101. Specifically, an opening was observed in a smoke barrier wall. This was observed in the smoke barrier walls on two of six resident floors. The findings include but are not limited to: During the Life Safety Code recertification survey, conducted on (MONTH) 6, 2025, and (MONTH) 7, 2025, an examination of the smoke barrier walls above the ceiling tiles revealed that 1) the 5th Floor adjacent to resident room 506 had an opening of approximately 2 inches around two armored cables; 2) adjacent to resident room 417 had a junction box missing a cover. 3) adjacent to resident room 217, a penetration of approximately 1 inch around blue, white, and yellow cables passing through. In an interview at the time of the observations, the Director of Maintenance stated that the penetrations would be sealed with a fire-stop material and that an audit of all smoke barrier walls throughout the facility would be done to ensure all openings are correctly sealed with fire-stop material. 2012 NFPA 101: 19. 3. 7. 3, 8. 3. 5. 6, 8. 3. 5. 6. 1, 8. 5. 6. 2, 8. 5. 6. 3 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedMarch 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Director of Maintenance permanently sealed the identified penetrations above the ceiling tiles in the smoke barrier walls on the 5th Floor adjacent to resident room 506 , adjacent to resident room 417, adjacent to resident room 217 with approved rated fire stop material on 2/10/ 2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance checked all smoke barriers for penetrations. No deficiencies were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with smoke barrier requirements in accordance with the requirements of NFPA 101 2012 edition 19. 3. 7. 3 and 8. 5. 6. 2. A audit tool was developed to inspect smoke barriers for penetration. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all smoke barriers for penetrations to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI 5. The title of the person responsible for correction of each deficiency Administrator, Director of Maintenance |