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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident. This was identified for one (Resident #85) of four residents reviewed for Advanced Directives and for one (Resident #99) of one resident reviewed for skin conditions. Specifically, 1) Resident #85 had physician's orders [REDACTED]. There was no comprehensive care plan developed to reflect the resident's Advanced Directives status. 2) Resident #99 had a physician's orders [REDACTED]. There was no documented evidence that the staff consistently provided the wound care as ordered by the Physician. The findings are: 1) The facility's policy titled, Minimum Data Set/Care Planning dated 11/20/2017 documented, that the facility shall have a care planning process that is person-centered which includes: integrating assessment findings in care planning, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, and providing the care and documenting the care. The care plan shall describe the services that are being provided and any services/treatment that would otherwise be required but are not provided due to the resident's/patient's exercise of the right to refuse treatment. The facility's policy titled, Advanced Directives last reviewed on 2/17/2017 documented the resident's advanced directives will be reviewed with the resident and/or their representative upon admission and periodically to ensure that such directives reflect the current wishes of the resident or representative, in light of the resident's medical status and life circumstances. As part of the admission process, the social worker will review any accompanying advanced directives for completeness, accuracy, and validity, and will review such directives with the resident and/or representative to ascertain the current wishes of the resident or representative. The resident's physician and staff involved in the resident's care will be notified of any change in advanced directives and the medical record and comprehensive care plan will be amended accordingly. Resident #85 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #85 had a Brief Interview for Mental Status score of 14 indicating an intact cognition. The Quarterly Minimum Data Set documented the resident's Advanced Directives as Do Not Resuscitate, Do Not Intubate (no breathing tube will be placed), and Feeding Restrictions. The resident had an invoked healthcare proxy (a designated person to make healthcare decisions on their behalf if they are unable to do so). A physician's orders [REDACTED].#85's advanced directives as Do Not Resuscitate. Treatment guidelines- limited medical interventions. Instructions for intubation and mechanical ventilation- Do not intubate. Future hospitalization /Transfer - Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled. Artificially administered fluid and nutrition- No feeding tube, a trial period of IV fluids. Antibiotics- Determine the use or limitation of antibiotics when infection occurs. Use antibiotics. The physician's orders [REDACTED]. A review of Resident #85's electronic medical record revealed that Resident #85 did not have an active Comprehensive Care Plan for Advanced Directives. Further review revealed an inactive Comprehensive Care Plan for Advanced Directives with an effective date of 2/2/2024 and the status of the Comprehensive Care Plan was documented as the resident was discharged on [DATE]. The admission, discharge, and transfer history in the electronic medical record documented that Resident #85 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. A social work progress note dated 5/15/2024 documented the resident was readmitted to the facility and the Medical Orders for Life Sustaining Treatment and advanced directives were in place. A social work progress note dated 5/26/2024 documented a care plan meeting was held with Resident #85 and the healthcare proxy. The interdisciplinary team updated and reviewed the plan of care. The resident had advanced directives and Medical Orders for Life-Sustaining Treatment in place with no changes. The Licensed Master Social Worker assigned to Resident #85 was unavailable for an interview. Licensed Master Social Worker #1 was interviewed on 9/3/2024 at 3:34 PM and stated Resident #85 should have an active Comprehensive Care Plan for Advanced Directives. Licensed Master Social Worker #1 reviewed Resident #85 physician's orders [REDACTED]. Licensed Master Social Worker #1 stated Resident #85 was sent to the hospital on [DATE] and because the resident did not return by midnight, the electronic medical record software automatically inactivated all of the resident's Comprehensive Care Plans. Licensed Master Social Worker #1 stated the assigned Licensed Master Social Worker was responsible for reviewing and reactivating the Comprehensive Care Plan for Advanced Directives when the resident was readmitted . The Comprehensive Care Plan for Advanced Directives with an effective date of 2/2/2024 appeared active in the electronic medical record on 9/3/2024 after the surveyor interviewed the Licensed Master Social Worker. The Acting Director of Nursing Services was interviewed on 9/5/2024 at 3:55 PM and stated an active Comprehensive Care Plan for Advanced Directives should have been in place for Resident #85. The Acting Director of Nursing Services stated when a resident is readmitted , after a hospital stay, all their relevant Comprehensive Care Plans should be reactivated. The Acting Director of Nursing Services stated they expected that a resident with Medical Orders for Life-Sustaining Treatment and physician's orders [REDACTED]. 2) Resident #99 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The resident had an application of nonsurgical dressings (with or without topical medications) other than to feet. The resident did not have pressure ulcers. The comprehensive care plan dated 8/5/2024 documented the resident had skin impairment with a full thickness wound to the left shin. Interventions included but were not limited to provide treatment as per the physician's orders [REDACTED]. The physician's orders [REDACTED]. Soak with normal saline to remove the old dressing twice daily. A review of the resident's Treatment Administration Record from 8/1/2024 to 8/31/2024 revealed there was no documented evidence that the wound treatments were administered on 8/10/2024 and from 8/14/2024 to 8/17/2024 during the 7:00 PM to 7:00 AM shift. Registered Nurse #5, who was assigned to Resident #99 on 8/15/2024 and 8/16/2024 was not available for an interview. Registered Nurse #7, who was assigned to Resident #99 on 8/17/2024 was interviewed on 9/4/2024 at 5:03 PM and stated they could not recall if they had administered the treatments for Resident #99 on 8/17/2024. Registered Nurse # 8, who was assigned to Resident #99 on 8/14/2024, was interviewed on 9/4/2024 at 5:06 PM and stated if the treatment record was not signed that means the treatment was not done. Registered Nurse #8 stated, I don't recall treating the resident's wound with Dakin's dressing. I have always applied Xeroform dressing. The Director of Nursing Services was interviewed on 9/4/2024 at 5:08 PM and stated that all nurses should provide treatment as per the physician's orders [REDACTED]. The Director of Nursing Services stated that if the treatment administration is not signed for, it is considered that the treatment was not provided. The Administrator was interviewed on 9/4/2024 at 5:15 PM and stated that all nurses should sign in the Treatment Administration Record that the treatment was provided as per the physician's orders [REDACTED]. 10 NYCRR 415.11(c)(1) | Plan of Correction: ApprovedOctober 3, 2024 Immediate Corrective Action: ?Çó Resident 85 -advance directive care plan completed (9/4/24) ?Çó Resident 99 wound care was completed and documented during the next shift as ordered by physician ?Çó Registered nurse #five received an educational counseling (9/20/24) ?Çó Registered nurse #seven received an educational counseling (9/20/24) ?Çó Registered nurse #eight received an educational counseling(9/20/24) ?Çó Social worker received an educational counseling (9/20/24) Identification of others: All residents who are admitted to the facility with advanced directives are at risk for this deficient practice. All residents with treatments ordered by a physician are at risk for the same deficient practice. A facility wide census was compiled listing all residents who were in the facility on 9/4/24 were reviewed and audited. All negative findings were corrected (9/5/24). A report of all undocumented treatments in the past 30 days were compiled and reviewed. All social workers will be re serviced on the importance of developing and implementing a comprehensive person-Centered care plan for each resident (9/20/24) All licensed nurses will be re-in serviced on documenting all wound care treatments as ordered by the physician. Systemic Changes: The DON and administrator reviewed the policy on minimum data set care planning, advance directives, wound care treatment and found to be compliant. All social work staff will be in serviced on the importance to develop and implement a comprehensive person-centered care plan for each resident. (9/20/24) All licensed nurses will be re-in-service on the importance on documenting treatment as evidence that staff consistently provided phone care as ordered by a physician.(ongoing) QA: The Director of social work and the Director of nursing Developed an audit tool to ensure that the facility develops a comprehensive person-centered care plan for each resident. Three new/readmitted residents per week will be audited for compliance for three months. An audit tool was developed to ensure that there is documented evidence that staff consistently provided wound care as ordered by the physician. Three treatments per unit per week will be audited for three months to ensure compliance. All negative findings will be corrected immediately. All negative findings will be brought to the/ Director of SWK and DON and reported to the Administrator and addressed immediately. All audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary Date and title of Responsible Party: The responsible person for this deficiency is The Director of social work/designee 10/29/24 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details Based on observations, record review, and interviews conducted during the Recertification Survey, initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, 1) an opened, undated package of cod fish and pancakes was observed in a single-door refrigerator. In the dry storage area, four packages of opened and undated dry cereals were observed 2) Dietary Aide #1 was observed licking their fingers and then setting up napkins and utensils on resident trays without performing hand hygiene. 3) A chicken salad sandwich temperature was not maintained within the acceptable temperature range for food safety. The findings are: A facility policy titled Label & Date Food, last reviewed on 8/29/2024, documented that the marking of the date of preparation and or opening of the food is required. Food that is not readily identifiable is to be stored in properly labeled original product containers or in containers labeled to identify the food by common name. Food removed from the original container or package is to be protected from contamination by storing the items in a clean, covered, sanitized container and maintained at safe temperatures. Unused, unprotected food of any kind may not be served again. A facility policy titled General Hazard Analysis and Critical Control Points (HACCP) Guidelines for Food Safety, dated 2010, documented that staff must be educated and supervised on all Hazard Analysis and Critical Control Points information and procedures. The Temperature Danger Zone (TDZ): Food must be held greater than 135 degrees Fahrenheit or less than 41 degrees Fahrenheit. A facility policy titled Hand Washing, dated 11/27/2000, last reviewed 8/29/2024 documented that all employees will ensure hands are clean by using the proper hand washing technique. At a minimum, this technique should be done when arriving for work, before and after handling food, before and after cleaning any equipment, when changing any job in the Nutritional Services Department, after eating, after smoking, after sneezing, after coughing, after using the bathroom, and when leaving for the day. 1) During the initial tour of the kitchen conducted on 8/26/2024 at 10:38 AM with the Food Service Director, the single-door freezer was observed with a bag of unidentified food items and a bag of pancakes with no date or a label. The unidentified bag of food, according to the Food Service Director, was cod fish. The dry storage room was observed with an open, unlabeled, and undated bag of rice crispy, cheerios, and cornflakes that were not stored in a tightly sealed container as instructed in the policy and procedure for food storage. There were also four pouches of tuna, four pouches of salmon, six bottles of ketchup, five bottles of relish, and six bottles of grape jelly observed removed from their original packaging, without a delivery date in the dry storage area. 2. During the initial tour of the kitchen conducted on 8/26/2024 at 10:46 AM with the Food Service Director, Dietary Aide #1 was observed licking their fingers and then continuing to pull napkins and other condiments to set up resident trays for the lunch meal. Dietary Aide #1 was interviewed immediately after the observation on 8/26/2024 and stated they did not realize that they had licked their fingers as they were preparing the tray. Dietary Aide #1 stated they should have performed hand hygiene after licking their fingers and before returning to setting up the resident meal trays. The Food Service Director was also interviewed immediately after the observation on 8/26/2024 and acknowledged that Dietary Aide #1 was licking their fingers while preparing the meal tray. The Food Service Director stated that Dietary Aide #1 should have performed hand hygiene. 3. During the follow-up tour of the kitchen conducted on 8/28/2024 at 11:41 AM with the Food Service Director, the Cook was observed making a chicken salad sandwich; however, the chicken salad was not chilled in an ice bath. The Cook was interviewed immediately after the observation on 8/28/2024 and stated they usually refrigerate the sandwiches prior to the start of the lunch meal service/tray-line; however, on this day they were running late and there was not enough time to chill the sandwiches to a proper temperature. The Cook stated that the temperature of the sandwich should not be above 41 degrees Fahrenheit. The temperature of a sandwich was taken and measured at 75 degrees Fahrenheit. The Food Service Director was interviewed on 8/28/2024 at 11:44 AM and stated that the chicken salad sandwich temperature of 75 degrees Fahrenheit was in the danger zone. The cook should have chilled the chicken salad in an ice bath. 10 NYCRR 415.14(h) | Plan of Correction: ApprovedOctober 2, 2024 Immediate Corrective Action: ?Çó Opened and undated package of codfish and pancakes and single door refrigerator was discarded (8/26/24) ?Çó four packages of opened and undated, dry cereals were discarded (8/26/24) ?Çó Napkins were discarded (8/26/24) ?Çó Utensils were removed and sanitized (8/26/24) ?Çó Chicken salad sandwich was discarded (8/28/24) ?Çó Staff member responsible for dating, open codfish, pancakes, and dry cereals received a counseling (8/26/24) ?Çó Aide #1 - received an educational counseling on Handwashing (8/26/24) ?Çó The Cook on duty received educational counseling on proper temperature range for food safety. (8/26/24, 9/9/24) Identification of others: All residents have the potential to be affected by the same deficient practice. an audit of all refrigerators, walk-in freezers, dry storage areas were audited for proper labeling, storing and dating and found to be compliant. No other issues were found (8/26,8/29). All Dietary staff are responsible for ensuring that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety and that the marking of the date of preparation and or opening of the food is required. Food that is not readily identifiable is to be stored in properly labeled original product containers or in containers labeled to identify the food by common name. Food removed from the original container or package is to be protected from contamination by storing the items in a clean, covered, sanitized container and maintained at safe temperatures. Unused, unprotected food of any kind may not be served again. Systemic Changes: The FSD and the Administrator reviewed the policy on label and dating food, general hazard analysis, and critical control points guidelines for food, safety, and handwashing policy and found to be compliant. All dietary staff will be re-in-service on dating, labeling and proper storing of all food items in all freezers, fridges and storerooms. All dietary staff will be. Re-in-service on proper temperatures with an acceptable temperature range for food safety. All dietary staff will be re in serviced on hand washing that all employees will ensure hands are clean by using the proper handwashing technique. (9/3/24) QA: The FSD and Administrator, developed an audit tool to ensure that the facility adheres to proper labeling, storing and dating of all food, proper food temperatures and proper hand washing techniques. Environmental rounds will be completed in the kitchen, refrigerators, walk in freezers and storerooms to ensure compliance and that all employees will ensure hands are clean by using the proper hand washing technique twice weekly for 3 months. Food temperature logs will be audited 3 times weekly for 3 months to ensure food is maintained within the acceptable temperature range for food safety. All negative findings will be corrected immediately and reported to the FSD. All Audit findings will be reported to QA Committee quarterly for evaluation and follow-up. The QA committee will determine a schedule for ongoing audits if deemed necessary. The person and title of Responsible Party: FSD/Designee 10/29/24 |
Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility failed to ensure the residents' environment remained free of accident hazards. This was evident at the resident sinks and common shower rooms on all 4 of 4 resident units. Specifically, the facility failed to protect all 114 residents from the likelihood [MEDICAL CONDITION] to excessive hot water temperatures from the facility's domestic hot water system. This resulted in no actual harm with likelihood of serious harm that is Immediate Jeopardy and Substandard Quality of Care to all residents' health and safety. The findings are: 42 CFR 483.470 (d)(3) PART 483-REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES 483.470 Condition of Participation: Physical environment. (d) Standard: Client bathrooms. The facility must ensure: (3) In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 ??Fahrenheit. NYS Rules and Regulations, Article 2 Medical Facility Construction, Part 713- Standards of Construction for Nursing home facilities, Section 713-1.9- Mechanical requirements, (m) Domestic hot water systems shall provide adequate hot water at each outlet at all times. Hot water temperature at fixtures used by residents shall not exceed one hundred ten degrees Fahrenheit. The facility's policy and procedure for Heating System and Water Temperature last revised in (MONTH) 2009 documented the tap water in the facility shall be kept within a temperature range to prevent scalding of residents. The water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. During an on-site visit on 8/27/2024 between 1:00 PM and 4:00 PM following observations were made: At 1:00 PM Surveyor #1, tested the hot water in the bathroom located in the main lobby, by running the water over their hand. After approximately 25-30 seconds, the hot water became so hot the surveyor had to remove their hand. On 8/27/2024 between 1:10 PM to 3:00 PM, Surveyor #2 tested the hot water temperature throughout the facility. The temperature readings were as follows: At 1:10 PM, the water temperature in the bathroom, located in the facility lobby, was measured at 124.3 degrees Fahrenheit. At 1:21 PM, the water temperature in the West Unit tub/shower room was measured at 127.9 degrees Fahrenheit. At 1:26 PM, the sink water temperature in the West Unit room [ROOM NUMBER] was measured at 125 degrees Fahrenheit. At 1:35 PM, the water temperature in the East Unit tub/shower room was measured at 124.3 degrees Fahrenheit. At 1:40 PM, the sink water temperature in the East Unit room [ROOM NUMBER] was measured at 124.7 degrees Fahrenheit. At 1:50 PM, the sink water temperature in Unit B room [ROOM NUMBER] was measured at 121.8 degrees Fahrenheit. During an observation and interview of the boiler room on 8/27/2024 at 3:00 PM with the Director of Plant Operations, the mixing valve digital display indicating the water temperature at the mixing valve was set at 130 degrees Fahrenheit. There were two boilers present in the boiler room. The water temperature of the boilers was checked and found to be 165 degrees Fahrenheit. In an immediate interview the Director of Plant Operations stated that the water temperatures at the mixing valve are manually adjusted if the temperature is noted to be too high. The Director of Plant Operations stated the water temperature at the mixing valve usually fluctuates between 115-118 degrees Fahrenheit and should not be set at more than 120 degrees Fahrenheit. During an observation and interview on 8/27/2024 at 3:10 PM, the Director of Plant Operations was observed checking the hot water temperature in the resident rooms on all units. There were mercury thermometers in the resident shower rooms and tub room secured with a string next to the shower faucet. The Director of Plant Operations used an infrared thermometer to measure the hot water temperature collected in a cup. The Infrared thermometer was unable to register the hot water temperature that was taken from the shower in room [ROOM NUMBER]. The Director of Plant Operations stated they would bring a calibrated digital thermometer from the kitchen. In an immediate interview the Director of Plant Operations stated they check the water temperatures daily at 8:00 AM by using the mercury thermometers that are present in the resident shower rooms and the tub rooms. The Director of Plant Operations stated that all resident shower rooms have mercury thermometers which can only read temperatures up to 120 degrees Fahrenheit. The Director of Plant Operations stated the water temperature is only checked for the resident shower rooms and tub rooms. The Director of Plant Operations stated the water temperature was checked on 8/27/2024 at 8:00 AM and was noted to be 115 degrees Fahrenheit. On 8/27/2024 at 3:15 PM, the Director of Plant Operations obtained a digital stem kitchen thermometer and used the thermometer to measure the water temperatures. Four resident rooms were checked between 3:15 PM to 4:00 PM. At 3:40 PM, the water temperature in the East unit room [ROOM NUMBER] shower was measured at 124.5 degrees Fahrenheit. At 3:45 PM, the water temperature in the West unit room [ROOM NUMBER] shower was measured at 122 degrees Fahrenheit. At 3:55 PM, the sink water temperature in Unit C room [ROOM NUMBER] was measured at 127 degrees Fahrenheit. At 4:00 PM, the sink water temperature in Unit B room [ROOM NUMBER] was measured at 129 degrees Fahrenheit. A review of the Temperature Logs for (MONTH) 2024 indicated that the water temperature levels were documented at 115 degrees Fahrenheit each day. During an interview on 8/27/2024 at 3:22 PM, Certified Nurse Assistant # 2 stated they provide showers to the residents during the evening shift and use the shower thermometer to test the water temperatures. The thermometer only reads up to 120 degrees Fahrenheit. Certified Nurse Assistant # 2 stated they also use their hand to test the water to make sure it is not too hot and then adjust the water temperature to the residents' preference. During an interview on 8/27/2024 at 3:27 PM, Certified Nurse Assistant #1 stated they usually provide showers to the residents in their rooms. Some bathrooms have thermometers, and some do not. If there is no thermometer available, they test the water temperature by using their hands. Certified Nurse Assistant #1 stated that water temperature above 110 degrees Fahrenheit is considered unsafe. During an interview on 8/27/2024 at 3:35 PM, Certified Nurse Assistant # 4 stated they check the water temperature by using their hand to make sure the water is comfortable for the resident. If the resident wants the water to be hot, they make the water hot. They do not use the thermometer to check the water temperature before showering a resident. During an interview on 8/27/2024 at 3:37 PM, Certified Nurse Assistant #3 stated they do not use the thermometer to check the water temperature before they shower a resident. They usually put the resident's feet in the water first to see if the resident is comfortable with the water temperature. Certified Nurse Assistant #3 stated for showers, safe water temperature should be between 70-89 degrees Fahrenheit. During an interview on 8/27/2024 at 3:28 PM, Certified Nurse Assistant # 5 stated they first check the water with their hands to make sure it is not too hot and then they use the thermometer to measure the water temperature before showering a resident. The water temperature should not be over 100 degrees Fahrenheit. If the water temperature is above 100 degrees Fahrenheit, they notify the charge nurse. During an interview on 8/27/2024 at 4:58 PM, the Administrator stated they were recently hired and were unaware of any unsafe hot water temperature issues at the facility. The Administrator stated water temperature above 120 degrees Fahrenheit is unsafe. During an interview on 8/28/2024 at 11:40 AM, the Director of Nursing Services (DNS) stated there were no reported burn injuries. The Director of Nursing Services stated the staff should run the water prior to showering a resident to ensure water temperatures are between 100 to 120 degrees Fahrenheit. The staff should check the temperature by using the thermometers that are available in the shower rooms. The Director of Nursing Services stated they did not know the thermometers that were in the shower rooms and the tub room could only measure temperature levels up to 120 degrees Fahrenheit. The Director of Nursing Services stated water temperatures above 120 degrees Fahrenheit would put residents at risk for burns. During an interview on 8/28/2024 at 11:55 AM, the Medical Director stated excessive hot water temperatures would increase the risk [MEDICAL CONDITION] the residents, especially residents with certain medical conditions such as [MEDICAL CONDITION] or other sensory issues. The Medical Director stated the water temperatures should be maintained below 120 degrees Fahrenheit. During an interview on 8/28/2024 at 5:00 PM, the Administrator stated they were unaware that the unsafe hot water temperature regulation was changed from 120 degrees Fahrenheit to 110 degrees Fahrenheit. The Administrator stated the facility policy and procedures did not match the regulatory requirements and would be changed to reflect the new regulations. 10 NYCRR 415.12(h)(l). The facility was notified of the Immediate Jeopardy on 8/28/2024. The Immediate Jeopardy was removed on 8/30/2024 prior to the completion of the survey. The facility implemented the following to remove the immediacy: -The facility revised the Water Temperature policy, and the procedure was updated to reflect the date, time, location, and intervention applicable. All Maintenance staff were re-in serviced on the usage of the new water temperature log sheet. - A full house audit of all residents was completed by the facility for the potential to be affected by this deficient practice, no issues were identified (8/28/2024). - Water Temperature in each resident room was tested and water temperature logs dated 8/28/2024 through 8/30/2024 were presented to the survey team by the facility with no negative findings. - The survey team interviewed 18 staff members from various disciplines and various shifts (including all 4 maintenance staff). All staff demonstrated knowledge of the new/revised policy related to Water Temperature. The facility provided in-service education to 99 % staff: Rehabilitation: 99%; Recreation- 100%; Maintenance/Housekeeping; 100%, Administration; 100%; Nursing- 99%; and Dietary- 100% | Plan of Correction: ApprovedOctober 9, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This as a formal Directed Plan of Correction. Immediate Corrective Action: [DATE] 5:58 pm: Maintenance Conducted an immediate assessment of the water management system. The temperature on the boiler was lowered and cold water was increased on the mixing valve. Issued work orders for immediate repairs and adjustments to ensure compliance with temperature regulations and safety standards. Water on all units were ran to flush out system to achieve favorable water temperature to meet facility requirements Inspection: Maintenance will complete a thorough inspection of all water management systems, including hot water heaters, pipes, and temperature controls. All resident showers have been halted until temperatures meet federal and state guidelines. All cognitive intact residents have been informed that showers will be halted temporarily. All non-cognitively intact residents Next of Kin will be informed. All residents and staff are encouraged to use hand wipes and Purell stations for hand washing and sanitation. An overhead announcement was made to all staff and residents able to use sinks and are cognitively intact to temporarily suspend usage of hot water. Those who are not cognitively intact will have their sinks shut off until temperatures have reached federal and state requirement of 110 degrees. Signage will be posted on all sinks to temporarily suspend usage of hot water at sinks until further notice if temperatures are deficient until temperatures are within safe levels which was reached on [DATE]. The outside plumbing service was completed and changed the gauge on boiler mixing valve ([DATE]). All resident rooms on each unit were tested for safe temperatures and found compliant ([DATE]) All showers and sinks resumed service ([DATE]). Identification of others: All residents and staff have the potential to be affected by this deficient practice. All resident showers have been halted until temperatures meet federal and state guidelines (resumed [DATE]). All residents and staff are encouraged to use hand wipes and Purell stations for hand washing and sanitation. Systemic Changes: A review of the policy on Water Temperatures was reviewed and revised ([DATE]). Maintenance temperature monitoring systems policy has been upgraded to ensure that water temperatures are maintained within the required range (usually ,[DATE]??F for hot water). Regular Checks: Maintenance has Implemented daily checks and logging of water temperatures by designated Maintenance staff members. The Maintenance temp log has been revised to include days, time, location, temperature and intervention if temperature does not meet requirements. Temperatures will be taken 3 times per day in various locations within the building. 5 resident rooms will be tested per unit per day and logged in the revised log sheet. Any temperatures found to be non-compliant will be immediately reported to the Maintenance Director/designee. They will then shut off the water valve in the affected resident room. The Maintenance Director will conduct training for all maintenance staff on proper water management practices including monitoring, temperature regulation, and responding to water-related issues ([DATE]). All staff were educated on monitoring and reporting of water temp issues ([DATE]). A consultant was retained to re in-service all staff on proper water temps and reporting water temp issues ([DATE]).(NAME)Simeon will ensure ongoing education and refresher courses by the outside consultant to keep new staff updated on best practices and regulatory requirements (ongoing). QA: The Administrator/Maintenance Director developed an audit tool to ensure that all residents care areas and staff areas including kitchen, boiler rooms, etc have water temperatures logged in various areas daily during various times of the day. All water temperatures taken must meet state and federal requirements. Any deficient water temperatures will be immediately reported and remedied by the Maintenance Director. This audit will be completed by the Maintenance Director/designee daily indefinitely. All negative findings will be brought to the Maintenance Director then reported to the Administrator and addressed immediately. All audit findings will be reported to the QA committee. Date and title of Responsible Party: The person responsible for this correction is the Maintenance Director. Removal plan compliance date: [DATE] |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This was identified for one (West Unit) of four Units during the infection control task. Specifically, the facility did not ensure staff appropriately discarded dirty linens in a sanitary manner and did not timely change suction canister and tubing after use. The findings are: The facility's Policy and Procedure titled, Infection Prevention and Control last reviewed (MONTH) 2023, documented that an Infection Control Program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Important facets of infection prevention include educating staff and ensuring they adhere to proper techniques and procedures. The facility's policy for Suction Equipment revised on 6/1/2009, documented that all suction equipment will be cleansed after each use to reduce the possibility of contamination. Procedures include: Licensed Nursing Staff will disinfect a suction bottle or machine by wiping down the suction machine after each use and at the end of each shift; discarding the disposable suction bottle at the end of each shift; replacing the tubing on the suction bottle once each week; and replacing suction tubing between residents. According to the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for best practices for linen (and laundry) handling found online at https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html, documented: - Always wear reusable rubber gloves before handling soiled linen (e.g., bed sheets, towels, curtains). - Never carry soiled linen against the body. Always place the soiled linen in the designated container. - Carefully roll up soiled linen to prevent contamination of the air, surfaces, and cleaning staff. Do not shake linen. - If there is any solid excrement on the linen, such as feces or vomit, scrape it off carefully with a flat, firm object and put it in the commode or designated toilet/latrine before putting linen in the designated container. -Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. 1) During an observation on the West Unit, on 8/26/2024 at 11:17 AM, Licensed Practical Nurse #2 was observed walking out of a resident room. The resident's room was identified by signage as being under Enhanced Barrier Precautions. Licensed Practical Nurse #2 was wearing gloves and was transporting the used linen to the dirty linen cart. The linen was not secured in a sealed bag and was observed touching Licensed Practical Nurse #2's uniform. Licensed Practical Nurse #2 was interviewed immediately after the observation on 8/26/2024 and stated I know I am not supposed to carry dirty linen without a plastic bag, but there were no plastic bags in the room. 2) On 8/26/2024 at 12:45 PM during the lunch meal observation, the West Unit dining room was observed to have a dirty suction canister that contained cloudy fluid with food particles and used suction tubing attached to the suction machine. Registered Nurse Supervisor #2 was interviewed immediately after the observation on 8/26/2024 and stated the suction machine was not used today. The canister and tubing should have been replaced after every use. Registered Nurse Supervisor #2 stated they were supposed to check the suction machine before each meal but they did not check the suction machine before today's lunch meal. The Infection Control Registered Nurse was interviewed on 9/04/2024 at 12:16 PM and stated the suction machine should be checked every night by the night shift staff. When the suction machine is used, the nurse should change the canister and the suction tubing after each use. The suction machine should be ready at meal times, in the event there is an emergency. The Infection Control Registered Nurse also stated all dirty linens should be sealed in a plastic bag and placed in the dirty linen cart. If there was no plastic bag available, the nurse should have called someone to bring the plastic bag to the room. 10 NYCRR 415.19 (a) (1-3)(c) | Plan of Correction: ApprovedOctober 2, 2024 Immediate Corrective Action: ?Çó Dirty linen was placed in a plastic bag and appropriately discarded. (8/26/24) ?Çó The suction machine canister was sanitized; tubing was discarded, and machine was sanitized 8/26/24 ?Çó LPN #2 was provided an educational counseling (9/20/24) ?Çó The LPN assigned to the west unit on 8/26/24 on 7a-7p tour was provided an educational counseling (8/26/24). Identification of others: The Director of nursing and administrator established a list of all suction machines throughout the facility. All suction machines on all units and dining rooms were checked for cleanliness. No other issues were found (8/26/24). All licensed nursing staff will be required to maintain clean and sanitized suction machines, canisters and tubing for all suction equipment. All licensed nurses will disinfect the suction machine by wiping down the suction machine, discard tubing and sanitize canister after each use. Suction machines must be checked by licensed nurse for compliance during each shift and to establish and maintain an infection control program to provide a safe sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. A tour of all units was completed to ensure that rubber gloves and plastic bags were available for use to properly discard dirty linen and to ensure that no other staff members were handling dirty linen without being properly secured and transported. No other issues were found. Systemic Changes: The administrator and Director of nursing reviewed the facilities policy on infection prevention and control and the policy for suction equipment and found it to be compliant. All licensed nurses will be re in serviced on the infection, prevention and control policy and procedure, as well as the policy for suction equipment and the importance of maintaining and providing a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, or licensed nurses will be required to adhere to proper techniques and procedures, as indicated by the facilities' infection prevention and control policy.(Ongoing) QA: The Director of nursing an administrator developed an audit tool to ensure that staff appropriately discard dirty linen in a sanitary manner. Three random units per week will be audited for 3 months to ensure compliance. The Director of nursing and administrator developed an audit tool to ensure that the suction machines including canisters and tubing are changed timely after use and sanitized. Three random suction machines will be audited weekly for three months to ensure compliance. All negative findings will be corrected immediately and reported to the DON/Designee. All audit findings will be reported to the QA committee quarterly for evaluation and follow-up. The QA committee will determine a schedule for ongoing audits if deemed necessary. The person responsible for this audit is the DON/designee. 10/29/24 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles. This was identified for three (Unit B, Unit C, and East Unit) of four units observed during the Medication Storage Task. Specifically, loose unidentifiable medications were observed in a medication cart for Unit B, East Unit, and Unit C. Additionally, the medication carts were utilized for storing items other than the medications. The findings are: The Medication Rooms/Areas Policy dated 6/1/2009 and last reviewed in (MONTH) 2023 documented to assure that the medication room/area contains only drugs, biological or other items needed for the administration of medication. The Medication cart policy dated 6/1/2024 and last updated (MONTH) 2023 documented that all medication carts will be maintained with adequate supplies, in a state of cleanliness, and will be appropriately safeguarded to assure the safety of the residents. The Unit B medication cart was observed on 8/26/2024 at 11:06 AM, in the presence of Licensed Practical Nurse #3. There were seven unidentified loose medications including capsules and tablets on the base of the second drawer of the medication cart. Licensed Practical Nurse #3 was interviewed on 8/26/2024 at 11:06 AM and stated they were not aware that the cart had loose pills and capsules. Licensed Practical Nurse #3 stated there should not be any unidentified loose pills in the cart. The East Unit medication cart was observed on 8/26/2024 at 11:25 AM, in the presence of Licensed Practical Nurse #4. There were 18 unidentified loose medications including capsules and tablets on the base of the second and third drawer of the medication cart. Licensed Practical Nurse #4 stated they did not know there were loose medications tablets and capsules in the medication cart and it was not okay to have the loose medications on the medication carts. The Unit C medication cart was observed on 8/26/2024 at 11:31 AM, in the presence of Licensed Practical Nurse #5. There were two unidentified loose medication tablets at the base of the second drawer. Additionally, a large nail clipper which was not kept in a separate bag was stored in the medication cart. Licensed Practical Nurse#5 was interviewed immediately after the observation on 8/26/2024 and stated they did not know who placed the nail clipper in the medication cart, but it should not be there because it is not a medication. Licensed Practical Nurse #5 stated the medication cart should not have loose medications in it. The Director of Nursing Services was interviewed on 9/5/2024 at 12:52 PM and stated it was not acceptable to have loose medications and nail clippers in the medication cart. 10 NYCRR 415.18(e)(1-4) | Plan of Correction: ApprovedOctober 2, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: ?ÇóThe unit B loose and unidentifiable medication in med cart were discarded ([DATE]) ?ÇóUnit C, loose and unidentifiable medication in med cart were discarded ([DATE]) ?ÇóEast unit all unidentifiable medication in med cart were discarded ([DATE]) ?ÇóUnit c med cart - nail clipper stored in medication carts was removed. ([DATE]) ?ÇóAll nurses assigned to unit C, East, and unit B in the past 30 days were counseled ([DATE]) Identification of others: All medication carts have the potential to be affected by this same deficient practice. All remaining medication carts and narcotics cabinets were checked to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles and that no other items other than drugs or biologicals needed for administration were stored in medication carts. ([DATE]) No other issues were found. Systemic Changes: The DON and Administrator reviewed the Policy on medication/room/areas and medication cart policy and found it to be compliant. All licensed Nurses will be responsible for checking all medication carts/narcotic boxes daily for expired, undated and unlabeled biologicals. All licensed nurses will be re in serviced on (a)Labeling/dating of Drugs and biologicals-Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles and that the medication room/area or cart contains ONLY drugs, biological or other items needed for the administration of medication. QA: The DNS and administrator developed an audit tool to ensure that all biologicals and drugs stored in medication carts in the facility are labeled in accordance with currently excepted professional principles and that no other medication cart were utilized for storing items, other than medication. 3 random medication carts and/or narcotic boxes will be audited weekly for 3 months for compliance. All negative findings will be corrected immediately and reported to the DON then Administrator. All Audit findings will be reported to QA Committee for evaluation and follow-up. The QA committee will determine a schedule for ongoing audits if deemed necessary. Responsible Person: DON/Designee [DATE] |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility did not ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. This was evident for one (Resident #79) of four residents reviewed for Nutrition. Specifically, Resident #79 was admitted to the facility on [DATE] and was receiving tube feeding via enteral means. The facility did not obtain and monitor the resident's weight since the resident was admitted to the facility. The finding is: A facility policy titled Weight and Weight Changes last updated in (MONTH) 2024, documented to obtain weights on all residents as per the medical doctors' orders. All residents will be weighed within 72 hours of admission and/or readmission to the facility. The resident's weight is rechecked on two consecutive days for accuracy and to verify initial weight; and then weekly for the next four weeks to establish a baseline. Thereafter, monthly weights will be obtained unless otherwise indicated by the Physician, Nurses, or Dietitian. Resident #79 had [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment dated [DATE] documented Resident #79 had a Brief Interview for Mental Status score of 9, which indicated the resident had moderate cognitive impairment. Resident #79 had no behaviors or refusal of care and was dependent on staff for Activities of Daily Living. The Minimum Data Set indicated the resident had an active [DIAGNOSES REDACTED]. The resident's height was 74 inches, and the weight was 172 pounds. Resident #79 was fed via the enteral (tube feeding) route. A comprehensive care plan titled Nutritional Status, effective 8/2/2024 documented the resident had nutritional deficiency and was on gastrostomy tube feeding. The interventions included aspiration precautions, to monitor laboratory values as per physician's orders [REDACTED]. The physician's orders [REDACTED].#79's weight: The admission physician's orders [REDACTED]. The Initial Nutrition Assessment completed on 8/3/2024 documented that the resident's current weight per hospital records was 172 pounds. A request for admission weight was made. The resident received enteral feeding as their primary source of nutrition and hydration and was at risk for malnutrition related to dependence on tube feeding related to dysphagia and a wound. Resident #79 received 1350 milliliters of [MEDICATION NAME] 1.5 (a high-fiber tube feeding formula). The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. A review of the medical record from 8/2/2024 to 8/27/2024 lacked documented evidence that the resident's weights were obtained as per the physician's orders [REDACTED]. Resident #79 was transferred to the hospital on [DATE] at 6:00 PM for evaluation for bleeding around urinary catheter insertion. Licensed Practical Nurse #1 was interviewed on 9/3/2024 at 2:03 PM and stated that the Certified Nursing Assistants are responsible for obtaining the resident's weights. The Certified Nursing Assistant should then verbally tell the Nurse the weight, and the Nurse should enter the information into the medical record. Licensed Practical Nurse #1 stated that for a new admission, the weight is taken on admission and then weekly. Licensed Practical Nurse #1 was not aware that Resident #79's weight was not obtained. Registered Dietitian #1 was interviewed on 9/3/2024 at 2:08 PM and stated that nursing staff is responsible for obtaining the resident's weights on admission and then daily for three days. The Dietitian will enter one-time orders for weights when additional weights are needed. When the resident's weights are missing, it is discussed in the morning meeting, and directly with the unit nurse and the nursing supervisors. Registered Dietitian #1 further stated that several attempts were made to alert the nursing staff to provide weights for Resident #79; however, the weights were never obtained. The Registered Nurse Supervisor was interviewed on 9/4/2024 at 1:05 PM and stated during the morning meeting they instructed the staff to obtain the residents' weights and the unit charge nurse also should have indicated the need for the resident's weights on the certified nursing assistant assignment sheet. They further stated that every nurse needs to make sure that the weights are completed. The Registered Nurse Supervisor was not aware that Resident #79's weights were not obtained. The Acting Director of Nursing Services was interviewed on 9/5/2024 at 10:50 AM and stated the unit nurses should have made sure that Resident #79's weights were obtained as per the physician's orders [REDACTED]. The Acting Director of Nursing Services stated Ultimately, it is everyone's responsibility to ensure that the weights are taken. 10 NYCRR 415.12 (i)(1) | Plan of Correction: ApprovedOctober 2, 2024 Immediate Corrective Action: ?Çó Resident 79 was weighed upon readmission on 9/5- 9/20/24 ?Çó Cna assigned to Resident on 8/2 received educational counseling 9/20/224 ?Çó Cna assigned to Resident on 8/3 received an educational counseling 9/20/24 ?Çó CNA assigned for Resident 8/4 received an educational counseling 9/20/24 Identification of others: All residents who are admitted to the facility are at risk for the same deficient practice. Facility wide census compiling residence with overdue /due admission and monthly weights was reviewed and audited. (9/5/24) All negative findings were corrected. (9/5/24) All nursing staff will be re in-service on ensuring that each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable weight range. Systemic Changes: The chief Dietician and administrator reviewed/revised the policy on weight and weight changes (9/20/24). The policy will now read that an admission weight will be obtained within 48 hours of admission, then weekly for 4 weeks and monthly thereafter. All licensed nurses and CNA's will be re in serviced on the revised weight policy(ongoing). QA: The Dietitian and Administrator developed an audit tool to ensure that all new and re admission weights will be obtained within 48 hours of Admission. Three new admissions per week for three months will be audited for compliance. All negative findings will be corrected immediately and reported to the Administrator. All audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date and title of Responsible Party: Dietician will be responsible for this deficiency. 10/29/24 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all residents received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #256) of one resident reviewed for Pain Management. Specifically, Resident #256 reported left-hand pain on 8/4/2024. The medical provider was contacted and ordered an x-ray of the left hand. Registered Nurse #6 wrote the telephone order in the medical record and erroneously indicated an x-ray order for the right hand. The x-ray of the right hand was completed; however, neither the Medical Doctor nor the Nurse Practitioner reviewed the x-ray results. The facility staff were not aware of the transcription error until it was brought to the facility's attention by the surveyor. The finding is: The facility's untitled and undated policy statement regarding medication administration documented, that the Licensed Nurse may obtain orders from a Physician, a Nurse Practitioner, or a Physician Assistant. Telephone orders must be read back to the medical practitioner to ensure that the order is correct. The facility's undated policy titled, Radiology Services documented, it is the Attending Physician's responsibility to provide a written order for an x-ray. The Licensed Nursing staff are responsible for completing the x-ray requisition form ensuring all pertinent [DIAGNOSES REDACTED]. The Licensed Nurse presents the results to the medical doctor. Resident #256 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data set assessment dated [DATE] documented Resident #256 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Quarterly Minimum Data set documented Resident #256 did not have an upper extremity impairment. The Musculoskeletal Disease Comprehensive Care Plan effective 8/29/2024 documented Resident #256 was diagnosed with [REDACTED]. Interventions included to monitor for pain or swelling of joints, to administer medications as per the medical doctor's orders, and to obtain diagnostic services as per the medical doctor's orders. The Pain Comprehensive Care Plan effective 6/26/2024 documented Resident #256 had the potential for pain. Interventions included to administer medications as per the medical doctor's orders, monitor for effectiveness and side effects, re-evaluate as necessary, and report any redness, pain, or swelling promptly. A Comprehensive Care Plan note dated 8/4/2024 documented Resident #256 complained of pain in their left hand, their index finger appeared slightly swollen, and the resident reported pain to the finger when touched. A Nursing Progress note dated 8/4/2024 documented the resident complained of pain to their left hand. The index finger looked slightly swollen and they had pain when touched. The Medical Doctor and Nurse Practitioner were notified, and an x-ray of the right hand was ordered. A physician's orders [REDACTED].#6, dated 8/4/2024 documented an order for [REDACTED]. The Nurse Practitioner's note dated 8/5/2024 documented they saw Resident #256 to assess the left index finger and trace [MEDICAL CONDITION] (swelling caused by fluid trapped in the body's tissues). The assessment and plan documented [MEDICAL CONDITIONS] (a type of [MEDICAL CONDITION] that is characterized by inflammation and typically affects the middle and last joints of the fingers) and mild gout (a form of arthritis that occurs when high levels of uric acid in the blood cause crystals to form and accumulate in and around a joint). The recommendation was to wait for the x-ray of the left hand. An x-ray report dated 8/5/2024 documented an x-ray of the right hand with three views. The right hand was noted with arthritic changes. There was no documented evidence that the x-ray report was reviewed by the physician or nurse practitioner. Resident #256 was interviewed on 8/26/2024 at 11:21 AM and stated they often had pain in their hands. Resident #256 stated they received [MEDICATION NAME] (Tylenol-drug used to treat pain) for pain. Resident #256 stated they could not recall how long they had the hand pain and did not recall injuring their hands. Resident #256 stated they were told by a nurse (they did not know the nurse's name) that they had Gout and Arthritis which could cause the pain and they received medication for Gout and [MEDICATION NAME] for pain. A Nurse Practitioner's note dated 8/28/2024 documented that Resident #256 had a complaint of pain to their left hand. Resident #256 was to continue [MEDICATION NAME] and have bloodwork to check their uric acid level (an indicator of gout). A second interview was conducted with Resident #256 on 9/4/2024 at 10:30 AM. Resident #256 stated they were having pain in their left hand. Resident #256 stated the index finger on their left hand hurt the most and they could not bend the finger, could not grip anything, or close their hand. Resident #256 stated they asked for and received [MEDICATION NAME] that morning for their left-hand pain. Licensed Practical Nurse #6 was interviewed on 9/4/2024 at 10:48 AM and stated Resident #256 complained of pain in their left hand and was given [MEDICATION NAME] that morning 9/4/2024 at about 8:00 AM. Licensed Practical Nurse #6 stated the resident has a physician's orders [REDACTED].#256 would ask for their pain medication when they are experiencing pain. A nursing progress note dated 9/4/2024 documented that Resident #256 complained of pain to the left hand. Tylenol was administered and the nursing supervisor was notified. Orders were placed for an x-ray of the left hand. A Nurse Practitioner's progress note dated 9/4/2024 documented Resident #256 reported pain to their left hand. There was trace [MEDICAL CONDITION] (swelling caused by fluid trapped in the body's tissues) of #1-#4 digits (the thumb, index finger, middle finger, and the ring finger) of the left hand, no [DIAGNOSES REDACTED] (redness of the skin), and decreased active range of motion (movement using their own muscles) to digits (fingers) at metacarpophalangeal joint (knuckle joint). The Nurse Practioner recommend to obtain an x-ray of the left hand. The Nurse practitioner documented to adding [MEDICATION NAME] (a nonsteroidal anti-[MEDICAL CONDITION] drug) 400 milligrams every twelve hours for forty-eight hours and starting [MEDICATION NAME][MEDICATION NAME] (a steroidal medication used to treat arthritis) in the morning. A nursing progress note dated 9/4/2024 documented the x-ray results of Resident #256's left hand were received and documented left-hand Arthritis. The Nurse Practitioner was notified of the findings. Registered Nurse #6 was interviewed on 9/4/2024 at 12:39 PM and stated they could not recall Resident #256 reporting pain in their left hand on 8/4/2024, whether or not they contacted the Nurse Practitioner, and entered an order for [REDACTED]. Nurse Practitioner #1 was interviewed on 9/4/2024 at 1:21 PM and stated Resident #256 had chronic pain in their left hand. On 8/4/2024 they gave Registered Nurse #6 a telephone order for an x-ray of the resident's left hand. Nurse Practitioner #1 stated they should have ensured the correct order had been placed when they signed off on the order. Nurse Practitioner #1 stated they did not review the right-hand x-ray report when it was received from the Radiologist because they were not informed of the receipt of the results. Nurse Practitioner #1 stated they are supposed to be notified by unit nurses that a radiology report was received. The Nurse Practitioner stated when they give a telephone order, they expect the order to be transcribed accurately. Nurse Practitioner #1 stated they also expect to be notified of the radiology results when received by the facility staff. The Acting Director of Nursing Services was interviewed on 9/5/2024 at 3:47 PM and stated the Registered Nurse is responsible for entering telephone orders as directed by the Physician or the Nurse Practitioner. The Acting Director of Nursing Services stated the Physician or the Nurse Practitioner was also responsible for ensuring the order's accuracy. The Acting Director of Nursing Services stated the unit nurses are responsible for notifying the Physician or the Nurse Practitioner when x-ray reports are received from the vendor company. The Acting Director of Nursing stated the Physician and the Nurse Practitioner were responsible for following up on the radiology results. 10 NYCRR 415.15(b)(2)(iii) | Plan of Correction: ApprovedOctober 2, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: ?Çó resident #256 x-ray of left hand completed. Resident 256 Xray results were reported to attend physician, and a note written in the EMR concerning results (9/4/24). ?Çó Registered nurse number six received an educational counseling on ensuring to follow and repeat doctors telephone orders for accuracy. (9/20/24) ?Çó Medical Director and nurse practitioner, receives educational counseling on reviewing ordered x-rays timely and ensuring that orders given to nursing staff is accurate when signing off on orders. (9/20/24) ?Çó The RN on duty was counseled on notifying nurse practitioner and attending on radiology results when received by the facility staff. (9/20/24) Identification of others: The DON established a list of residents with X-rays ordered by their primary care physician or NP for the past 30 days, no other issues were found. All residents are required to receive Quality of care which is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, all licensed nurses must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. All X-ray telephone orders must be read back to the medical practitioner to ensure its accuracy. Licensed nursing staff are responsible for completing the x-ray requisition form, ensuring all pertinent [DIAGNOSES REDACTED].ÇÖ rationale for ordering the diagnostic service. The license nurse will present the results to the medical doctor. Systemic Changes: A review of the Policy and Procedure on medication administration and radiology services was reviewed and found to be complaint. All licensed nursing will be re in serviced by the DON/designee on the importance of ensuring that the license nurse may obtain orders from a physician or physician, assistant, or nurse practitioner. Telephone orders must be read back to the medical practitioner to ensure that the orders are correct. The licensed nurse?ÇÖs staff are responsible for completing the x-ray requisition form, ensuring all pertinent [DIAGNOSES REDACTED].ÇÖ rationale for ordering a diagnostic service. The license nurse must present all the results to the attending physician. Any issues concerning off or onsite radiology, services or discrepancy in physicians?ÇÖ orders, will be communicated to the appropriate staff and documented in the EMR and reported to the referring MD. QA: The Director of Nursing and administrator developed an audit tool to ensure that the facility adequately provides quality of care and that all licensed nurses ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices and ensure that all telephone orders are carried out by licensed nurses accurately, and that medical doctors and nurse practitioner, receives and reviews the results timely. All telephone orders will be reviewed and checked for accuracy weekly for three months. All results from x-rays will be reviewed to ensure that medical doctors and/or nurse practitioners receive results timely weekly for three months. All negative findings will be corrected immediately. All negative findings will be brought to the DON/Medical Director then reported to the Administrator and addressed immediately. All audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date and title of Responsible Party: The person responsible for this deficiency is the DON/Designee. 10/29/24 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 29, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 9/5/2024, the facility did not ensure that all residents were provided a safe, clean comfortable, and homelike environment. This was identified for two (B Unit and West Unit) of four units reviewed during the environmental task; and for two residents (Resident #48 and Resident #100) of three residents reviewed for the environment task. Specifically, 1) the suction machine on the West Unit dining room was observed with used suction tubing and a dirty suction canister that contained cloudy fluid with food particles, and 2) the privacy curtains for Resident #47 and Resident #100 were observed to be soiled. 3) The hallway bathroom on B Unit and the bathroom in room [ROOM NUMBER] were observed to have a dried brown feces-like substance on the toilet bowl seat. The findings are: The facility's undated policy titled, Department Protocols: Housekeeping Department documented that the purpose of the policy was to prevent infections. Resident rooms and toilets are cleaned daily and when needed. The documented department protocols for terminal cleaning were to remove and clean the drapes and cubicle curtains. The facility's policy for Bathroom Cleaning dated 11/14/2023 documented that housekeepers were to clean each resident's bathroom including all surfaces, toilets, and handrails at least once daily and as needed. The facility's policy for Suction Equipment revised on 6/1/2009, documented that all suction equipment will be cleansed after each use to reduce the possibility of contamination. Procedures include: Licensed Nursing Staff will disinfect a suction bottle or machine by wiping down the suction machine after each use and at the end of each shift; discarding the disposable suction bottle at the end of each shift; replacing the tubing on the suction bottle once each week; and replacing suction tubing between residents. 1 ) On 8/26/2024 at 12:45 PM during the lunch meal observation, the West Unit dining room was observed to have a dirty suction canister that contained cloudy fluid with food particles and used suction tubing attached to the suction machine. Registered Nurse Supervisor #2 was interviewed immediately after the observation on 8/26/2024 and stated the suction machine was not used today and the canister/tubing should have been replaced after every use. Registered Nurse Supervisor #2 stated they were supposed to check the suction machine before each meal I had not checked the machine prior to lunch meal. The Infection Control Registered Nurse was interviewed on 9/04/2024 at 12:16 PM and stated the suction machine should be checked every night by the night shift staff. When the suction machine is used, the nurse should change the canister and the suction tubing after each use. The suction machine should be ready at meal times, in the event there is an emergency. 2) Resident #47 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of six, which indicated severe cognitive impairment. Resident #47 had moderate visual impairment with corrective lenses. During an environmental tour of Resident #47's room on 8/26/2024 at 11:49 AM, Resident #47's privacy curtain was observed with staining along the bottom edge of the curtain and had gray spots and streaks of gray stains throughout the rest of the curtain. Resident #47 stated they could not see the stains on the curtain. During an observation on 8/29/2024 at 4:05 PM Resident #47's privacy curtain was observed with staining along the bottom edge of the curtain and had spots and streaks of stains throughout the rest of the curtain. Resident #100 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, indicating an intact cognition. Resident #100 had adequate vision without corrective lenses. During an environmental tour of Resident #100's room on 8/26/2024 at 12:03 PM, Resident #100's privacy curtain was observed to have a large reddish-brown stain in the middle of the curtain. Resident #100 stated they would like a clean curtain. During an observation on 8/29/2024 at 4:08 PM, The privacy curtain was observed with the same reddish-brown stain. There was no resident in the room at the time of the observation. Certified Nursing Assistant #6, Resident #47's assigned Certified Nursing Assistant, was interviewed on 8/30/2024 at 1:17 PM and stated they saw the stains on Resident #47's privacy curtain but they did not know how long the stains had been there. Certified Nursing Assistant #6 stated they should have reported the stained privacy curtain to the nurse on the unit or the housekeeper so the curtain could be cleaned. Certified Nursing Assistant #6 stated Resident #100 moved to a new room on 8/28/2024 and a new resident moved into the room on 8/28/2024 and was discharged on [DATE]. Housekeeper #1 was interviewed on 8/30/2024 at 1:20 PM and stated they were the assigned housekeeper for the unit and they cleaned all the resident rooms on the unit. Housekeeper #1 stated they are supposed to check the privacy curtains as part of their room cleaning task. Housekeeper #1 stated they did not see the dirty privacy curtain in Resident #47's room, but they should have checked it. Housekeeper #1 stated the privacy curtain in Resident #100's room should have been removed and laundered after Resident #100 moved to another room. Housekeeper #1 stated when a resident moves out of a room the room is cleaned and disinfected, and the privacy curtain is removed and laundered. Licensed Practical Nurse #2, the charge nurse, was interviewed on 8/30/2024 at 1:36 PM and stated they did not notice the dirty privacy curtains in Resident #47's or Resident #100's room. Licensed Practical Nurse #2 stated the resident's privacy curtains should be clean and without stains. Licensed Practical Nurse #2 stated when a resident moves out, the room should be thoroughly cleaned and disinfected, including laundering the privacy curtains before a new resident moves in the room. The Director of Operations was interviewed on 9/3/2024 at 4:50 PM and stated they oversee housekeeping operations and that the housekeepers on the unit are responsible for the cleanliness of resident rooms, including the privacy curtains. The Director of Operations stated the housekeeper would be responsible for removing the privacy curtains and taking them to the laundry room. The Director of Operations stated when a resident moves out of a room, the room should have a terminal cleaning, meaning the room is thoroughly cleaned and disinfected, including the privacy curtains. The Administrator was interviewed on 9/5/2024 at 4:06 PM and stated the resident's privacy curtains should be clean and free of stains. The Administrator stated they expected the privacy curtains to be inspected during daily room cleaning and if they are dirty they should be removed and replaced immediately. 3) During an environmental tour of the B Unit, on 8/29/2024 at 4:26 PM, the resident bathroom in the hallway was observed with a dried brown feces-like substance on the toilet bowl seat. During an environmental tour of the West Unit on 8/30/2024 at 12:53 PM, room [ROOM NUMBER]'s bathroom was observed with a dried brown feces-like substance on the toilet bowl seat. Housekeeper #2, assigned to the B Unit, was interviewed on 8/30/2024 at 1:03 PM and stated they cleaned each resident's room daily and had already cleaned the bathroom in room [ROOM NUMBER] this morning. Licensed Practical Nurse #3 was interviewed on 9/4/2024 at 10:10 AM and stated the housekeepers clean the resident bathrooms every day and as needed. Licensed Practical Nurse #3 stated when the housekeeper had already cleaned the bathroom, and the bathroom was soiled afterward, then Certified Nursing Assistants should have notified the housekeepers to clean the bathroom. The Director of Housekeeping and Maintenance was interviewed on 9/5/2024 at 9:18 AM and stated that it was not acceptable that the toilet seat in the resident's bathroom and the toilet in the hallway were soiled. The Director of Housekeeping and Maintenance stated they would start doing frequent rounds on the floors to ensure the resident environment remains clean. The Director of Nursing Services was interviewed on 9/5/2024 at 1:08 PM and stated it was not acceptable to have a soiled toilet seat in the resident's bathroom and would expect nursing staff to report soiled and dirty toilets and other resident areas to the housekeeping department to maintain a clean environment for each resident. 10 NYCRR 415.5(h)(2) | Plan of Correction: ApprovedOctober 3, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: ?Çó The suction machine on the west unit dining room suction tubing was discarded and changed suction canister replaced (8/26/24) ?Çó Privacy curtain for resident 47 replaced (8/29/24) ?Çó Privacy curtain for resident 100 replaced (8/29/24) ?Çó Hallway bathroom, on B unit cleaned (8/29/24) ?Çó Hallway bathroom in room [ROOM NUMBER] toilet bowl seat cleaned. (8/30/24) ?Çó The nurse 7p-7a assigned to west unit on (8/25) received an educational counseling (9/20/24) ?Çó The Housekeeping Aide on B unit (8/26) received an educational counseling (9/4/24) ?Çó The Housekeeping Aide on West Unit (8/26) received an educational counseling (9/4/24) Identification of others: The Housekeeping Director and the administrator established a list of all resident rooms and bathrooms. The Director of nursing and administrator established a list of all suction machines throughout the facility. All resident bathrooms and hallway bathrooms were checked for cleanliness and found compliant. (9/20/24) All curtains in resident Rooms were checked for cleanliness. All privacy curtains were changed.( 9/7, 9/14). All suction machines on all units and dining rooms were checked for cleanliness.(8/26/24) No other issues found. All housekeeping staff will be required to maintain a safe, clean, comfortable and homelike environment and conduct environmental rounds in all facility areas noted to be deficient. All licensed nursing staff will be required to maintain clean and sanitized suction machines, canisters and tubing for all suction equipment. Systemic Changes: The facilities policy for bathroom cleaning was reviewed and found compliant. All housekeeping staff will be re in service on cleaning each residence bathroom including all surfaces, toilets, and handrails at least once daily and as needed. The total room cleaning log was reviewed and revised to include curtain changed as a column to be checked off when total room cleanings are completed daily and checked by housekeeping supervisor for compliance. All Housekeeping staff was in serviced on new cleaning log (9/13/24). The facilities policy for suction equipment was reviewed and found compliant. All licensed nurses will be re in serviced to disinfect a suction bottle on machine by wiping down the suction machine after each use and at the end of each shift discarding to disposable suction bottles at the end of your shift and replacing the tubing on the suction bottle once each week replacing suction tubing between residents. QA: The Housekeeping director developed an audit tool to ensure that that the necessary housekeeping services are provided to maintain a safe, clean, comfortable, and homelike environment. An audit of all resident bathrooms, hallway bathrooms and privacy curtains was conducted by housekeeping director/designee to ensure compliance. A total of 5 random resident bathrooms and 5 random resident rooms with privacy curtains will be chosen per unit will be completed weekly for 3 months to ensure that the facility is providing necessary housekeeping services to maintain a safe, clean, comfortable, and homelike environment. The nursing Director/designee developed an audit tool to ensure that all suction machines are clean and sanitized and ready for use. Three random suction machines will be checked weekly for three months to ensure that tubing, canisters and suction machines are cleaned and disinfected. All negative findings will be brought to the Housekeeping Director/DON and reported to the Administrator and addressed immediately. All audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary Date and title of Responsible Party: DON will be responsible for the correction of this deficiency. 10/29/24 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: November 4, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.1.6 Minimum Construction Requirements. 2012 NFPA 101: 19.1.6.1 limits existing health care occupancies to the building construction types shown in Table 19.1.6.1 Construction Type Limitations. Table 19.1.6.1 Construction Type limits buildings of Type II (000) building construction to two stories in height and requires complete automatic sprinkler protection. Based on observation, document review and staff interviews, the facility did not ensure that the three-story building was in accordance with NFPA 101 Life Safety Code. Specifically, it could not be verified that the addition building was at least Type II (111) construction type or that it had a fire resistance rated ceiling assembly. This was observed in three of three floors in the addition building of the facility. The findings are: During the Life Safety Code recertification survey, from (MONTH) 27, 2024, to (MONTH) 29, 2024, between 9:00 AM and 5:00 PM, observations of the floor/ceiling assembly above the drop ceiling in the three-story addition building revealed unprotected steel structural members (e.g., joists and beams) not provided with fire proofing, locations include but are not limited to the following areas: the smoke barrier in C Unit on the third floor, the storage closet in the dietitian office on the first floor. In addition, a complete fire resistance rated ceiling assembly could not be verified for the three-story addition building. The lack of adequate fire proofing on steel structural members or not having a complete fire resistance rated ceiling assembly indicates that this three-story building would be considered a Type II (000) unprotected, non-combustible structure. The Life Safety Code prohibits existing health care occupancies from utilizing buildings of Type II (000) construction that are more than two stories in height. On (MONTH) 28, 2024, at approximately 10:30 AM, the Director of Plant Operations stated that no construction work has been performed to address the building construction type deficiency; further stating that the facility implemented the following safety measures: two fire drills per month and placed additional fire extinguishers in the three-story building. Document review of the CMS Time Limited Waiver letter dated (MONTH) 20, 2023, states that a Time Limited Waiver (TLW) to correct the deficiencies for K161, cited on the [DATE] Life Safety Code survey, was approved; the letter indicates that the TLW expired on (MONTH) 09, 2023. Document review of the construction Waiver/Equivalency request dated (MONTH) 12, 2023, indicates that the TLW was requested to address K161 deficiency, which will take ,[DATE] months to complete, with a start date of [DATE] and end date of [DATE]. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings, and stated that they will apply for a waiver. 2012 NFPA 101: 19.1.6, 19.1.6.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedNovember 26, 2024 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action for Residents affected: No residents were affected by the deficient practice. The facility contracted with an outside architect to assess the building regarding the extent of the K-161 construction type deficiency for the building to facilitate a building evaluation which determined that the building is a 2 story NOT a 3-story building, therefore a FSES equivalency is not required at this time([DATE]) Identification of other Residents: All areas containing exposed structural steel were protected with the sprinkler system. All residents could potentially be affected by this deficient practice. Systematic Changes In addition to fire safety measures that are in place (in addition to the sprinkler system), such as smoke detectors, fire alarm system, interior wall and ceiling finishes, two fire drills per month being conducted and the added fire extinguishers. The facility will add Frequencies of visual inspections of the Sprinkler System and Fire Alarm Systems will be increased to bi weekly and documented on a log to ensure the systems and components are in working order. A Fire Watch Training Program will be implemented for 3 months to designated staff and will be in serviced on how to complete and document during each shift to ensure awareness of fire separations and actions needed if a failure should occur. (11/4/24) Documentation on the fire watch/safety rounds will be maintained. The facility has hired an architect to facilitate a building evaluation which determined that the building is a 2 story NOT a 3-story building, therefore a FSES equivalency is not required at this time. QA The Maintenance Director /designee developed an audit tool to ensure that visual Sprinkler system and fire alarm system logs are compliant. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. The Person responsible for the correction of this deficiency is The Maintenance Director/ Administrator (11/4/24) |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: November 6, 2024
Citation Details 2012 NFPA 101: 19.5 Building Services. 2012 NFPA 101: 19.5.1 Utilities. 2012 NFPA 101: 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 2012 NFPA 101: 9.1.3 Emergency Generators and Standby Power Systems. Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2. 2012 NFPA 101: 9.1.3.1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2012 NFPA 99: 6.5.4 Administration (Type 2 EES). 2012 NFPA 99: 6.5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches. 2012 NFPA 99: 6.5.4.1.1.2 Inspection and Testing. Generator sets shall be inspected and tested in accordance with 6.4.4.1.1.3. 2012 NFPA 99: 6.4.4.1.1.3 Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8. 2012 NFPA 99: 15.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2012 NFPA 99: 6.5.4.2 Record Keeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction. 2010 NFPA 110 8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards. 2010 NFPA 110: 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months. 2010 NFPA 110: 8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2). 2010 NFPA 110: 8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. Based on document review and staff interviews, the facility did not ensure that the generator was inspected and tested in accordance with NFPA 99 Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Specifically, there was no evidence that the generator was exercised once every 36 months for four continuous hours, and that a fuel quality test was completed within the last year. This was observed for the only generator serving the facility. The findings are, On (MONTH) 28, 2024, at approximately 1:30 PM, document review of the generator logs did not include a fuel quality test completed within the last year, and a continuous four-hour exercise within the last 36 months. On (MONTH) 29, 2024, at approximately 1:37 PM, the Director of Plant Operations, stated that they will contact the generator's maintenance company for the fuel test results and will search the generator's four-hour exercise. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings, and stated that they will submit the pending documents. No additional documentation was provided to determine that the generator was exercised once every 36 months for four continuous hours, and that a fuel quality test was completed within the last year. 2012 NFPA 101: 19.5, 19.5.1, 19.5.1.1, 9.1.3, 9.1.3.1 2012 NFPA 99: 6.5.4, 6.5.4.1.1, 6.5.4.1.1.2, 6.4.4.1.1.3, 15.5.1.3, 6.5.4.2 2010 NFPA 110 8.3.8, 8.4.9*, 8.4.9.1, 8.4.9.2 10 NYCRR 711.2 (a)(1) | Plan of Correction: ApprovedSeptember 28, 2024 Immediate Corrective Action: The generator was exercised for four continuous hours, and a fuel quality test was completed (9/23/24 ) Identification of others: All residents have the potential to be affected by the same deficient practice. An audit of the generator logs did not include a fuel quality test completed within the last year, and a continuous four-hour exercise within the last 36 months. The Maintenance staff are required to ensure that the generator was inspected and tested in accordance with NFPA 99 Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Systemic Changes: The Administrator and Maintenance Director reviewed the policy entitled Generator Maintenance and deemed it compliant. A predated PM log for the 3 year 4 hour testing and fuel quality testing has been developed to maintain the generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. All Maintenance staff will be in serviced on the importance to maintain the pre-dated PM log which would prompt Maintenance staff to test, maintain and inspect the generator every 36 months for four hours, and to complete a fuel quality test every year for compliance. QA: The Maintenance Director and Administrator created an audit tool that audits the PM Generator Maintenance Log to ensure that the facility is in compliance with the generator testing. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediate, audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits, if deemed necessary. Date and title of Responsible Party: The Director of Maintenance.11-4-24 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: November 4, 2024
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: 110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. (A) Working Space. Working space for equipment operating at 600 volts, nominal, or less and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code. (B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitable guarded. Based on observation and staff interview, the facility did not ensure that its electrical system was in compliance with NFPA 70: National Electrical Code. Specifically, minimum clear spaces for electrical equipment were not maintained. This was noted in one of three floors within the facility. The findings are: On (MONTH) 28, 2024, between 11:00 AM and 12:00 PM, during the Life Safety Code recertification survey, the storage of assorted items, less than 3 ft apart from electrical panels, were observed at the following locations: - The storage room in the dietitian office on the first floor in the addition building. - The server room on the first floor in the west wing. The Director of Plant Operations, who was present at the time of observations, stated that they have told staff to not store anything around the electrical panels, and that they will remove the items around the electrical panels. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings. 2012 NFPA 99: 6.3.2.1 2011 NFPA 70: 110.26 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedOctober 3, 2024 Immediate Corrective Action: ?ÇóAll items observed around the electrical panels in the storage room in the Dietician office on the first floor was removed (8/28/24) ?ÇóAll items observed around electrical panel in the server room on the first floor in the west wing removed (8/28/24) Identification of others: All residents have the potential to be affected by this deficient practice. All storage rooms with an electrical panel, have the potential to be affected by the same deficient practice. The Maintenance staff should ensure that there should be no storage of assorted items less than 3 feet apart from electrical panels. Minimum clear spaces for electrical equipment should be maintained as per state guidelines mentioned in NFPA 70. An audit of all electrical closets was inspected for minimum clear spaces and no other issues were found. (8/28/24) All electrical storage rooms will be locked to ensure that no other staff other than maintenance will have access. All Recreation staff that use the storage room will be re in serviced about the minimum clear space for electrical closets (9/30/24). Systemic Changes: The Maintenance Director and Administrator reviewed the policy Entitled electrical Equipment Closets, and clear spaces and deemed it to be compliant. All Maintenance staff will be re in serviced to ensure that a minimum clear space for electrical equipment is maintained. no items less than 3 feet apart from the electrical panels should be maintained in the storage closet. QA: The Maintenance Director and administrator created a log to ensure that all electrical panels storage closets maintain minimum clear spaces for electrical equipment. 3 random electrical closets will be audited for compliance weekly for three months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits, if necessary. Date and title of Responsible Party: The Director of Maintenance. (11-4-24) |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: November 4, 2024
Citation Details 2012 NFPA 101: 19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4. 2012 NFPA 101: 9.4.6 Elevator Testing. 2012 NFPA 101: 9.4.6.1 Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators. 2012 NFPA 101: 9.4.6.3 The elevator inspections and tests required by 9.4.6.1 shall be performed at frequencies complying with one of the following: (1) Inspection and test frequencies specified in Appendix N of ASME A17.1/CSA B44, Safety Code for Elevators and Escalators (2) Inspection and test frequencies specified by the authority having jurisdiction. 2012 NFPA 99: 15.5.3.4 Elevator Testing. Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighters' emergency operations in accordance with 9.3.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1. (101:9.4.6) 2007 ASME A17.1: 8.11.1.3 Periodic Inspection and Test Frequency. The frequency of periodic inspections and tests shall be established by the authority having jurisdiction. NOTE: Recommended intervals for periodic inspections and tests can be found in Nonmandatory Appendix N. Based on document review and staff interview, the facility did not ensure that the only elevator serving the facility was inspected every six months in accordance with NFPA 101:Life Safety Code and ASME A17.1: Safety Code for Elevators and Escalators. The findings are: On (MONTH) 29, 2024, at approximately 1:49 PM, during the document review part of the Life Safety Code Survey, it was noted that the elevator last inspection was performed in (MONTH) 2023. Notice written in the inspection report indicates: Notice to Passengers - Please advise building management/owner of any malfunction of elevator or if inspection has not been made within six months of current date On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings, and stated that the elevator's maintenance company were supposed to come and do the inspection of the elevator, but has not done it yet due to logistic issues and the location of the facility. On (MONTH) 12, 2024, at approximately 3:28 PM, the Administrator submitted a letter form the elevator company. The letter, dated (MONTH) 2023, states that the most recent date the equipment was examined was during the month of (MONTH) 2023. 2012 NFPA 101: 19.5.3, 9.4.6, 9.4.6.1, 9.4.6.3 2012 NFPA 99: 15.5.3.4 2007 ASME A17.1: 8.11.1.3 10 NYCRR 711.2 (a)(1) | Plan of Correction: ApprovedSeptember 28, 2024 Immediate Corrective Action: The elevator was inspected. (9/23/24) The Maintenance Director was provided with and educational counseling. (9/24/24) Identification of others: All residents have the potential to be affected by the same deficient practice. The Maintenance Director is responsible for ensuring, periodic testing and inspection of the elevator or elevator shall be subject to periodically expect inspections and test as specified in ASME A17.1. Safety code for elevators and escalators. All elevators equipped with fire fighters' emergency operations in accordance with 9.3.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME A17.1. The only elevator serving the facility will be tested every 6 months as per state regulations. Systemic Changes: The Maintenance Director and Administrator reviewed the elevator Testing policy and found it compliant. An Elevator Testing log has been created and added to the PM Manual with preset due date for the next inspection and test of the elevator. All Maintenance staff will be re-in-service on code NFPA101 where it states the facility must have elevators inspected every six months with a written record of the findings made and kept on the premises as required by ASME A17.1. The Maintenance staff will be in serviced on the usage of the Elevator Inspection log and the audit tool and will continue to document inspections on the log. QA: The Maintenance, Director and Administrator created an audit tool to ensure that the elevator is inspected every six months as required by state regulations. All negative findings will be brought to the maintenance Director and reported to the administrator and addressed immediately or what his findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits, if necessary, respond to the party, the Director of maintenance. Date and title of Responsible Party: The Maintenance Director (11-4-24) |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: November 4, 2024
Citation Details 2012 NFPA 101: 9.6.1.3 A fire alarm system required for life safety shall be installed, tested , and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101: 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable 2012 requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2010 NFPA 72: 14.1.2 The inspection, testing, and maintenance of single and multiple-station smoke and heat alarms and household fire alarm systems shall comply with the requirements of this chapter. 2010 NFPA 72: 14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7. 2010 NFPA 72: 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 2010 NFPA 72: 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3. 2010 NFPA 72: 14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. 2010 NFPA 72: 14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer's calibrated sensitivity test instrument (3) Listed control equipment arranged for the purpose (4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction 2010 NFPA 72: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date (2) Test frequency (3) Name of property (4) Address (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number. (6) Name, address, and representative of approving agency(ies) (7) Designation of the detector(s) tested (8) Functional test of detectors (9)*Functional test of required sequence of operations (10) Check of all smoke detectors (11) Loop resistance for all fixed-temperature, line-type heat detectors (12) Functional test of mass notification system control units (13) Functional test of signal transmission to mass notification systems (14) Functional test of ability of mass notification system to silence fire alarm notification appliances (15) Tests of intelligibility of mass notification system speakers (16) Other tests as required by the equipment manufacturer's published instructions (17) Other tests as required by the authority having jurisdiction (18) Signatures of tester and approved authority representative (19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested , device abandoned in place). 2010 NFPA 72: 14.6.3.2 Upon request, a hard copy record shall be provided to the authority having jurisdiction. Based on document review and staff interviews the facility did not ensure that the Fire Alarm System was inspected, tested , and maintained in accordance with NFPA 72, National Fire Alarm and Signaling Code. Specifically, the fire alarm inspection and testing report did not include the smoke detectors' sensitivity test, and the complete Fire Alarm System report was not provided for review. This was observed for the Fire Alarm System serving the whole facility. The findings are: On (MONTH) 28, 2024, at approximately 3:55 PM, during the document review part of the Life Safety Code Survey, it was noted that the Fire Alarm Inspection Report dated 11/15/2023 did not include the sensitivity test in the automatic smoke detection system tests. The report contained a section named Smoke Detectors Sensitivity, with two lines designated as: Sensitivity Range and Sensitivity Value, both lines were marked as N/A for the following locations: Corridor by room B22, corridor by room B26, corridor by room B31 and corridor by room B33, no other location was included in the report. In addition, the report provided for review was incomplete. The report only included four pages out of 56 total pages (as indicated on the report footnote). On (MONTH) 29, 2024, at approximately 1:37 PM, the Director of Plant Operations stated that they will search for the complete report and the last smoke detectors' sensitivity test. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings, and stated that they will submit the pending documents. No additional documentation was provided to determine the smoke detectors' last sensitivity test or manufacturer product specifications indicating the smoke detectors meet the requirements for NFPA 72 sensitivity testing, neither the complete Fire Alarm Inspection report. 2012 NFPA 101: 9.6.1.3 , 9.6.1.5* 2010 NFPA 72: 14.1.2, 14.4.5.3*, 14.4.5.3.1, 14.4.5.3.2, 14.4.5.3.3, 14.4.5.3.4, 14.6.2.4*, 14.6.3.2 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 28, 2024 Immediate Corrective Action: A complete fire alarm inspection was completed which included the smoke detectors' sensitivity test. (11/23/23) The next Annual sensitivity test is now due and will be completed (10/15-10/16/24) The Maintenance Director was provided with and educational counseling. (9/24/24) Identification of others: All residents have the potential to be affected by this deficient practice. An audit of the logbook for Preventative Maintenance, specifically fire alarm system was completed and found compliant. All Maintenance staff will be re-in-serviced on the importance of inspecting and testing the fire alarm system annually and the sensitivity test every 2 years in accordance with NFPA 72. A full report will be made available upon request and inspections will be maintained every year as per state regulations. This test will ensure operational integrity and shall have an approved maintenance and testing program complying with the applicable 2012 requirements of NFPE 70 national electrical code end, national fire alarm and signaling code. Systemic Changes: The Maintenance Director and Administrator reviewed the policy on Fire Alarm Inspections and deemed it to be compliant. The facility will ensure that the Fire Alarm System is inspected, tested , and maintained in accordance with NFPA 72, National Fire Alarm and Signaling Code. Specifically, the fire alarm inspection and testing report will include the smoke detectors' sensitivity test, and the complete Fire Alarm System. An audit tool and log were developed to ensure that the testing and maintenance of the fire alarm system including the soke detectors sensitivity test is maintained yearly and every 2 years according to state guidelines. The log will include pre-set dates in which the fire alarm and smoke detectors sensitivity tests are due for inspections and added to the PM Manual. The Audit tool will ensure that the log is filled out in its entirety and that inspections were completed and that a full report is maintained. The Maintenance staff will be in serviced on the usage of the Fire Alarm Testing log and the audit tool and will continue to document Preventative Maintenance on the log. QA: The Maintenance, Director and Administrator developed a log to ensure the fire alarm inspection and testing report includes the smoke detectors' sensitivity test (every alternate year) and the complete Fire Alarm System report due dates. All negative findings will be brought to the maintenance Director and reported to the administrator and addressed immediately audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if necessary. Date and title of Responsible Party: Director of Maintenance (11/4/24) |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 30, 2024
Citation Details 2012 NFPA 101: 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. Based on documentation review and staff interview, the facility did not ensure that fire drills were held at unexpected times. Specifically, the fire drills conducted during two of three shifts were held at similar times. The findings are: On (MONTH) 28, 2024, at approximately 1:15 PM, during the document review part of the Life Safety Code Survey, record revision of the facility fire drill logs for the past 12 months revealed the following: 1. Six of six drills conducted in the evening shift, 3 PM - 11 PM, were held between 3:05 PM - 5:31 PM. 2. Six of six drills conducted in the night shift, 11 PM - 7 AM, were performed at similar times. Three were held at 11:20 PM, 12:15 AM, 11:30 PM; and the other three at 4:30 AM, 4:15 AM, 4:00 AM respectively. On (MONTH) 29, 2024, at approximately 1:37 PM, the Director of Plant Operations, stated that they will do the drills more spread throughout each shift. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings. 2012 NFPA 101: 4.7.4* 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 28, 2024 Immediate Corrective Action: A fire drill was held at an unexpected time at a different time to what was recorded in the fire drill log (9/24/24) The Maintenance Director received an in service (9/24/24) Identification of others: All residents have the potential to be affected by the same deficient practice. The Maintenance Director is responsible to ensure that fire drills are held at expected and unexpected times on the varying conditions, at least quarterly on each shift according to NFPA101.:4.7.4. An audit of past fire drills was completed and found that they were performed at similar times. Maintenance director is responsible to complete facility fire drills at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. Systemic Changes: The Maintenance Director and Administrator reviewed the fire drill policy and found it to be compliant. Maintenance staff will be re-in-service on the importance to ensure that fire drills are held at unexpected times under variant conditions, at least quarterly on each shift to stimulate the unusual conditions that can occur in an actual emergency in accordance with state regulations. QA: The Maintenance Director and Administrator created an audit tool to ensure that Fire Drills that are logged into the log are held at expected and unexpected times. All negative findings will be brought to the Administrator and addressed immediately audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if necessary. Date and title of Responsible Party: The Director of Maintenance. (11/4/24) |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: October 16, 2024
Citation Details 2012 NFPA101: 19.5.2 Heating, Ventilating, and Air-Conditioning. 2012 NFPA101: 19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications, unless otherwise modified by 19.5.2.2. 2012 NFPA101: 9.2 Heating, Ventilating, and Air-Conditioning. 2012 NFPA101: 9.2.1 Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 90A: 5.4.8.1 2012 NFPA 90A: 5.4.8 Maintenance. 2012 NFPA 90A: 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 2010 NFPA 80: Chapter 19 Installation, Testing and Maintenance of Fire Dampers. 2010 NFPA 80: 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where frequency shall be every 6 years. Based on document review and staff interview the facility did not ensure that the heating, ventilating, and air conditioning (HVAC) system was maintained in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. This was evidenced by the lack of documentation that the fire/smoke dampers installed within the facility were inspected and tested every 4 years. The findings are: On (MONTH) 28, 2024, at approximately 4:10 PM, during the document review part of the Life Safety Code Survey, it was noted that the facility's fire / smoke damper logs were not included in the documents provided for review. On (MONTH) 29, 2024, at approximately 1:37 PM, the Director of Plant Operations stated that they will search for the last fire/smoke dampers report. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings, and stated that they will submit the pending documents. No additional documentation was provided to determine that an inspection of the fire/smoke dampers was performed within the last four years. 2012 NFPA 101: 19.5.2.1, 9.2 2012 NFPA 90A: 5.4.8.1 2010 NFPA 80: 19.4.1.1 10 NYCRR 711.2 (a)(1) | Plan of Correction: ApprovedSeptember 28, 2024 Immediate Corrective Action: The fire/smoke dampers will be inspected and tested (10/5/24) The Maintenance Director received an educational counseling. (9/24/24) Identification of others: All residents have the potential to be affected by the same deficient practice. All Maintenance employees will be re in serviced on the importance of ensuring that the heating ventilating and air conditioning system must maintained in accordance with NFPA 80 standard for fire doors, and other opening protectives and that the fire/smoke dampers installed within the facility, are inspected and tested every four years as per state regulations. Systemic Changes: The Maintenance, Director and Administrator reviewed the policy on the inspection and testing of the fire/smoke dampers and deemed it complaint. A Damper log has been created and added to the PM Manual with preset due date for the next inspection and test of smoke dampers. All Maintenance staff will be re-in-service on the importance of adhering to NFPA 80 the fire and smoke dampers will be inspected and tested every four years the facilities, fire/smoke. It will be maintained for four years and available for review upon request. All Maintenance staff will be in serviced on the usage of the log and the frequency in which the fire/smoke dampers inspection must be performed. QA: The Maintenance, Director and administrator developed an audit tool to ensure that the testing and inspection of the fire/smoke dampers will be completed every four years. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits, if deemed necessary. Date and title of Responsible Party: The Maintenance Director 11/4/24 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 5, 2024
Corrected date: November 4, 2024
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 415.29 Physical environment. The nursing home shall be designed, constructed, equipped, and maintained to provide a safe, healthy, functional, sanitary, and comfortable environment for residents, personnel, and the public. (a) Life safety from fire and other hazards. (1) Buildings and equipment shall be maintained and operated so as to prevent fire and other hazards to personal safety. (i) Grounds and building. Grounds and buildings shall be maintained: (1) in a clean condition free of safety hazards. (j) Housekeeping. (1) The entire nursing home, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment, and furnishings, shall be clean. The facility shall be maintained in good repair including, but limited to buildings, utilities, fixed equipment, resident care equipment and furnishings. Based on observation, document review and staff interview the facility did not ensure that the building was maintained in good repair to prevent hazards to personal safety. Specifically, resident accessible windows' safety mechanisms were not maintained to prevent the window from fully opening, potentially creating a fall hazard to residents, personnel and the public. This was observed in two of three residents' floors in the three-story addition building. The findings are: On (MONTH) 27, 2024, between 11:15 AM - 1:30 PM, during the Life Safety Code recertification survey, it was noted that residents' accessible windows were not provided with an effective mechanism that will prevent the window to be fully opened. Observation of windows in residents' rooms and common areas revealed that screws were installed in the window frames as a safety mechanism; however, when tested , the screws did not provide guard as the windows were able to be opened pass its position. Locations included but not limited to: - Resident room C44 on the third floor - right hand window opened approximately 16 inches and left hand window opened approximately 10 inches. - Resident room C60 on the third floor - right hand window opened approximately 15 inches and left hand window approximately 9 inches. -Day room in the C unit on the third floor, right hand window opened approximately 14 inches; the window on the left opened approximately 11 inches; and the window adjacent to the window Air Conditioning unit opened approximately 8 inches. -Resident room B21 on the second floor - window opened approximately 7 inches. -Day room in the B unit on the second floor, all three windows opened approximately 14 inches. On (MONTH) 27, 2024, at approximately 12:46 PM, the Director of Plant Operations, stated that to the best of their knowledge the windows have not been replaced; the windows have stops installed, and the latches are kept in the locked position; further stating that four staff members from the maintenance department inspect the windows, each member take a nursing unit to inspect and do the necessary repairs when the window go all the way up; and the last time the windows were checked was in (MONTH) 2024. On (MONTH) 28, 2024, at approximately 3:22 PM, the Window Safety Policy was provided for review. The policy, signed 12/22/2023, states the following: - All resident room windows are checked quarterly by maintenance staff. - Each window is to open 3 inches from the sill of the window to prevent windows from opening fully. - Each window has a [MEDICATION NAME] in place to prevent the window from opening fully. -The [MEDICATION NAME] are installed by maintenance department. - Any windows found non-compliant will be serviced immediately by the maintenance department. On (MONTH) 29, 2024, at approximately 2:15 PM, during the exit interview, the Administrator acknowledged the findings. 10 NYCRR (a) (1), (i) (1), (j) (1) | Plan of Correction: ApprovedSeptember 28, 2024 ?Çó Resident room C 44 right- and left-hand window was secured (8/27/24) ?Çó Resident room C60 right hand window and left-hand window was secured (8/27/24) ?Çó The room on the C unit, right hand window and left-hand window and a window adjacent to the window. Air- conditioning unit was secured. (8/27/24) ?Çó Resident room B 21 was secured (8/27/24) ?Çó The room B unit was secured (8/27/24) ?Çó All Maintenance staff received an educational counseling (9/23/24) Identification of Others All residents have the potential to be affected by this deficient practice. An audit of all windows was completed to ensure window safety was enforced. All deficient windows were secured correctly. All Maintenance staff will ensure that the building is maintained in good repair to prevent hazards to personal safety. Specifically resident accessible windows, safety mechanisms. The facility shall be maintained in good repair, including but limited to buildings, utilities, fixed, equipment, resident care, equipment, and furnishings. Systematic Changes The Maintenance Director and Administrator reviewed the policy on window safety and found it to be compliant. A log of all windows throughout the building that fully opens was created in order to document and maintain a PM system to all windows to ensure it is maintained and in good repair to prevent hazards to personal safety. All Maintenance staff will be re-in serviced on the importance of ensuring that the resident accessible windows and safety mechanisms are maintained to prevent the window from fully opening to prevent the risk of potentially creating a fall hazard to residents personal and the public. All Maintenance staff will be in serviced on the window safety log and will continue to monitor and document latches and stops on all windows to prevent the window from fully opening potentially creating a fall hazard to residents, personnel and the public. QA The Maintenance, Director and Administrator developed an audit to ensure that the building is maintaining good repair to prevent hazards to personal safety, specifically window safety. Three random rooms per unit per week will be audited for compliance for three months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately, audit findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits, if necessary. Date and title of Responsible Party: The Director of Maintenance.(11/4/24) |