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NYS Health Profiles
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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 18, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview conducted during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of the two (2) resident unit nourishment rooms. Specifically, in the main kitchen, the dishwashing machine temperature display panel and floors under the dishwashing machine were soiled with food particles or dirt; the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried and contained moisture. In the A-Unit nourishment room, the refrigerator door gaskets were soiled with food particles, and in the B-Unit nourishment room, the refrigerator and floor were soiled with food particles or dirt. This is evidenced by: The following items were noted during observations on 4/17/2025 at 11:15 AM in the main kitchen and unit nourishment rooms. In the main kitchen, the dishwashing machine temperature display panel and floors under the dishwashing machine were soiled with food particles or dirt; the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried and contained moisture. The refrigerator door gaskets in the A-Unit nourishment room and the floor in the B-Unit nourishment room were soiled with food particles or dirt. During interviews on 04/17/2025 at 1:23 PM, Food Service Director #1 stated that it is a joint effort between nursing staff on the unit and the kitchen staff to keep the areas clean. They indicated they had placed a cleaning schedule and checklist for the unit's nourishment areas. They stated they did not have the gasket area on the checklist and would need to add it. They stated that the staff will need to be more diligent in placing the pots and pans away to make sure they are completely dry before doing so. They stated that the dishwasher was not getting to the proper temperature for sanitizing and had to be repaired. They stated that the maintenance director had repaired the dishwasher but needed to clean the area after they had finished. They stated that staff would clean the area and instructed the staff to make sure the dishwasher area was clean after each use. 10 New York Code of Rules and Regulations 415.14(h) | Plan of Correction: ApprovedMay 2, 2025 1. Corrective Action for residents affected by deficient practice: A. Immediately the dishwashing machine display panel and floors under dishwasher were cleaned. B. Nesting pots and pans were rewashed, rinsed, sanitized, and air dried. C. Immediately the refrigerator gaskets and the floors of the nourishment rooms on the units were cleaned. 2. Identification of other residents having potential to be affected by deficient practice: All residents have the potential to be affected by the deficient practice. 3. Systemic changes: A. Cleaning assignment sheets were reviewed and updated to reflect and include dish machine display panel and dish room floors. All dietary staff were educated on the updated changes. Dietary staff were educated on the updated cleaning checklist. B. Dietary staff were educated on proper procedures on manual washing of dishes including allowing food containers to fully air dry prior to stacking and storing. C. Updated the unit nourishment cleaning checklist to include gasket cleaning. Dietary staff were educated on the updated elements of nourishment room cleaning checklist. Housekeeping was educated on the importance of keeping the nourishment floor clean. Dietary staff to review check list on elements and alert housekeeping if nourishment room floor requires additional cleaning. 4. Monitoring corrective action: The food service director or designee will audit cleanliness of dish machine display, dish room floor, nourishment room refrigerators, gaskets, floors, and audit storage area for proper drying procedure weekly for three months. The results of the audits will be discussed at the Quality Assurance Performance Improvement Committee monthly for three months for review and compliance. If non compliance is found during review, the food service director will be instructed to reeducate dietary staff and continue audits for additional three months. 5. The Food Service Director will be the responsible party |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 18, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported during interviews that the facility was short-staffed at times, which resulted d in call bells not being answered in a timely manner with long wait times for care to be provided. An analysis of the actual staffing schedule showed that on 10 occasions from 2/15/2025 to 4/13/2025, the facility did not meet their facility assessment for staffing needs. This is evidenced by: Upon entrance to the facility on [DATE] at approximately 10:00 AM, 86 residents resided in two (2) units. Upon observing and reviewing the Facility Staffing Sheet, nine (9) Licensed Nurses and ten (10) Certified Nurse Aides were on duty. The Facility Assessment, last reviewed on 10/07/2024, documented that the facility's bed capacity was 88. The section titled, Staffing Plan, documented the following: - Day shift required three (3) Registered Nurses, four (4) Licensed Practical Nurses, and 12 Certified Nurse Aides - Evening shift required two (2) Registered Nurses, four (4) Licensed Practical Nurses, and 12 Certified Nurse Aides - Night shift required one (1) Registered Nurse, two (2) Licensed Practical Nurses, and four (4) Certified Nurse Aides - A complete census would require the facility to provide 215.6 hours of direct Certified Nurse Aide care for all residents on that day. A review of staffing sheets provided by the facility from 2/15/2025 through 4/13/2025 documented that they did not meet their assessed minimum staffing on most day and evening shifts, for the following: - On 2/15/2025, the facility census was 83 residents, which required 203.35 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 2/16/2025, the facility census was 83 residents, which required 203.35 hours of direct Certified Nurse Aide care. The facility schedule had 160 hours of direct Certified Nurse Aide care. - On 2/26/2025, the facility census was 87 residents, which required 213.15 hours of direct Certified Nurse Aide care. The facility schedule had 144 hours of direct Certified Nurse Aide care. - On 3/07/2025, the facility census was 88 residents, which required 215.6 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 3/11/2025, the facility census was 88 residents, which required 215.6 hours of direct Certified Nurse Aide care. The facility schedule had 136 hours of direct Certified Nurse Aide care. - On 3/17/2025, the facility census was 88 residents, which required 215.6 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 3/26/2025, the facility census was 85 residents, which required 208.25 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 4/1/2025, the facility census was 85 residents, which required 208.25 hours of direct Certified Nurse Aide care. The facility schedule had 160 hours of direct Certified Nurse Aide care. - On 4/07/2025, the facility census was 84 residents, which required 205.8 hours of direct Certified Nurse Aide care. The facility schedule had 144 hours of direct Certified Nurse Aide care. - On 4/11/2025, the facility census was 83 residents, which required 203.35 hours of direct Certified Nurse Aide care. The facility schedule had 120 hours of direct Certified Nurse Aide care. During a surveyor-led group resident meeting on 4/15/2025 at 10:30 AM, the 7 residents attending the meeting reported insufficient staffing to meet their needs. They often had to wait an extended period of time to get care. They stated staffing was extremely low on weekends when only one (1) or two (2) aides per unit. During an interview on 4/18/2024 at 10:45 AM, Staffing Coordinator #1 stated that a program created the daily schedule via a spreadsheet, created by corporate, that allocated the number of staff personnel per the daily census. They stated that the program does not change, and all they are required to do is input the daily census, and the program would provide the number of Certified Nurse Aides and nursing personnel required. During an interview on 4/18/2025 at 10:45 AM, Director of Nursing #1 stated that they were aware of the federal regulation regarding required hours for Certified Nurse Aides per the census. They stated that the schedule was done by a program created by corporate to determine the number of staff they would require per the daily census. They stated that according to a complete census of 88 residents, the facility was budgeted for six (6) Certified Nurse Aides during the day, six (6) Certified Nurse Aides for the evening, and four (4) Certified Nurse Aides for the night shift. They stated that the staffing would be adjusted when there are call-ins, and they made every attempt to fill in with additional staff. They stated that the pool for additional staffing was relatively small due to their remote location. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedMay 2, 2025 1. The facility currently has ads posted for Certified Nurses Aide positions. The facility will begin offering a Certified Nurse?ÇÖs Aide sign-on bonus for new hires to increase recruitment. Facility will offer all current Certified Nurse?ÇÖs Aide overtime shifts to ensure that open shifts are covered. Due to the remote location of the facility and the lack of sufficient local Certified Aides the facility will increase out-of-state staff recruitment to complement the local Certified Nurse?ÇÖs Aide staff. 2. All residents have the ability to be affected. An audit of alert and oriented residents will be conducted to determine if residents were adversely affected by insufficient staffing in the past quarter. Any issues noted will be addressed by the appropriate discipline. 3. The Administrator, Director of Nursing Services, Human Resources Director and Staff scheduler will be educated on the necessity of meeting the required number of staff per day per section 483.35(a)(1)(2) Sufficient Nursing Staff of the NY State Nursing Home regulations. Following review of the facility assessment, the facility?ÇÖs Certified Nurse?ÇÖs Aide schedule was adjusted to reflect the required number of staff found in section 483.35(a)(1)(2) Sufficient Nursing Staff of the NY state Nursing Home regulations. The facility will offer a sign on bonus for new Certified Nurse?ÇÖs Aide hires and increase recruitment of out of state staff to increase the staff roster. The facility will set up a retention committee to develop strategies to attract and retain staff. The committee will meet monthly and will include management and line staff. 4. The facility will use an audit tool to audit 4 random work-week shifts and an additional 2 random weekend shifts per week for 4 weeks and then per month for 3 months to ensure compliance. The minutes of the retention committee and results of the audits will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and determine if changes were effective and explore other options if not meeting regulations. 5.The responsible party is the Administrator |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 18, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated (Case #NY 414) survey, the facility did not ensure residents were provided the proper treatment and assistive devices to maintain vision for one (1) (Resident #86) of one (1) resident reviewed for vision. Specifically, for Resident #86, the facility did not ensure that the resident ' s glasses were replaced and follow up appointments for optometry were obtained. This is evidenced by: Resident #86 Resident #86 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 3/30/2024 documented the resident usually understood others, sometimes was understood by others, and was severely cognitively impaired. The Minimum Data Set documented the resident had moderately impaired vision and used corrective lenses. A Consult Form dated 5/18/2023 documented the resident had been seen by the optometrist with the next follow-up scheduled for 11/2023. A handwritten note at the bottom of the consult dated 12/5/2023 documented the resident would be seen because their glasses were broken. There was no documented evidence of any other consult forms for optometry services. Record review of an email provided by the facility from the optometry service dated 4/18/2025 documented the resident was not seen by the optometrist following the 5/18/2023 visit. During an interview on 4/18/2025 at 11:15 AM, Director of Nursing #1 did not recall this issue with the resident and stated the resident should have had a follow up appointment and should have received new glasses. 10 New York Codes, Rules, and Regulations 415.12(2)(b) | Plan of Correction: ApprovedMay 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Corrective Action for resident affected by deficient practice: Resident #86 died in the facility on [DATE] without the broken glasses resolved. The staff member who wrote the handwritten note on the bottom of the consult form was instructed to follow the new procedure to formally notify optometrist when glasses are broken and to begin the follow-up process. 2. Identification of other residents having potential to be affected by deficient practice: All residents who need corrective eyewear and/or have vision consults have the potential to be affected. All residents with a care plan for glasses were checked and it was verified those residents have glasses that are in good condition. All vision consults for the last quarter were reviewed and it was determined that there were no recommendations missed or follow ups not scheduled. 3. Systemic changes: A procedure and checklist have been developed by the facility that will ensure that when broken glasses are reported to, or discovered by, staff the optometrist will be notified to add to list for next visit. The checklist serves as a follow-up tool that tracks the broken glasses from notification, to visit, to new or repaired glasses returned to the resident within a timely manner. All nursing staff will be educated on the new procedure and checklist. All staff will be educated to notify unit manager or nursing supervisor when broken glasses are found or reported. All licensed nurses will be educated to review hearing/vision consult paperwork to look for any new orders or recommendations. 4. Monitoring corrective action: All residents with a care plan for glasses will be checked monthly x3 months to ensure that corrective eyewear is present and in good repair. The vision repair checklist will be audited monthly x3 months to ensure that proper follow-up and documentation have occurred when broken glasses are identified and sent for repair or replacement. An audit of all residents with vision consults will be completed monthly x3 months to ensure that no orders or recommendations have been missed. The results of these audits will be submitted to the Quality Assurance Performance Improvement Committee for review and to determine if the need for continued audits, education or a change in procedure is necessary. 5. The Director of Nursing is the responsible party. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include contact information of and The Office of the State Long-Term Care Ombudsman. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Plan, Communication Plan included that names and contact information for Physicians and The Office of the State Long-Term Care Ombudsman. During an interview on 04/22/2025 at 11:45, Administrator #1 stated that the Emergency Plan master copy would be updated with the missing names and contact information identified. 42 Code of Federal Regulations 483.73(c) | Plan of Correction: ApprovedJune 13, 2025 1) The name and contact information for the medical director and the Office of the State Long-Term Care Ombudsman were immediately updated in the Emergency Preparedness Plan. 2) All residents could have been affected by the deficient practice. 3) The name and contact information for the medical director and the Office of the State Long-Term Care Ombudsman were immediately updated in the Emergency Preparedness Plan. 4) When there is a change in name or contact information for any required contact in the Emergency Preparedness Plan, the Plan will be updated. Upon annual review of the Emergency Preparedness Plan, all names and contact information will be reviewed for accuracy and completeness. Person Responsible: Environmental Services Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on observation and interviews during the recertification survey, the facility did not ensure that egress doors were not equipped with a lock or latch the required special knowledge or the use of a tool. Specifically, staff were not able to unlock the gate to the Courtyard, an outdoor resident area, as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 19.2. This is evidenced by: During observations on 04/21/2025 from 1:12 PM, the courtyard gate could not be opened from the exit access side; a resident was present in the courtyard during observations. During an interview on 04/21/2025 at 1:14 PM,(NAME)Rathbun, Registered Nurse #1 stated that the door to the courtyard gate could not be opened from the exit access side. During an interview on 04/21/2025 at 1:58 PM, Environmental Services Manager #1 stated that they would move the slide lock on the courtyard gate door to the exit access side. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.2.2.5 | Plan of Correction: ApprovedJune 13, 2025 1) The slide lock on the courtyard gate door was removed. A new lock was installed. A combination lockbox with key inside for the newly installed lock was put in place. 2) All staff could have been affected by the deficient practice. 3) The slide lock on the courtyard gate door was removed. A new lock was installed. A combination lockbox with key inside for the newly installed lock was put in place. All staff will be educated on the new lock and use of the combination lockbox for means of egress from the courtyard. New staff will be educated as part of orientation during the initial tour of the building and grounds. 4) Each month for 3 months, 3 random staff members will be asked to show how to use the combination lockbox and the new lock as means of egress from the courtyard. The results of this audit will be presented at the facility Quality Assurance Performance Improvement meeting. Person Responsible : Environmental Services Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the recertification survey, the facility did not conduct testing and maintenance protocols on patient care-related electrical equipment in accordance with adopted regulations. Specifically, patient care-related electrical equipment was not tested or inspected prior to being put into service as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 10.3. This is evidenced by: There was no documented evidence that the vital monitor (patient care-related electrical equipment) located near the A-Wing nurse station, was inspected prior to being placed in service. During an interview on 04/22/2025 2:04 PM, Environmental Services Manager #1 stated that the vital monitor was not inspected prior to being placed in use. 42 Code of Federal Regulations 483.70 (a) (1) 2012 NFPA 99 10.3, 10.5.2.1 10 New York Codes, Rules, and Regulations 713-1.1, 711.2 (19) | Plan of Correction: ApprovedJune 13, 2025 1) The vital monitor was inspected by the Environmental Services Manager and the monitor was added to the currect patient care related electrical equipment (PCREE) list. 2) All residents could have been affected by the deficient practice. 3) An audit of the patient care related electrical equipment in use in the building was performed to ensure that all had been properly inspected by the Environmental Services Manager. Education was provided that all new equipment must be inspected prior to being put into use. 4) An audit of all patient care related electrical equipment will be performed annually. An audit of all equipment in use in the building was performed and will be reported to the next Quality Assurance Performance Improvement committee meeting. Person Responsible: Environmental Services Manager |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations. Specifically, the emergency generators test logs did not document the generator transfer times and the percentage of the nameplate under which the monthly full load test was conducted, and the 4-hour load test records did not document engine performance as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: Document titled Generator Weekly/Monthly (test log) and dated from 08/02/2022 through 04/22/2025 did not record: ?? Percentage of the nameplate under which the monthly full load test was conducted. ?? Generator transfer times. Document titled Generator Weekly/Monthly (test log) and dated 06/22/2024, the recorded the three-year four-hour load bank test, did not record the engine performance at one-hour intervals. During an interview on 04/23/2025 at 10:21 AM, Environmental Services Manager #1 stated that they would add the transfer times and the percentage of the nameplate to the record of the monthly load tests, and they would conduct another 4-hour load test to meet the requirements of NFPA 110, including documentation of the engine performance at one-hour increments. 42 Code of Federal Regulations 483.70 (a) (1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedJune 13, 2025 1) The Generator Weekly/Monthly (test log) was updated to include a recording of - Percentage of the nameplate under which the monthly full load test is conducted - Generator transfer times. A 4-hour load test was scheduled with vendor. 2) All residents could have been affected by the deficient practices. 3) The Generator Weekly/Monthly (test log) was updated to include a recording of - Percentage of the nameplate under which the monthly full load test is conducted - Generator transfer times. A three-year 4-hour load test has been completed by vendor and will be added to the Preventive Maintenance Schedule. The Environmental Services Manager was educated on the requirements of the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. 4) The Generator Weekly/Monthly (test log) will be audited for completeness and accuracy for 3 months and the results reported at the facility Quality Assurance Performance Improvement meeting. Person Responsible: Environmental Services Manager |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the emergency plan did not provide documentation about the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. This could affect all residents at the facility. This is evidenced as by: There was no documented evidence that the emergency plan documented a description of the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. During an interview on 04/22/2025 at 12:13 PM, Administrator #1 stated that they would start with the assessment of the resident population and the description of the building emergency services then add a description of the of the resident populations that would be at risk during an emergency event and the type of services the facility had put in place to address their unique vulnerabilities. 42 Code of Federal Regulations: 483.73(a)(3) | Plan of Correction: ApprovedJune 13, 2025 1) A description of the resident population and the services and resources available to care for the residents in the event of an emergency was added to the Emergency Preparedness Plan. 2) All residents sould have been affected by the deficient practice. 3) A description of the resident population and the services and resources available to care for the residents in the event of an emergency was added to the Emergency Preparedness Plan. 4) During annual review of the Emergency Preparedness Plan, we will review and ensure the most up-to-date information is in the plan as it pertains to the resident population at risk and the services the facility can provide to these residents in an emergency. Person Responsible: Environmental Services Manager |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Standard Life Safety Code Survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Plan, Training Program included training in the following most likely hazards as identified by the risk assessment: ?? Transportation Failure, ?? Information Systems Failure, ?? Supply Shortage, ?? Snow Fall, ?? Ice Storm, ?? Temperature Extremes, ?? Epidemic. There was no documented evidence that the Training Program included a demonstration of knowledge for the response to the most likely hazards as identified by the risk assessment as follows: ?? Transportation Failure, ?? Information Systems Failure, ?? Supply Shortage, ?? Tornado, ?? Severe Thunderstorm, ?? Snow Fall, ?? Blizzard, ?? Ice Storm, ?? Temperature Extremes, ?? Epidemic. During an interview on 04/22/2025 at 11:46 AM, Administrator #1 stated that they would update the training program of the emergency plan to include training and a demonstration of knowledge of the most likely hazards identified in the Hazard Vulnerability Analysis. 42 Code of Federal Regulations 483.73(d)(1)(ii) | Plan of Correction: ApprovedJune 17, 2025 1) The Emergency Plan Training Program has been updated to include training with demonstration of knowledge for the most likely hazards as identified by the risk assessment. 2) All residents could have been affected by the deficient practice. 3) The Emergency Plan Training Program has been updated to include training with demonstration of knowledge for the most likely hazards as identified by the risk assessment. Specifically - Transportation Failure, - Information Systems Failure, - Supply Shortage, - Tornado, - Severe Thunderstorm, - Snow Fall, - Blizzard, - Ice Storm, - Temperature Extremes, - Epidemic. All staff will be trained on the appropriate response to these hazards and demonstrate knowledge following the training. The Hazard Vulnerability Assessment will be reviewed and additional training with demonstrated knowledge will be completed for any new hazards identified. 4) Upon annual review of the Emergency Preparedness Plan, we will ensure that training with demonstrated knowledge will be accomplished for all of the most likely hazards as identified by the risk assessment. Responsible Person: Environmental Services Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 04/21/2025 from 10:00 AM through 12:14 PM, smoke detectors were installed within 3-feet of a ventilation ducts in the following areas: ?? Dietary Office. ?? Staffing Office. ?? Finance Office. ?? Administration storeroom. ?? Lobby. ?? Inservice Office. ?? Minimum Data Set Office. ?? Registered Nurse Supervisor Office. ?? Assistant Director of Nursing Office. ?? Director of Nursing Office bathroom. ?? A-Wing tub room. B-Wing tub room. During an interview on 04/22/2025 at 1:10 PM, Environmental Services Manager #1 stated that the smoke detectors in all rooms would be audited and moved if within 3-feet of ventilation ducts. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedJune 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) The vendor was immediately scheduled to move the smoke detectors more than 3-feet from the ventilation ducts in the areas found deficient. 2) All residents could have been affected by the deficient practice. 3) Smoke detectors will be moved more than 3 feet from ventilation ducts in the following areas by completion date: - dietary office, staffing office, finance office, administration storeroom, lobby, inservice office, minimum data set office, registered nurse supervisor office, assistant director of nursing office, director of nursing office bathroom, A-wing tub room and B-wing tub room. A full-building audit was performed to identify any other smoke detectors that may have been within 3 feet from ventilation ducts. The following areas were identified: room [ROOM NUMBER] and small dining room. These 2 rooms have also had the smoke detectors moved more than 3 feet from ventilation ducts. The Environmental Services Manager was educated on the requirements of the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1 4) Should any new smoke detectors need to be installed for any reason, the Environmental Services Manager will ensure they are placed at least 3 feet from a ventilation duct. Person Responsible: Environmental Services Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview during the recertification survey, the facility did not store pressurized oxygen cylinders in accordance with adopted regulations in one of 3 oxygen storage areas. Specifically, empty oxygen cylinders were mixed with full cylinders in the B-Wing Clean Utility room oxygen storage room and empty cylinders were not marked as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition sections 11.6.5.2 and 11.6.5.3. This is evidenced by: During observations on 04/23/2025 at 11:35 AM, empty oxygen cylinders were mixed with full cylinders in the B-Wing Clean Utility room oxygen storage room. During an interview on 04/23/2025 at 11:37 AM, Licensed Practical Nurse #1 stated that the empty oxygen cylinders should not have been mixed with the full cylinders. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 11.6.5 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(26) | Plan of Correction: ApprovedJune 13, 2025 1) Empty oxygen cylinders and full oxygen cylinders were immediately separated. 2) All residents could have been affected by the deficient practice. 3) Education on proper oxygen storage will be completed with all staff who have responsibility for storage, use or movement of oxygen cylinders. 4) Weekly audits of oxygen storage areas will be completed 3x weekly for 3 months and the results of these audits will be reported at the facility Quality Assurance Performance Improvement meeting. Person Responsible: Environmental Services Manager |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations for 2 of 2 resident units. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 04/21/2025 from 10:00 AM through 12:14 PM, emergency lighting along the path of exit discharge was missing from the following areas: ?? Between the A-Wing short corridor and A-Wing long corridor. ?? Between the B-Wing short corridor and B-Wing long corridor. ?? Between the A-Wing long corridor and B-Wing long corridor. Emergency lighting with two fixtures was missing above the exit discharge doors from the Maintenance Shop and Boiler Room. Emergency lighting or emergency lighting that would operate automatically without manual intervention was not provided along the means of egress in the following areas: ?? Therapy gym ?? Outpatient Gym ?? Lobby During an interview on 04/22/2025 at 1:08 PM, Administrator #1 stated that the missing exit lighting would be installed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedJune 17, 2025 1) The missing emergency lighting along the path of exit discharge, emergency lighting with two fixtures above the exit discharge doors, and emergency lighting that operates automatically without manual intervention were all installed. 2) All residents could have been affected by the deficient practice. 3) The missing emergency lighting along the path of exit discharge, emergency lighting with two fixtures above the exit discharge doors, and emergency lighting that operates automatically without manual intervention were all installed. Specifically, emergency lighting along the path of exit discharge was installed between the A-wing short corridor and A-wing long corridor; between the B-wing short corridor and B-wing long corridor; between the A-wing long corridor and B-wing long corridor. Emergency lighting with two fixtures was installed above the exit discharge doors from the maintenance shop and boiler room. Emergency lighting that operates automatically without manual intervention was installed in the therapy gym, outpatient gym and lobby. An audit of all paths of exit discharge, exit disharge doors, and areas requiring emergency lighting to operate automatically without manual intervention was completed and no additional areas were identified requiring emergency lighting. The Environmental Services Manager was educated on the requirement by National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. 4) Emergency lighting along the path of exit discharge will be checked monthly to ensure it is operational and illuminates the path properly. The areas requiring emergency lighting that operates automatically without manual intervention will be checked monthly. All installed lightling will be checked monthly as part of the preventive maintenance program. Person Responsible: Environmental Services Manager |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include strategies for addressing loss of call bell system and care-related emergencies. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the facility emergency preparedness plan developed plans for loss of call bell system and care-related emergencies. During an interview on 04/22/2025 at 12:35 PM, Administrator #1 stated that they would update the emergency plan to include the facility policies and procedures for loss of call bell system and care-related emergencies. 42 Code of Federal Regulations 483.73(a)(1) | Plan of Correction: ApprovedJune 13, 2025 1) The policy and procedure for loss of call bell system was placed in the Emergency Preparedness Plan. The services and care that can be offered to our residents was added to the Emergency Preparedness Plan. 2) All residents could have been affected by the deficient practice. 3) A loss of call bell policy and services that can be offered during care-related emergency was added to the Emergency Preparedness Plan. 4) During the annual review of the Emergency Preparedness Plan we will ensure the most up-to-date call bell policy and any changes to emergency care-related services will be in the Emergency Prepardness Plan. Person responsible: Environmental Services Manager |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 23, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. Specifically, the top of storage was less than 18 inches of the automatic sprinkler system deflectors, sprinkler heads were not free from foreign materials (dust), sprinkler protection was not provided in areas of combustible construction (roof overhang), and dry sprinkler heads were not replaced every [AGE] years as required by the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition section 4.1.6.1 and 4.5.3.1.1.1.6. This is evidenced by: During observations on 04/21/2025 from 10:00 AM through 12:14 PM, combustible storage was within 18-inches of sprinkler deflectors in the administration supply closet and dietary supply room and sprinkler heads were dusty in the following locations: ?? Employee entrance foyer. ?? Therapy Gym. ?? Corridor by room A8. During observations on 04/23/2025 at 11:49 AM, 25 plastic crates were stored under the loading dock roof overhang and the Courtyard roof overhang was wood framing construction; sprinkler protection was not found in these areas. There was no documented evidence that the dry sprinkler head servicing hazardous materials room was replaced within the past [AGE] years. During an interview on 04/23/2025 at 12:35 PM, Environmental Services Manager #1 stated that they would have the dry sprinkler head replaced and add cleaning sprinkler heads and checking for proper storage to their preventative maintenance list. And to eliminate the need to install additional sprinkler protection, they would exchange the wood framing with fire-retardant treat wood and strategize with the dietary department on a new location for the plastic crates. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.7.5 2010 NFPA 13: 8.15.1 2011 NFPA 25: 4.1.6.1, 5.3.1.1.1.6 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedJune 13, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) - Combustible storage within 18-inches of sprinkler deflectors in the administration supply closet and dietary supply room was immediately removed. - Sprinkler heads in the employee entrance foyer, therapy gym and corridor by room A8 were immediately dusted. - Plastic crates were immediately removed from under the loading dock roof overhang. - The wood framing construction of the courtyard roof overhang was removed. - The replacement of the dry sprinkler head servicing hazordous materials room was immediately scheduled. 2) All residents have the potential to be affected by the deficient practices. 3) -Storage closets were audited to ensure no material is stored within 18 inches of sprinkler deflectors. An 18 inch mark will be placed in storage closets to alert staff not to store anything above. - Quarterly audit of all sprinkler heads will be performed to ensure dust free. - Plastic milk crates have been given a different location that is not under the loading dock roof overhang for storage until pickup. - The wood framing construction was removed. - The replacement of the dry sprinkler head is scheduled for (MONTH) 2025. This has been added to the Preventive Maintenance Schedule. - The Environmental Services Manager was educated on the requirement to replace dry sprinkler heads every [AGE] years as required byhe National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition section 4.1.6.1 and 4.5.3.1.1.1.6. 4) - Audits of storage closets will be completed 4x weekly for 3 months. - Audits of sprinkler heads will be completed monthly for 3 months then quarterly going forward. - Audits of materials under the loading dock roof overhang will be performed weekly. - All audits will be reported at the facility Quality Assurance Performance Improvement meeting. Person Responsible: Environmental Services Manager |