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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised to reflect the resident's status. This was evident in 1 (Resident #217) of 8 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #217's comprehensive care plan was not revised to accurately reflect the resident's mode of transfer. The findings are: A facility policy titled Comprehensive Care Planning with a reviewed date of 10/28/2024 documented it is the policy of the facility to develop a comprehensive, person-centered plan of care that includes measurable objectives and timetables individualized and appropriate to the resident's needs, strengths, and goals. The interdisciplinary team must review and update the care plan when there has been a significant change in a resident's condition. Resident #217 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3. 0 assessment dated [DATE] documented Resident #217 had intact cognition and was dependent with chair/bed-to-chair transfers. The Functional Status Endorsement from Rehab to Nursing form dated 11/30/2024 documented that Resident #217's required partial/moderate assistance with 1 person physical assist and a use of a sliding board. Registered Nurse #5 signed the endorsement indicating that they agreed, and the Care Plan and task was updated. A Comprehensive Care Plan for Activities of Daily Living was initiated for Resident #217 on 11/30/2024 and was last revised on 12/18/ 2024. The care plan documented Resident #217 required a Hoyer lift with two-person physical assist from chair/bed-to-chair transfers. There was no documented evidence that the Comprehensive Care Plan had been revised to reflect that Resident #217 required partial/moderate assistance of one person with a sliding board to transfer to and from a bed to a chair (or wheelchair). On 12/19/2024 at 12:44 PM, the Director of Rehabilitative Therapy was interviewed and stated there was a recent endorsement from the rehabilitative team that Resident #217 required a 1-person physical assist transfer using a sliding board from bed to chair to wheelchair and same way from wheelchair to bed. They stated Registered Nurse #5 reviewed and signed the endorsement but did not update the Certified Nursing Assistant Task instructions or care plan to reflect the endorsement's new instructions. On 12/19/2024 at 1:23 PM, Registered Nurse #5 was interviewed and stated they signed the Physical Therapy Endorsement dated 11/30/2024 acknowledging that they agreed with the recommendation. They stated they were responsible for updating the care plan, however, when Registered Nurse #5 discussed Resident #217's transfer with the assigned aide, the aide stated they used a Hoyer lift to transfer Resident #217 and that was what they documented in the Certified Nursing Assistants Task instructions. On 12/19/2024 at 2:16 PM, The Director of Nursing was interviewed and stated since Registered Nurse #5 picked up the Physical Therapy assessment, they would be responsible for updating the care plan and certified nursing assistant instructions. 10 NYCRR 415. 11(c)(2)(i-iii) | Plan of Correction: ApprovedJanuary 22, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice Care Plan for the identified resident was reviewed and updated. Resident #217- The ADL care plan and C.N.A. instructions/tasks were updated by the charge nurse to reflect the residents need for partial/moderate assistance with 1-person physical assist and a use of a sliding board. The Educator issued an educational counseling to all staff involved on the policy of care planning to ensure that care plans are reviewed and revised at least quarterly, with a change in condition and as needed. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The Assistant Directors of Nursing/designee conducted a facility wide audit of all residents to ensure that all endorsements to Nursing from Rehabilitation was accurately reflected on the comprehensive care plan and C.N.A. instructions/tasks, at least quarterly, annually, and as needed. The Educator/designee will provide additional education to all licensed nursing staff on the, ?ôComprehensive Care Planning?Ø policy, and updating of C.N.A. instructions/tasks, with emphasis on the review and revision of rehabilitation endorsements to nursing in a timely manner after each assessment, at least quarterly, annually, and as needed. 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, Director of Nursing and Medical Director will review and revise, as needed policies and procedures related to the review and revision of Comprehensive Care Plans after each assessment, at least quarterly, annually, and as needed. The Educator/designee will provide additional education to all staff involved in the care planning process regarding the above protocol so that residents care plans are reviewed and revised to reflect accurate plans with emphasis on updating the care plans and C.N.A. instructions/tasks after each Rehabilitation assessment and endorsement to Nursing. Licensed Nursing Staff will audit the care plans at the Comprehensive Care Plan meetings to ensure that care plans of residents are reviewed and updated based on the residents current condition and needs. Any findings will be reported to the Director of Nursing/designee for correction. 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 The Assistant Directors of Nursing/designee will audit 10% of all residents weekly for 3 months or until improvement is sustained to ensure that care plans and C.N.A. instructions/tasks are implemented and revised timely in regards to Rehabilitation endorsements to Nursing. The Director of Nursing/designee, will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure a comprehensive person-centered care plan was developed for each resident, that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #20) of 38 total sampled residents. Specifically, a care plan for a [DIAGNOSES REDACTED].# 20. The findings are: The facility policy titled Comprehensive Care Planning with a last reviewed date of 10/28/2024 documented that it is the policy of the facility to develop a comprehensive, person-centered plan of care that includes measurable objectives and timetables individualized and appropriate to the resident's needs, strengths, and goals. The comprehensive care plan is developed within seven (7) days of the completion of the required comprehensive Minimum Data Set Assessment. The Interdisciplinary Team must review and update the care plan when the resident has been readmitted to the facility from a hospital stay. Resident # 20 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented that Resident #20 had moderately intact cognition and had an active [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Psychiatric Consultant Note dated 11/22/2024 documented psychiatric [DIAGNOSES REDACTED]. A Provider Comprehensive assessment dated [DATE] documented Resident #20 was seen for review of chronic medical conditions for provider comprehensive and medication review. Resident had a psychiatric history of Major [MEDICAL CONDITION] and had orders for [MEDICATION NAME] 50 milligram tablet orally once per day. A Multidisciplinary Care Conference form dated 12/10/2024 documented an interdisciplinary team meeting review for Resident #20's quarterly reassessment identified Major [MEDICAL CONDITION] as a problem/need for Resident # 20. A review of Resident #20's Comprehensive Care Plans from the admission date of [DATE] revealed no documented evidence that a care plan for the [DIAGNOSES REDACTED]. On 12/18/2024 at 10:03 AM, Registered Nurse #2 was interviewed and stated it is the admitting nurse's responsibility to create the resident's care plans on admission or readmission. Registered Nurse #2 stated it was both nursing and social services' responsibility to update the resident's admission care plans. They stated that Resident #20's care plan for depression was overlooked. On 12/18/2024 at 9:25 AM, the Director of Social Services was interviewed and stated it is the social workers' responsibility to create the care plan for major mood disorders, but it was all discipline's responsibility to update the care plan during quarterly assessments. The Director of Social Services stated all the disciplines missed entering or updating the care plan for Depression. On 12/18/2024 at 10:36 AM, The Director of Nursing was interviewed and stated that admission care plans are developed based on the resident's needs, diagnoses, and medications. They stated multiple nurses are responsible for completing the care plans. The Minimum Data Set assessment nurse is responsible for developing comprehensive care plans on admission, or it could be the next shift or the Head Nurse. The Director of Nursing stated that on readmission or quarterly assessment, the interdisciplinary team is responsible for reviewing or developing the comprehensive care plans. The Director of Nursing stated that Resident #20's care plan for depression was not re-opened when they were readmitted on ,[DATE], and that it should have been added during the quarterly assessment in 11/ 2024. 10 NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedJanuary 16, 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 Care Plan for the identified resident was reviewed and updated. Resident #20- A depression care plan was developed and implemented by the charge nurse after review of the medical record and physician orders [REDACTED]. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Assistant Directors of Nursing/designee will review the medical record of all residents to ensure that residents comprehensive care plans are reviewed and revised to reflect accurate plans. Additional corrective actions will be implemented as needed. The Educator/designee will provide additional education to all licensed nursing staff regarding policies and procedures related to reviewing and revising comprehensive care plans to reflect accurate plans. The Director of Nursing/designee will monitor compliance with care plan development and implementation and will: A. Create a report of all [MEDICAL CONDITION] medications to ensure that each resident maintained on a [MEDICAL CONDITION] medication has an active care plan for the medication and its use. B. All affected residents care plans will be reviewed by the Interdisciplinary Team at the Comprehensive Care Plan meetings. C. All care plans for readmitted residents will be reactivated in the EMR, reviewed and revised as needed for the use of [MEDICAL CONDITION] medications 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 facilitys compliance will be monitored utilizing the following quality assurance system: The Assistant Directors of Nursing/designee will audit 10% of all residents to ensure that residents comprehensive care plans are reviewed and revised to reflect accurate plans. Findings will be reported to the Director of Nursing on a monthly basis. Additional corrective action will be implemented as needed. The Administrator, Director of Nursing and Medical Director will review and revise, as needed, policies and procedures related to Comprehensive Care Plans. The Educator/designee will provide education to all staff involved in the care planning process regarding the above protocol so that upon readmission, residents care plans are reactivated and care plans are reviewed and revised as necessary to reflect accurate care needs. Interdisciplinary Care Planning meeting will be utilized to review that all appropriate care plans are implemented based on residents needs. 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 The Assistant Directors of Nursing /designee will audit all care plans of residents who are on [MEDICAL CONDITION] medications monthly for 3 months or until improvement is sustained to ensure that care plans are implemented and resident centered for [MEDICAL CONDITION] medications. The Director of Nursing/designee, will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5. Responsible Individual: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated (NY 380) Survey from 12/12/2024 to 12/19/2024, the facility did not ensure each resident received adequate supervision to prevent accidents. This was evident in 1 (Resident #22) of 3 residents reviewed for Abuse out of 38 total sampled residents. Specifically, Resident #22, who was identified as high risk for falls and had history of numerous falls, was not provided adequate monitoring or supervision. On 08/13/2024 at 3:20 PM, Resident #22 stood up from their wheelchair and fell on to the floor while in the dining room. The findings are: The facility's policy titled Fall Reduction and Injury Prevention Program dated 10/28/2024 documented it is the policy of this facility to take appropriate measures to provide a safe environment and minimize the risk of resident injuries resulting from a fall. The policy documented that after a fall has occurred, the Registered Nurse must perform a complete assessment including neurological status check and assess for injuries before moving the resident. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented that Resident #22 had severely impaired cognition, non-ambulatory, dependent with transfers, and uses wheelchair for mobility. A care plan for falls was initiated for Resident #22 on 12/19/ 2020. The care plan documented that Resident #22 sustained actual falls on 12/19/2020, 03/03/2021, 02/20/2022, 02/25/2023, 12/28/2023, and 08/13/ 2024. The facility interventions include half hourly monitoring, incontinence care every 2 hours when awake, and positioning resident close to staff doing monitoring when in dining/common area. A progress notes by Nurse Practitioner #1 dated 08/13/2024 at 4:32 PM documented that Resident #22 was seen status [REDACTED].#22 sliding down their wheelchair but was too late to stop them from falling. Resident #22 had no physical injuries, did not hit their head, and had no change in mental status. A nurse's progress notes by Registered Nurse #8 dated 08/13/2024 at 8:19 PM documented they were informed by the Certified Nursing Assistant that Resident #22 was witnessed sliding out of the wheelchair on to the floor at 3:20 PM in the dining room. Resident #22 had no visible injuries, neurological status within normal limits, and range of motion at baseline. The Nurse Practitioner was notified, x-ray to bilateral hips complete awaiting for results. The Nursing Home Investigative Report completed by the Deputy Director of Nursing documented that on 08/13/2024 at 3:20 PM, Resident #22 stood up from the wheelchair while seated in the dining room and sustained a fall. The report documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. Patient Care Technician #10, who was responsible for monitoring the residents in the dining room at the time of the incident, was not being attentive to the residents, nor was observed to be in close proximity to assist residents if needed. Resident #22's x-ray results documented acute right femoral neck fracture. Upon further evaluation at the hospital, computed tomography scan of the right hip revealed no discrete acute fracture, it was an old, healed fracture with superimposed severe right hip [MEDICAL CONDITION]. A copy of the facility's video surveillance was reviewed by the State Surveyor. The facility's video surveillance showed on 08/13/2024 at 3:16:48 PM, Resident #22 was on a wheelchair in the dining room with 2 other residents. At 3:20 PM, Resident #22 stood up while holding on the arm rest and the footrest of the wheelchair, and then fell backwards onto the floor. It was noted that there was no staff seen in the camera that was in close proximity of the residents during the incident. A review of the Daily Half Hourly Dining Room Monitoring Sheet documented that Patient Care Technician #10 was assigned to monitor the dining room on 08/13/2024 from 3:00 PM - 3:30 PM. The employee written statement completed and signed by Patient Care Technician #10 dated 08/14/2024 documented that on 08/13/2024 at 3:20 PM, they were sitting in the back of the kitchen completing the monitoring sheet when the incident happened. They stated they heard another Patient Care Technician shouting, they rushed but the Resident was already on the floor. On 12/18/2024 at 10:25 AM , Patient Care Technician #10 was interviewed and stated they no longer work at the facility and had no knowledge of the alleged incident. On 12/17/2024 at 11:14 AM, Patient Care Technician #1 was interviewed and stated on the day of the incident, they had Resident #22 on their assignment. They stated they put Resident #22 in the wheelchair and wheeled the Resident in the dining area. Patient Care Technician #1 stated there was a Patient Care Technician who was supposed to be on 30-minute monitoring duty at the dining room to supervise the residents, however, could not recall who it was. Patient Care Technician stated they were standing in the middle of the foyer when they heard someone screaming, and when they turn around, they saw Resident #22 screaming and sliding out of their wheelchair. Patient Care Technician #1 stated they tried to run and catch Resident #22 but was too late. Patient Care Technician #1 stated when they got to Resident #22, the 2 other Patient Care Technicians that were sitting by the window came over to assist. Patient Care Technician #1 stated they were not sure if Resident #22 had history of previous falls or if they have any fall interventions in place. On 12/17/2024 at 10:45 AM, Patient Care Technician #11 was interviewed and stated on the day of the incident, they were doing their charting when they heard Patient Care Technician #1 yelling. They stated Patient Care Technician #1 saw Resident #22 sliding from the wheelchair. Patient Care Technician #11 stated they helped pick up Resident #22 from the floor. On 12/17/2024 at 12:45 PM, Registered Nurse #8 was interviewed and stated they were the nurse in charge on the day of the incident. Registered Nurse #8 stated on the day of the incident they were in the nurse's station when Licensed Practical Nurse #1 came to inform them of Resident #22's fall. Registered Nurse #8 stated that according to Patient Care Technician #1, Resident #22 slid out of their wheelchair and that the Patient Care Technician #1 ran but was too late to catch the Resident. Registered Nurse #8 stated there were 2 other Patient Care Technicians that were supposed to monitor the dining room, but they were not sure where they were at the time of the fall. On 12/17/2024 at 2:39 PM, the Deputy Director of Nursing was interviewed and stated they investigated the incident and upon review of the video surveillance, it was determined that Patient Care Technician #10 who was assigned to monitor the day room, was not in close proximity of the residents prior to the fall. The Deputy Director stated that it is the responsibility of the Patient Care Technicians who are assigned to every 30-minute monitoring duty to not do anything else but monitor the residents in the day room as well as be in close proximity of the residents. They stated the investigation revealed there was no cause to believe neglect occurred to Resident # 22. On 12/17/2024 at 2:06 PM, the Director of Nursing was interviewed and stated Resident #22 was identified as high risk for falls. They stated at the time of the incident, Resident #22 was in the dining room but the Patient Care Technician who was assigned to monitor the dining room was not in close proximity of the residents as instructed in the facility policy. 10 NYCRR 415. 12(h)(2) | Plan of Correction: ApprovedJanuary 16, 2025 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice The Interdisciplinary team met, reviewed, and updated the Care Plan for Resident #22 to insure all interventions related to falls are in place. After physical therapy assessment and team discussion a geri chair was provided to resident # 22. Resident #22 is non-ambulatory and has no ability to transfer independently. This seating provided a stable and secure seating surface. Resident #22 continues to be placed in the Dining room for close monitoring when awake and staff are reminded to be in close proximity when monitoring. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The Director of Nursing/ Designee will ensure that staff assigned to the Dining Room for monitoring are attentive to all residents in the Dining area and positioned in the dining room within close proximity to the majority of the residents. The Educator/Designee will provide additional education to all staff on the, ?ôFall Reduction and Injury Prevention Program?Ø and protocols on how to adequately monitor the Dining Room to prevent falls and injury. 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, Director of Nursing and Medical Director will review and revise, as needed, policies and procedures related to fall reduction and injury prevention. The Educator/Designee will provide additional education to all staff on the, ?ôFall Reduction and Injury Prevention Program?Ø and protocols on how to adequately monitor the Dining Room to prevent falls and injury. 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 The Assistant Directors of Nursing/designee will audit 10% of the Dining rooms on all 3 shifts to ensure assigned staff are attentive and within proximity of residents in the dining room on a weekly basis for 3 months or until improvement is sustained to ensure that staff are appropriately monitoring residents to prevent falls and accidents. The Director of Nursing/designee, will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective actions will be implemented as needed. 5: Responsible Individual: Director of Nursing |
Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 19, 2024
Corrected date: N/A
Citation Details Based on observations, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the daily nurse staffing information included all the required information. Specifically, the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. This was evident during the review of the Staffing task. The findings are: The facility policy and procedure titled Minimum Staffing with a last revision date of 03/06/2024 documented that it is the facility's policy to establish compliance with minimum nursing staffing levels. Posted nurse staffing information shall include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Nurses, and Certified Nurse Aides. During an observation from 12/12/2024 through 12/19/2024, nurse staffing information was posted next to the elevators, and the nursing units. The information that were documented on the form includes the facility name, current date, actual hours worked, and resident census. There was no documentation of the total number of nursing staff. On 12/19/2024 at 10:38 AM, the Deputy Director of Nursing was interviewed, and stated that the Assistant Director of Nursing from each shift is responsible for posting the nurse staffing information for the following shift. The Deputy Director of Nursing further stated that according to the Director of Nursing, the staff information posting is based on the regulations and done by the hours. They stated they do not document the number of nursing staff. On 12/19/2024 at 11:30 AM, the Director of Nursing was interviewed and stated they do not put the number of staff in the posted daily nurse staffing information and that they had been doing that for a long time. The Director of Nursing stated it was an oversight. On 12/19/2024 at 11:50 AM, the Administrator was interviewed and stated they were unaware that they must post the total number of staff and the hours. 10 NYCRR 415. 13 | Plan of Correction: ApprovedJanuary 16, 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 form was revised to include all required elements of posting, specifically, a column for the total number of licensed and unlicensed nursing staff directly responsible for resident care was added to the form that is posted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The Director of Nursing/designee will monitor compliance with the daily posting of nurse staffing to include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Educator/designee will provide additional education to all licensed nursing staff on the, ?ôMinimum Staffing?Ø policy. 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 and Director of Nursing will review and revise as needed policies and procedures related to the posting of staffing. The Educator/designee will provide additional education to all staff involved in the posting of daily nurse staffing to include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. 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 The Assistant Directors of Nursing/designee will audit 10% of all Daily Nurse Staffing Forms on a weekly basis for 3 months to ensure that the posted staffing includes the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The Director of Nursing/designee, will report findings to the Facility Quality Assurance/Performance Improvement Committee on a monthly basis for evaluation and follow up to ensure 100% compliance. Additional corrective action will be implemented as needed. 5: Responsible Individual: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
Corrected date: N/A
Citation Details 19. 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) 13?4 in. (44 mm) thick, solid-bonded core wood (2) Material that resists fire for a minimum of 20 minutes Based on observation and staff interviews the facility did not ensure that the corridor doors were maintained to resist the passage of smoke in accordance with NFPA 101. Specifically, the corridor doors to the resident rooms, would not resist the passage of smoke. This was observed on eight of eight resident floors. The findings are: During the Life Safety Recertification Survey of (MONTH) 30, 2024, and (MONTH) 31, 2024, between 9:00 AM and 3:00 PM, the corridor doors to the resident suites were observed with openings between the two doors and would not resist the passage of smoke. In an interview with the Director of Maintenance at the time of the findings, the Director of Maintenance stated that astragals would be installed on the doors to resist the passage of smoke. 2012 NFPA: 19. 3. 6. 3, 19. 3. 6. 3. 13, 8. 4 10 NYCRR: 711. 2 (a) | Plan of Correction: ApprovedFebruary 3, 2025 K363 Corridor Doors 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice Astragals will be installed on the corridor doors to the resident suites to ensure they resist the passage of smoke. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken Astragals will be installed throughout the skilled nursing facility building on all the corridor doors to ensure they resist the passage of smoke. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur A follow-up inspection will be conducted by the Director of Maintenance to verify that the astragals have been installed and are functioning properly. The facilitys compliance will be monitored utilizing the following quality assurance system: Weekly rounds will be conducted to ensure the astragals have been installed and are functioning properly. and that all corridor doors are maintained to resist the passage of smoke in accordance with NFPA 101. The Maintenance and Fire Safety Staff were in-serviced on Corridor doors installed to resist the passage of smoke, in accordance with NFPA 101. The Fire Safety Staff and Maintenance Staff will conduct weekly rounds confirming the corridor doors resist the passage of smoke. The Maintenance Staff will address any doors that are not compliant with the standard. 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 The Director of Maintenance will gather information from the maintenance checks performed and report the findings to the QAPI committee for a period of 3 months or until compliance is achieved. 5. Responsible Individual: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
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) 30, 2024, and (MONTH) 31, 2024, the facility did not ensure that extension cords and power strips were used in accordance with NFPA 70. Specifically, power strips were observed in use. The findings include but are not limited to: 1. Four unmounted power strips in room 5. 132 2. One unmounted power strip in room 5. 125 3. One unmounted power strip in the Dietary office 4. Two unmounted power strips were observed in use in the Staff Work Room on the 12th Floor 5. One unmounted power strip in the Office of the Assistant Director of Nursing 6. A power strip on the floor, powering a microwave was observed in the Office of Community Outreach & Marketing. At the time of the findings, the Director of Maintenance stated that the extension cords would be mounted, and the microwave was immediately plugged directly into an outlet. The Director of Maintenance further stated that an audit of the facility. 2012 NFPA 101: 9. 1. 2 2011 NFPA 70: 400. 8 10 NYCRR 711. 2(a) | Plan of Correction: ApprovedJanuary 31, 2025 K920 Power Strips 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice The following was addressed for the identified areas: Four unmounted power strips in room 5. 132 were mounted, one unmounted power strip in room 5. 125 was mounted, one unmounted power strip in the Dietary office was mounted, two unmounted power strips in the Staff Work Room on the 12th Floor were mounted, one unmounted power strip in the Office of the Assistant Director of Nursing was mounted and the power strip on the floor, powering a microwave in the Office of Community Outreach & Marketing, was mounted, and the microwave was plugged directly into an outlet. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: all skilled nursing facility rooms were checked to ensure that any power strips in use were mounted or that electrical items were plugged directly into an outlet. The Director of Maintenance/Designee will provide education to all staff regarding the policies and procedures related to electrical safety highlighting the proper use and installation of power strips. An educational summary will be provided to all staff highlighting the proper use and installation of power strips. Information on the proper use and installation of power strips will be shared at a Resident Council Meeting. 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 facilitys compliance will be monitored utilizing the following quality assurance system: The Director of Maintenance/Designee will conduct regular maintenance checks to ensure that all power strips are properly mounted and used in accordance with NFPA 101. Findings will be collected on a monthly basis and additional corrective action will be implemented as needed. 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 The Director of Maintenance will gather information from the maintenance checks performed and report the findings to the QAPI committee for a period of 3 months or until compliance is achieved. 5. Responsible Individual: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101: 19. 2. 8 Illumination of Means of Egress. Means of egress shall be illuminated in accordance with Section 7. 8. 7. 8 Illumination of Means of Egress. Based on observation and staff interviews the facility did not ensure that the illumination of means of egress was installed and maintained in accordance with NFPA 101. Specifically, light fixtures were not installed in the loading dock area to ensure continuity in the path of egress. The findings are: On (MONTH) 31, 2024, during the Life Safety Code recertification survey, between 9:30 AM - 2:00 PM, the following was observed: -On the basement level, the emergency exit discharge located by the Dry Storage Room, was observed without a light fixture above the door. On the basement level, the emergency exit discharge leading to the loading dock was observed without a light fixture above the door. Light fixtures were not seen along the path leading to a public way. The Chief Executive Officer and the Director of Maintenance, who were present at the time of the survey acknowledged the findings and stated that they would install the light fixtures. 2012 NFPA 101 10NYCRR 711. 2(a)(1) 10 NYCRR 415. 29 | Plan of Correction: ApprovedFebruary 3, 2025 K281 Illumination of Means of Egress 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice Light fixtures were installed above the emergency exit discharge. Light fixtures were installed above the emergency exit discharge located by the Dry Storage Room on the basement level. Light fixtures were installed above the emergency exit discharge leading to the loading dock on the basement level. Additional light fixtures were installed along the path leading to a public way to ensure continuity in the path of egress. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The following corrective actions will be implemented to identify other residents who may be affected by the same practice: all areas of egress were assessed to ensure proper illumination is in place. 3 What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Hospital Police will add inspection of proper illumination of the means of egress to daily building rounds. Hospital Police has been educated on this new responsibility, on confirming illumination of egress. Regular maintenance checks will be conducted to ensure that all light fixtures are functioning properly and that the means of egress remain illuminated in accordance with NFPA 101. All maintenance staff were in-serviced regarding illumination of means of egress. 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 All egress areas will be monitored for proper illumination and functionality of the light fixtures monthly for a period of 3 months or until compliance is achieved. The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
Corrected date: N/A
Citation Details 2012 NFPA 101: 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. 2012 NFPA 101: 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 8. 6. 4. 1 Distance Below Ceilings. 8. 6. 4. 1. 1 Unobstructed Construction. 8. 6. 4. 1. 1. 1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. ( 25. 4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler. 8. 5. 6* Clearance to Storage. Based on observation and staff interviews during the recertification survey, the facility did not ensure that all sprinklers were installed in accordance with 2010 NFPA 13. Specifically, sprinkler heads were installed greater than 12 inches from the ceiling. The findings include: During the Life Safety Recertification Survey of (MONTH) 30, 2024, and (MONTH) 31, 2024, between 9:00 am and 3:00 pm, in the corridor of the secondary access to the Loading Dock, pendent-style sprinkler heads were installed approximately 56 below the ceiling, at the same level as the lighting fixture. At the time of these findings, the Director of Maintenance stated that the ceiling had been removed and would be put back. 2012 NFPA 101 NFPA 13 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 3, 2025 K 351 Sprinkler System -Installation 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice The ceiling, in the corridor of the secondary access to the loading dock, was reinstalled where the sprinkler heads were found to be greater than 12 in. from the ceiling. The ceiling in the corridor of the secondary access to the Loading Dock was reinstalled to its original position. The pendent -style sprinkler heads were adjusted to ensure the installation is in accordance with 2010 NFPA 13. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken The Director of Maintenance or Designee will conduct a thorough inspection of all sprinkler heads to confirm that installation is not greater than 12 in. from the ceiling. 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 Fire Safety Team and the Maintenance team were in-serviced on NFPA Standard for the installation of Sprinkler Systems and highlighted their role in ensuring that pendant style sprinkler heads are not greater than 12 in. from the ceiling in accordance with NFPA 13. The Fire Safety Staff and Maintenance Staff will conduct weekly rounds confirming that Sprinkler Heads are not greater than 12 in from the ceiling. The Maintenance Staff will address any sprinkler heads that are not compliant with the standard. Regular maintenance checks will be conducted to ensure that all sprinkler heads are installed and maintained in accordance with 2010 NFPA 13. 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 The Director of Maintenance/Designee will review 10% of all sprinkler heads to confirm that they are installed no greater than 12 in from the ceiling for a period of 3 months or until improvement is sustained that all sprinkler heads are no more than 12 in from the ceiling: The results from the monitoring will be reported to the QAPI Committee. 5. Responsible Individual: Director of Maintenance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 31, 2024
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 one-half-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 eight resident floors. The findings include but are not limited to: During the Life Safety Code recertification survey, conducted on (MONTH) 30, 2024, and (MONTH) 31, 2024, an examination of the smoke barrier walls above the ceiling tiles revealed that 1) on the 13th Floor adjacent to resident room 1314 had an opening of approximately 1/8 inch around a 1-inch metal pipe; 2) on the 11th Floor adjacent to resident room 1126, a penetration of approximately 4 inches x 4 inches. In an interview at the time of the observation, the Director of Maintenance stated that the pipe 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: ApprovedJanuary 31, 2025 K372 Smoke Barrier Walls 1. What Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice The opening observed in the smoke barrier wall of approximately 1/8 inch around a 1-inch metal pipe on the 13th Floor adjacent to resident room 1314 was sealed with a fire stop material. The opening observed in the smoke barrier wall of approximately 4 inches x 4 inches on the 11th Floor adjacent to resident room 1126 was sealed with a fire stop material. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken An audit of all smoke barrier walls throughout the facility was conducted to ensure all openings are correctly sealed with fire stop material. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur A system for a regular review of the smoke barrier walls was developed. The Director of Maintenance will oversee the sealing of the openings and the audit of the smoke barrier walls. 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 The Director of Maintenance/Designee will gather the data from the audit of the smoke barrier walls and report findings to the QAPI Committee for a period of 3 months to the smoke barrier walls are compliant 5. Responsible Individual: Director of Maintenance |