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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed 1/8/25, the facility did not store all drugs and biologicals in locked compartments for one (Unit 2 East) of two medication storage rooms. Specifically, 16 medications for 7 residents were left unattended, unsecured on a shelf in the nurse's station. This involved Resident #s 17, 22, 68, 70, 72, 94, and 267. The findings are: The policy titled Ordering and Receiving Medications from the Dispensing Pharmacy dated 11/27/24 documented a licensed nurse receives medications delivered to the facility, immediately delivers the medications to the appropriate secure storage area (medication cart and/or narcotic cabinet) or to another licensed nursing staff member to place in their specific secure storage area on the appropriate unit. During an observation on 1/3/25 at 8:30 AM, the 2 East Nurses Station without a door or means to lock the area, located in the center of the unit near the common area where residents were sitting and no facility staff within visual view revealed the following medications on a shelf: - Resident #17 - 2 unopened bottles (473 milliliters in each) of [MEDICATION NAME] 0. 12% mouth rinse. - Resident #22 - 6 unopened bottles (473 milliliters each) of [MEDICATION NAME] (laxative) and 1 unopened bottle (473 milliliters) of [MEDICATION NAME] 70% (laxative). - Resident #68 - 2 unopened boxes of [MEDICATION NAME] 0. 5 milligram and [MEDICATION NAME] (medications used to open the airways) 3 milligram inhalation (30 vials in each). - Resident #70 - 1 unopened 30-ounce bottle of [MEDICATION NAME] Powder (laxative). - Resident #72 - 2 unopened bottles (355 milliliters in each) of Lanta liquid (antacid). - Resident #94 - 1 unopened box of Refresh tears (eye drops) (2 bottles, 15 milliliters in each). - Resident #267 - 1 opened bottle [MEDICATION NAME] 10% (antiseptic used to clean minor cuts) solution (approximately 400 milliliters remaining). During an interview on 1/3/25 at 9:16 AM, Licensed Practical Nurse #2 observed the medications sitting on the shelf in the nurse's station and stated they should not be stored there because the nurse's station doesn't have a door and residents could freely enter the area, and there was not always an employee at the nurse's station to monitor the area. They stated they didn't know how long the medications had been on the shelf and they should be either in the medication cart, stored in a cabinet or given to the nursing supervisor if they were discontinued to be returned to the pharmacy. They stated they were not sure why or when they were put there and should be locked in a secure area. During an interview on 1/3/25 at 9:17 AM, Unit Manager Licensed Practical Nurse #4 stated they didn't know overflow medications could not be stored on the self in the nurse's station. They stated there were no doors at the nurse's station and there was not always staff at the nurse's station to prevent residents from wandering into the area to prevent them from having access to the medications. Unit Manager Licensed Practical Nurse #4 identified each medication and stated all the identified medications were recently delivered from the pharmacy, except Resident #267's [MEDICATION NAME] was discontinued and Resident #94's refresh tears were brought in by the resident and they should have been given to the Nursing Supervisor to be returned. They stated the facility's process for receiving medications from the pharmacy was the Nursing Supervisor received the medications from the pharmacy and they delivered the medication to the appropriate unit and gave the medication to the staff nurse. The staff nurse usually placed the medication into the appropriate medication cart unless there was no room in the drawer, then the medication was placed on the shelf in the nurse's station until there was room in the medication cart. They stated they didn't know how long the identified medications had been stored on the shelf. During an interview on 1/3/25 at 3:29 PM, Licensed Practical Nurse #3 stated they noticed several medication bottles on the shelf a few days ago but did not look at the medication bottle labels therefore were unable to describe the medications. They didn't know why they were on the shelf. They stated the nurse's station didn't have a door and the medications were not in a secure location and should have been placed in the medication cart. They sated they did not question why the medications were on the shelf and did not inform the Nursing Supervisor. They stated they left the medication bottles on the shelf and should not have. During an interview on 1/8/25 at 7:44 AM, Licensed Practical Nurse #5 stated they had been working at this facility for approximately a year and it had been the facility's process to store the overflow medications that could not fit into the medication cart on the shelf in the nurse's station. They stated there was not any doors at the nurse's station, the shelf was an unsecured location and there was not always an employee at the nurse's station to prevent a resident from access to the medications. They stated they didn't know they could not store medications on the shelf in the nurse's station. During an interview on 1/8/25 at 8:02 AM, Nursing Supervisor Registered Nurse #6 stated the process for receiving medications from the pharmacy, was the Nursing Supervisor received the medications from the pharmacy delivery driver and took the medications to the appropriate unit, gave the medications to the staff nurse, and expected the staff nurse to place the medications into a secure location such as a medication cart or locked cabinet. They stated medications left on a shelf in the nurse's station was not a secure location and should not have been stored on the shelf as wandering residents would have access. During an interview on 1/8/25 at 9:46 AM, the Director of Nursing stated medications should always be stored in a locked secure area and not on a shelf at the nurse's station because the nurse's station was not a locked area and there was not always an employee at the nurse's station to prevent a resident access. They stated there was a medication cabinet on the unit and the nurses should either place all medications into the medication cart or place the overflow medications into the locked medication cabinet. They stated they would have expected the nurses to ensure all medications were stored in a locked secure location. During an interview on 1/8/25 at 10:50 AM, Pharmacy Consultant stated they completed medication storage audits of medication carts and medication cabinets and had not looked at the shelves at the nurse's station because it was not a secure medication storage area, and medications should not be stored there. They stated medications stored on the shelves in the nurse's station potentially allowed a resident access to the medications and would consider this to be a safety issue for residents. 10 NYCRR 415. 18(e)(1) | Plan of Correction: ApprovedFebruary 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F761- Label/store Drugs and Biologicals 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? a. For Resident number 94 the eye drops were removed and ordered directly through pharmacy with patient label b. For Resident number 267 the [MEDICATION NAME] was discarded c. For Residents 17, 22,68,70,72 immediately removed the medications from the unsecure shelf and placed all their medications in their locked med cabinet and or med cart. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. a. All residents who receive medication and or biologicals have the potential to be affected by this deficient practice. b. On (MONTH) 9, 2025 the DON, ADON and Manager of the unit did a complete med audit. This included all shelves in the center of the unit near common areas where residents sit and no medications were found. An audit was also completed on all medication orders as they relate to supplies on hand. (01) 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur. a. Three (3) cabinets on 2 east were identified to use for stock meds and over flow meds. Maintenance installed locks and all stock and over flow medications are now in the 3 locked cabinets located in the common area above the sink off the nurses station. The cabinets are located high on a wall that is in the common area to residents and staff and open to the nurses station, the cabinets will remain locked at all times. They are against the wall above the sink. The cabinets are sufficient to hold any overflow medications which do not fit in the locked medication cart and also for stock meds. No narcotics are stored in this area. The narcotics are kept in a double locked cabinet in the nurses stations. There is no over flow area necessary for narcotics. Nursing staff will unlock and obtain overflow medication/biologicals or stock meds as needed per specific orders for patients, lock the cabinet and bring the medication/biological directly to the respective medication cart to be administered and secured and stored. All RNs, LPNs will be in serviced by our ADON or nurse managers on all aspects of medication administration & storage, including proper receiving of medications and biologicals from pharmacy and the immediate delivery of the medications and biologicals to the appropriate secured storage area. All RNs and LPNs will have the P&P reviewed regarding Medication Cart audits, Medication room audits or medication cabinet audit, medication administration & documentation, storage of medication, and ordering and receiving medications from the dispensing pharmacy. (02) 4. How the corrective action will be monitored to ensure the deficient practice will not reoccur a. Our nurse manager or designee will be completing weekly audits in the common area and nurses station to ensure no medications are in an unlocked area. The manager will also conduct weekly medication cart and storage cabinet audits to ensure there are no discontinued medications. Medication administration audits will also be conducted yearly with each RN and LPNs evaluations to ensure adherence to policy & procedure. (03) b. The nurse manager and or designee is responsible for conducting, medication cart audits, medication room audits, medication storage audits, and audits of any medication storage cabinet and refrigerator storage of medications weekly on all Nursing units within TMR. Any negative findings will be addressed and corrected immediately. The results of these audits are given to quality and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. (04) c. Any negative findings will be addressed and corrected immediately. The results of these audits will be reported by the DON at our Quarterly Quality and Resident Safety Committee for review. d. The pharmacy consultant agreed with the decision for the new location for stock and over flow meds and the security of medications. The pharmacy consultant will audit med storage areas every 2 week until we achieve 100% compliance for 8 consecutive audits. Thereafter, the pharmacy consultant will conduct spot audits and a full audit of med carts and med storage yearly throughout the building. (05) e. The Audits done by the nurse manager and or designee will be done weekly until we achieve 100% compliance over 8 consecutive weeks, after which, the findings will be reviewed by the Quality Assurance Committee for compliance. The Quality Committee will provide us with a schedule to follow for future medication cart and storage cabinet audits throughout the year. Medication administration audits will continue to be conducted yearly with each RN and LPNs evaluations The results of these audits will be given to the Quality Department and to the DON who also reports on them at our Quarterly Quality and Resident Safety Committee for review. f. While the primary responsibility for audits will be the unit manager, weekly audits may be done by a designee. The designee may include the DON, ADON, the Quality Team, other unit manager and or supervisor. The manager of each unit will be responsible for the delegation each week depending on staff schedules. 5. The date of the correction and the title of the person responsible for the correction of the deficiency. Date of Correction: (MONTH) 5, 2025 Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 1/8/25, the facility did not provide routine dental services to meet the needs of each resident for one (Resident #101) of one resident reviewed for dental services. Specifically, Resident #101 had complaints of tooth pain while chewing and was not evaluated by the dentist. The finding is: The policy titled Community Based Care: Dental Care effective date 11/18/21 documented that nursing staff will provide oral health care for each resident, assess resident's oral health upon admission, and obtain routine and 24-hour emergency dental care. Within 14 days of admission, the resident will have a comprehensive oral assessment completed by a dentist or dental hygienist unless refused by the resident. A dental service will perform an oral evaluation annually/as needed and make recommendations for an oral hygiene care plan as necessary for changes in oral/dental status. The physician/dentist will be informed of any changes noted in oral status (pain, swelling, redness, loose teeth, broken teeth, rash, etc.) and recorded in the plan of care and in the resident medical record. Resident #101 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (a Resident Assessment Tool) dated 11/11/24 documented the resident was always understood, always understands, had moderate cognitive impairment, had mouth or facial pain, discomfort or difficulty with chewing, and did not receive routine or emergent dental care. The comprehensive care plan dated 11/6/24 documented Resident #101 had oral/dental health problems related to mouth or facial pain, discomfort, or difficulty with chewing. Interventions included to monitor, document, and report as needed an signs/symptoms of oral dental problems needing attention: pain (gums, toothache, palate), teeth missing loose, broken, eroded, decayed, and ulcers in mouth or [MEDICAL CONDITION]. On 11/18/24 the resident was alert and oriented to person, place and time and could participate in their plan of care. Interventions included to encourage the resident to make independent decisions and to participate in their plan of care as needed. Review of the nursing admission/readmission assessment dated [DATE] completed by Registered Nurse #4 documented Resident #101 had mouth or facial pain, discomfort, or difficulty with chewing. Review of the nursing Progress Notes dated 11/5/24-1/7/25 lacked documented evidence that Resident #101 was seen by the dentist or dental hygienist or that a medical provider was notified the resident had tooth pain. Review of Nurse Practitioner #1's progress note dated 11/8/24 and 11/11/24 documented Resident #101 had chronic back pain and received [MEDICATION NAME] (Tylenol). There was no documentation that Nurse Practitioner #1 was notified of Resident #101's complaint of tooth pain. Review of the document titled Dental Services dated 12/5/24 documented Resident #101 consented for dental services at the facility. The Schedule of Residents to be Seen by the Dentist lists dated 11/18/24 and 12/16/24 did not include Resident # 101. The Schedule of Residents to be Seen by the Dentist list dated 12/2/24 documented Resident #101 was to be seen by the dentist for the purpose of: New Admit. The Schedule of Residents to be Seen by the Dentist list dated 1/6/25 documented Resident #101 was to be seen by the dentist for the purpose of: New Admit (2nd attempt). The Dental Orders and Progress Notes dated 12/2/24 documented New Admission to sub-acute/short term rehab unit. Patient will be seen for acute issues/as needed/or when converted to long term care. Will follow up 30 days. There was a tooth chart at the top of the progress note form that was blank. Review of the Dental Orders and Progress Notes dated 1/6/25 documented new admission Covid-19 positive. There was a tooth chart at the top of the progress note form that was blank. During an observation and interview on 1/3/25 at 8:31 AM, Resident #101 stated they were supposed to be seen by the dentist at the facility, but they have not seen them. They began rubbing their left lower jaw and stated they had a problem with previous dental work that was done and there was a problem with the caps on their teeth. They stated they were having trouble describing the feeling, but then stated it was like a pain but not a pain; it was a sensitivity, and they felt like a dentist needed to look at it. During an interview on 1/7/25 at 12:02 PM, Licensed Practical Nurse #1 stated not all residents on the subacute unit were seen by the dentist. The residents were asked on admission if they would like to see the dentist; they would sign the consent form or sign that they declined to see the dentist. They stated if a resident had told them that they had mouth or tooth pain, they would look in their mouth and then report the resident's complaints to Registered Nurse # 2. During an interview on 1/7/25 at 12:12 PM, Registered Nurse #2 stated when a resident was admitted to the facility, they were asked if they wanted to see the dentist and if they did then they would go on the dental list. They stated they had completed the Dental Services form for consent/declination with Resident #101 on 12/5/24 because they could not find the original consent form that was signed on 11/5/ 24. The Dental Services consent/declination form was not in the chart, and neither were the Dental Progress Notes. They stated after the consent form was signed, the Health Information Management Clerk #1 was notified and placed the resident on the list to be seen by the dentist. During an interview on 1/7/25 at 12:16 PM, Registered Nurse #3 stated they recalled when Resident #101 was admitted they were complaining about the crowns on their teeth hurting and they wanted to see the dentist. They stated they were unsure how often the dentist came into the facility, but they should have seen Resident #101 the month after they were admitted . During a telephone interview on 1/8/25 at 8:19 AM, the Quality Assurance Regional Manager, from the facility's dental contractor, stated the dentist who went to the facility was unavailable, but they would be able to answer questions regarding the process for residents to be seen by the dentist and some resident specific questions. They stated the dental team went to the facility twice a month to see residents, but if there was a more urgent dental problem, they were able to send a dentist sooner if needed. The Health Information Management Clerk #1 was responsible to give a list of any acute dental issues, the new admissions, and discharged residents. The Quality Assurance Regional Manager stated the facility had informed the contracted dental provider not to see any residents who were on the first floor unless there was an acute dental concern because they were subacute residents. Because of that, when there was a new admission on the subacute unit it would be documented on the Dental Orders and Progress Notes: New Admission to sub-acute/short term rehab unit. Patient will be seen for acute issues/as needed/or when converted to long term care. They stated the dental team wrote this as a reminder for themselves to follow up and see the resident within the next 30-60 days. It did not indicate that the resident was seen by the dentist. They expected the facility to let them know when a resident became long term care or had an acute complaint. Acute complaints included any pain or lost dentures; pain was something that would trump everything and the dentist would make sure to see the resident if they had any complaints of tooth or mouth pain. During a telephone interview on 1/8/25 at 8:53 AM, the Quality Assurance Regional Manager, from the facility's dental contractor, stated the dentist was not aware that Resident #101 had any pain or discomfort and if they were aware, it would have been documented on the Dental Orders and Progress Notes and it would have been documented on the Schedule of Residents to be | Plan of Correction: ApprovedFebruary 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F790 Routine/Emergency Dental Services in SNFs 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? a. For Resident 101, Dent Serv was immediately notified of need for patient to be seen for dental pain while chewing, patient was in isolation for COVID and an appointment was made for patient when out of quarantine. Patient was seen by dental service on 1/27/ 25. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. All residents have the potential to be affected by the same deficient practice. b. An MDS report was run on the most recent MDS completed on all in house residents questioning L0200F Mouth or facial pain, discomfort or difficulty with chewing. A look back period went from (MONTH) 2024 to [DATE], 2025. No other residents triggered for this question. ( 01) 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur a. All RNs who complete admission assessments will be in-serviced on P&P CBC-NUR-402 community based dental care and notifying the medical provider immediately of any resident complaints related to mouth or facial pain, discomfort or difficulty with chewing. They will also be in-serviced on placing a call to our dental service to schedule a visit and fill out the Dental visit form with concern for visit and fax to the Dent Serv. ( 02) b. C.N.As and nursing staff will be in serviced to notify the patients primary nurse and or nurse manager if any resident complains of any mouth or facial pain, discomfort or difficulty with chewing ( 03) c. All RNs will be in-serviced to ensure all new admissions sign the dental consent service form, those who wish to receive dental services will be scheduled to have a comprehensive oral assessment by the dentist or dental hygienist within 14 days of admission. ( 04) d. All nursing staff will be in-serviced to add any resident complaints related to mouth or facial pain, discomfort or difficulty with chewing to 24 hour report for Nurse Manager to bring to am report. This will also include the follow up to the medical and dental provider notification. ( 05) 4. How the corrective action will be monitored to ensure the deficient practice will not reoccur a. All new admissions and readmissions will be audited within 72 hrs. of admission by nurse manager or designee to see if dental service consent form is completed, signed and also to see if any resident complains of mouth or facial pain, discomfort or difficulty chewing. (06) b. The DON will run the MDS analyzer report each week to see if there is any resident with any complaints of mouth or facial pain, discomfort or difficulty chewing for appropriate follow up. Any deficient findings would be corrected immediately. (07) c. The ADON will complete an audit to be filled in after am huddle with the name of each resident who is on 24 hour report with complaints of oral pain and note that medical provider and dental provider were notified and follow up visit and care is documented. Any deficient findings would be corrected immediately. (08) d. The results of these audits will be reported by the Director of Nursing at our quarterly Quality and Resident Safety committee for review. These audits will continue until we achieve 100% compliance for 8 consecutive weeks. 5. The date of the correction and the title of the person responsible for the correction of the deficiency Date of corrections: (MONTH) 5, 2025 Person Responsible: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 1/8/25, containers of alcohol-based hand sanitizer in an aggregate amount of greater than ten gallons were stored in a single smoke compartment outside of a flammable liquids storage cabinet. Storage did not meet the requirements of the 2012 edition of National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code. This affected one of one basement. The finding is: Observation in the basement on 1/2/25 at 11:42 AM revealed 54, 1. 2-liter containers of alcohol-based hand sanitizer were stored on open shelving in the Main Storage Room. The labels indicated the products were 76 percent alcohol. This totaled 64. 8 liters, equivalent to 17. 1 gallons. During an interview on 1/7/25 at 2:50 PM, the Administrator stated the facility was without a Director of Plant Operations from (MONTH) 2024 until January 2025. In that time, another person took over ordering supplies and they must have kept the standing order going, which resulted in a greater than usual amount of alcohol-based hand sanitizer stored in the basement. Additionally, on 1/7/25 at 3:30 PM, the Administrator stated the facility did not have a policy regarding the storage of alcohol-based hand sanitizers. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2. 6, 8. 7. 3. 1(1) 2012 NFPA 30: 4. 3. 1, 9. 6, 9. 6. 2, 9. 6. 2. 1, Table 9. 6. 2. 1, 9. 6. 2. 2 | Plan of Correction: ApprovedFebruary 5, 2025 Corrective action for affected area: The excess alcohol-based hand sanitizer was removed from the Main Store room. Identification of other areas potentially affected: all residents have the potential to be affected by the same deficient practice, all storage areas were checked for alcohol-based hand sanitizer. Steps to prevent further recurrence: Measures to be put in place include monthly audit of Main Store room to monitor amount of alcohol-based hand sanitizer in stock. Updated policy implemented to ensure safe use and storage of alcohol-based hand sanitizer. Maintenance staff will be educated to ensure containers of alcohol-based hand sanitizer in an aggregate amount of greater than ten gallons are not stored in a single smoke compartment outside of a flammable liquids storage cabinet. How corrective action will be monitored: Monthly audit will be reviewed by administration and reported to the Quality assurance committee. Director of Plant Operations will be responsible to ensure compliance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 1/8/25, a delayed egress door locking mechanism did not release to open the door after 15 seconds, as designed. This affected one (first floor) of two resident use floors. The finding is: The policy and procedure titled Fire and Egress Door Inspection and Maintenance, effective 11/5/24, documented delayed egress doors shall be tested on a regular basis to ensure they properly release when pressure is applied and door alarm sounds as designed. Should any door fail to operate as designed when tested , the Administrator shall be notified immediately. The item shall be repaired promptly and interim life safety measures put into place. Observation on the first floor on 1/6/25 at 1:10 PM revealed a delayed egress locking mechanism (a timed-release, magnetic locking mechanism) was attached to both doors in the set of doors outside of the Physical Therapy Gym, on the left side. Both doors were equipped with signs that read, Emergency Exit Push Until Alarm Sounds Door Will Open in 15 Seconds. At this time, the Director of Plant Operations from a sister facility attempted to test the delayed egress locking mechanism by pushing on the crash bar of the door on the right in the set. An audible alarm sounded, but the door did not open upon pushing the crash bar for at least 30 seconds. At the time of the observation, the Director of Plant Operations from a sister facility stated the door should have opened after 15 seconds and they were not sure why it did not. Review of the log titled Exit Door Delayed Egress Testing revealed the facility's eight doors with delayed egress mechanisms were tested for proper function of the alarm weekly and tested for proper function of the 15 second door release monthly. Further review revealed the most recent monthly test occurred on 12/20/24 and the most recent weekly test occurred 12/26/24, and all doors were listed as pass on those dates. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2. 1, 19. 2. 2. 2. 4, 7. 2, 7. 2. 1. 6. 1, 7. 2. 1. 6. 1. 1 | Plan of Correction: ApprovedJanuary 31, 2025 Corrective action for Affected Area: Physical Therapy gym doors were repaired on 1/6/ 25. Identification of other areas potentially affected: All residents have the potential to be affected by the same deficient practice. All of the facilities delayed egress door locking mechanisms were audited and are in working order. Steps to prevent further recurrence: Maintenance staff were reeducated on exit door delayed egress testing. Weekly testing of exit door alarms with delayed egress is occurring. How corrective action will be monitored: Director of Plant Operations will conduct monthly audits on each door to assure delayed egress doors are working properly. Results will be reported to the quality assurance committee. Director of Plant Operations will ensure compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 1/8/25, patient care related electrical equipment was not inspected and tested per manufacturer's recommendations. This affected two (suction machine and portable resident lift) of four pieces of electrical equipment reviewed for compliance with patient care related electrical equipment regulations. The findings are: The policy and procedure titled Electrical Safety Program - Portable Equipment, effective 3/28/24, documented new and existing portable electrical equipment used within the organization must be UL (Underwriters Laboratory) listed, meet the manufacturer's recommendations for inspection, if any, and be inspected in accordance with this policy. Clinical Engineering will inspect portable medical equipment before being put into service for the first time and after repair. Re-inspection shall occur based upon the risk classification and corresponding inspection frequency assigned by Clinical Engineering per manufacturer and New York State guidelines. 1. The Operation, Maintenance and Service Manual for Brand A suction machines documented the air filters and gasket should be checked or replaced at a minimum of at least once a year. In order to access the air filters and gasket, five(NAME)head screws must be removed from the top cover of the pump. The manual also provided instructions for replacement of valves and diaphragm, which required removal of four socket head machine screws that held the pump head in place. The manual did not indicate a frequency for valve or diaphragm check or replacement. Observation on the first floor on 1/2/25 at 10:15 AM revealed a Brand A suction machine was located on the crash cart in Unit 1 East. The suction machine had two stickers from an outside contractor who specialized in inspecting and testing medical equipment. One sticker provided an inventory number and the other sticker indicated the next preventative maintenance was due (MONTH) 2025, although did not indicate the date of the most recent preventative maintenance. During an interview on 1/7/25 at 9:10 AM, the Director of Plant Operations stated an outside contractor maintained the suction machines in the facility, and in-house maintenance staff did not perform any maintenance on them. The Director of Plant Operations also stated they spoke to the outside contractor earlier today and the outside contractor reported that although stickers appeared on the suction machine in Unit 1 East, they had no record of the device in their inventory and had no record of any inspection of the device. The outside contractor told the Director of Plant Operations that their employee may have placed the stickers on the device without following proper inspection procedures. During an interview on 1/7/25 at 2:05 PM, Registered Nurse #5 stated nursing staff would not take the suction machine apart to check, clean or replace the internal air filter, gasket, valve, or diaphragm. 2. The Preventive Maintenance Schedule for Brand B portable Hoyer-type resident lifts documented items to be checked every twelve months that included the condition of the friction discs and bushings, friction assembly, all external parts for damage, cracks, or sharp edges, battery, lifting straps, gap between T-piece flange and jib, torque tightening check, jib pivot force check, a test of the automatic cut-out function, a test of the immediate stop facility, a test of the system failure wind down facility, and verification of width of the legs. Observation on the first floor on 1/2/25 at 11:00 AM revealed a Brand B portable Hoyer-type resident lift was located in the 1 West Unit. The lift had two stickers from an outside contractor who specialized in inspecting and testing medical equipment. One sticker provided an inventory number and the other sticker indicated the next preventative maintenance was due (MONTH) 2025, although did not indicate the date of the most recent preventative maintenance. Review of the outside contractor's Service History Report for the Brand B lift on 1 West Unit revealed it was last inspected on 11/15/ 23. During an interview on 1/6/25 at 8:35 AM, the Director of Plant Operations stated an outside contractor maintained the lifts in the facility, and in-house maintenance staff did not perform any maintenance on them. During an interview on 1/7/25 at 11:15 AM, the Director of Long Term Care Facilities stated they believed the outside contractor who inspected and tested the facility's medical equipment came automatically and their visits did not need to be scheduled by any facility staff member. They stated they were unaware that the twelve-month preventative maintenance on the lift was overdue. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 99: 10. 5, 10. 5. 3, 10. 5. 3. 1. 2, 10. 5. 6, 10. 5. 6. 1, 10. 5. 6. 2, 10. 5. 6. 2. 1, 10. 5. 6. 2. 2, 10. 5. 6. 3 | Plan of Correction: ApprovedFebruary 5, 2025 What corrective action will be accomplished. The suction machine on 1 East Unit and the Hoyer-type resident lift on 1 West unit have been removed from service and will not return to service until have preventative maintenance is completed. All residents have the potential to be affected by the same deficient practice. Facility suction machines and Hoyer-type resident lifts will be audited by outside contractor beginning (MONTH) 3, 2025 to ensure that timely preventative maintenance has occurred. Measures to be put into place include audit of facility suction machines (monthly) and Hoyer-type resident lifts (weekly) to ensure preventative maintenance has occurred. Maintenance staff will be educated to ensure suction machine and portable resident lift are inspected, tested , and maintained per manufacturer's recommendations. Facility will maintain documentation for their inspections, testing and maintenance. How the corrective action will be monitored: The audits will be reviewed by Administration and reported to the Quality Assurance Committee. Plant Operations Director will be responsible to ensure compliance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 1/8/25, the emergency generator was not maintained. Issues included undocumented monthly load tests, undocumented weekly generator checks, a four-hour continuous generator run was not completed every 36 months, main and feeder circuit breaker inspection was not completed annually, and it was unknown if the generator meet 30 percent of its nameplate kilowatt rating during load tests. This affected the emergency generator that provided emergency backup power to two (first floor, second floor) of two resident use floors and the basement. The findings are: Observation in the basement on 1/2/25 at 11:25 AM revealed the emergency generator was located in the Generator Room and was powered by diesel fuel. 1. Review of written generator maintenance records revealed the generator was exercised under load each month in 2023 and the last load test was completed on 12/28/ 23. The records indicated no load tests since that date. 2. Review of written generator maintenance records revealed the generator was visually inspected each week in 2023. The records indicated no weekly checks since December 2023. 3. Review of written generator maintenance records revealed no documentation that the generator had been run under load for four continuous hours in the last 36 months. 4. Review of written generator maintenance records revealed no documentation of an inspection of the main and feeder circuit breakers. 5. Review of written generator maintenance records revealed the generator's nameplate rating was 350 kilowatts. There was no documentation that the generator reached 30 percent of the nameplate rating or maintained minimum exhaust gas temperatures as recommended by the manufacturer during load tests. During an interview on 1/3/25 at 10:20 AM, the Director of Plant Operations stated they had just started working at this facility this week, and they would expect all monthly load tests and weekly checks of the generator to be documented. They further stated at this time, they could not locate any generator maintenance records from 2024. Additionally, on 1/6/25 at 10:20 AM, the Director of Plant Operations stated they could not locate documentation that a four-hour continuous generator run under load occurred in the last 36 months and they did not know if the generator met 30 percent of the nameplate rating during load tests, as it was not indicated on the written records. During an interview on 1/6/25 at 11:25 AM, the Administrator stated the facility was without a Director of Plant Operations from (MONTH) 2024 until January 2025. They stated the responsibility of maintaining the generator belonged to the Director of Plant Operations, but during the time the facility had no Director of Plant Operations, the responsibility fell on the Administrator. The Director of Plant Operations from a sister facility came in as much as they could to help, but they were not specifically assigned generator maintenance duties. Additionally, the Administrator stated they were confident that the generator was maintained in 2024, but the records could not be located. During an interview on 1/7/25 at 11:05 AM, the Director of Long Term Care Facilities stated the main and feeder circuit breaker inspection was scheduled to be done by an outside contractor in November 2024. The outside contractor postponed the service. They stated a new date for the main and feeder circuit breaker inspection had not yet been scheduled, but was in-process. The Director of Long Term Care Facilities also stated it was unknown if the generator met 30 percent of its name plate rating or if it maintained minimum exhaust gas temperatures as recommended by the manufacturer during load tests. They also stated load bank testing had not been performed on this generator. During an interview on 1/7/25 at 3:30 PM, the Administrator stated the facility did not have a policy regarding generator maintenance, but they followed manufacturer's instructions. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 5, 19. 5. 1. 1, 9. 1, 9. 1. 3, 9. 1. 3. 1 2012 NFPA 99: 6. 5, 6. 5. 1, 6. 4. 1, 6. 4. 1. 1. 6. 1, 6. 5. 4. 1. 1. 2, 6. 4. 4. 1. 1. 3, 6. 4. 4. 1. 2. 1 2010 NFPA 110: 4. 4, 4. 4. 1, 4. 4. 2, 8. 3. 3, 8. 3. 4, 8. 3. 4. 1, 8. 4, 8. 4. 1, 8. 4. 2, 8. 4. 2. 3, 8. 4. 9, 8. 4. 9. 1, 8. 4. 9. 2 | Plan of Correction: ApprovedMarch 4, 2025 Corrective Action for Affected Area: Load test was completed (MONTH) 29, 2025, and weekly visual inspections began week of (MONTH) 20, 2025. The generator is scheduled to be run under load for four continuous hours on (MONTH) 20, 2025, at this time the load bank test will reach its 30% as listed on the name plate Inspection of the main and feeder circuit breakers is scheduled for (MONTH) 17, 2025. All residents have the potential to be to be affected by the same deficient practice, steps to prevent recurrence include weekly visual inspection of generator, a 30 minute load test occurred (MONTH) 29, 2025 and will occur monthly. The generator is scheduled to be run under load for four continuous hours on (MONTH) 20, 2025. Inspection of the main and feeder circuit breakers is scheduled for (MONTH) 17, 2025. Steps to Prevent Recurrence: Weekly and monthly generator audit/log forms which include weekly inspection and monthly load are being utilized. Maintenance staff will be educated to ensure monthly generator load test are completed and documented, weekly generator checks are completed and documented, the generator is run under load for four continuous hours every 36 months and documented, an annual load bank test is completed on the generator and documented, and main and feeder circuit breaker inspection is completed annually if the generator does meet 30 percent of its nameplate kilowatt rating during load tests. How Corrective Action Will be Monitored: The audits will be completed to ensure the generator is run under load for four continuous hours every 36 months and documented, an annual load bank test is completed on the generator and documented and main and feeder circuit breaker inspection is completed annually if the generator does meet 30 percent of its nameplate kilowatt rating during load tests Audits will be reviewed by Administration and reported to the Quality Assurance committee. Plant Operations Director will be responsible to ensure compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 1/8/25, the Firefighter's Service in the elevators was not tested monthly. This affected two (Elevators A and B) of two elevators that served two (first floor, second floor) of two resident use floors and the basement. The finding is: Observation during the facility tour on 1/2/25 from 9:00 AM to 12:15 PM revealed the facility had two elevators, and each served the basement, first floor, and second floor. During an interview on 1/3/25 at 8:10 AM, the Director of Plant Operations stated both elevators were equipped with Firefighter's Service. They also stated members of the in-house maintenance staff were testing Firefighter's Service on a monthly basis, but had not been recording it. Additionally, the Director of Plant Operations stated they had just started working at this facility this week, and they would expect the Firefighter's Service testing to be documented. During an interview on 1/6/25 at 11:25 AM, the Administrator stated the facility was without a Director of Plant Operations from (MONTH) 2024 until (MONTH) 2025 and they were not sure about testing of the elevators' Firefighter's Service during that time. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 5. 3, 9. 4. 2, 9. 4. 3, 4. 5. 8, 4. 6. 7. 5 | Plan of Correction: ApprovedFebruary 5, 2025 Corrective Action for Affected Area: Director of Plant operations completed Firefighters Service on both elevators. Identification of other areas potentially affected: all residents have the potential to be affected by the same deficient practice. Both elevators had firefighters service completed. Steps to prevent further recurrence: Monthly audit to occur to ensure firefighters service is completed. Maintenance staff will be educated to ensure the firefighter's service is tested and documented for all of the facility elevators. How Corrective Action Will be Monitored: Monthly audits will be reviewed by Administrator and reported to quality assurance committee. Director of Plant operations will be responsible for compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 8, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 1/8/25, required exit signs did not correctly indicate the egress path. This affected two (first floor, second floor) of two resident use floors. The finding is: 1a. Observation in the second floor Activities Suite on 1/2/25 at 9:40 AM revealed there was an illuminated exit sign mounted perpendicular to the suite entrance. Further observation revealed the word Exit was illuminated on both sides, with no chevrons lit on either side to indicate the path of egress was through the suite entrance. Without the chevrons lit, the sign indicated path of egress was into the Activities Room at one end of the suite, which had no egress, or into the Conference Room at the other end of the suite, which allowed access to the Center Stairway through a different door and corridor. At the time of the observation, the Director of Plant Operations stated the most direct egress route from this part of the suite was through the main suite entrance and the chevrons on both sides of the sign above the main suite entrance should be illuminated. 1b. Observation on the first floor in the 1 West Unit on 1/2/25 at 9:55 AM revealed the north and south stairways had illuminated exit signs mounted perpendicular to the stairway entrances. Further observation revealed the word Exit was illuminated, with no chevrons lit to indicate the path of egress was into the stairway. Without the chevrons lit, the sign indicated the path of egress was at the end of the corridor, which had no egress. At the time of the observation, the Director of Long Term Care Facilities stated many illuminated exit signs in this facility were replaced about four to five months ago. Also at this time, the Director of Plant Operations stated the chevrons pointing to the stairways should be lit because the stairways had exterior doors. 1c. Observation on the first floor in the 1 East Unit on 1/2/25 at 10:15 AM revealed the north and south stairways had illuminated exit signs mounted perpendicular to the stairway entrances. Further observation revealed the word Exit was illuminated, with no chevrons lit to indicate the path of egress was into the stairway. Without the chevrons lit, the sign indicated the path of egress was at the end of the corridor, which had no egress. 1d. Observation on the second floor in the 2 West Unit on 1/2/25 at 3:40 PM revealed the north and south stairways had illuminated exit signs mounted perpendicular to the stairway entrances. Further observation revealed the word Exit was illuminated, with no chevrons lit to indicate the path of egress was into the stairway. Without the chevrons lit, the sign indicated the path of egress was at the end of the corridor, which had no egress. During an interview on 1/7/25 at 2:52 PM, the Director of Plant Operations stated they could not locate any documented checks of illuminated exit signs. During a telephone interview on 1/7/25 at 2:55 PM, Maintenance Technician #1 stated to the Director of Plant Operations that they checked illuminated exit signs every week and the Administrator had the records. During an interview on 1/7/25 at 3:30 PM, the Administrator stated they could not locate any documented checks of illuminated exit signs. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 2. 10. 1, 7. 10, 7. 10. 1, 7. 10. 1. 1, 7. 10. 1. 2, 7. 10. 1. 2. 1, 7. 10. 1. 5, 7. 10. 1. 5. 1 | Plan of Correction: ApprovedJanuary 31, 2025 Corrective action for affected area: plant operations director corrected activities suite, 1 west Unit north/south stairway, 1 East Unit north and south stairway and 2 West Unit north and south stairways exit sign chevrons so they illuminated and indicate the path of egress. Steps to prevent further recurrence: A walk through of facility has been conducted to identify any exit signs that needed adjustment, any needed corrections were made. Steps to prevent further recurrence: use of a monthly exit sign audit where auditor ensures the sign reflects the correct direction. Maintenance staff will be educated on the importance of ensuring the illuminated exit signs properly identify the path of egress. How corrective Action Will be Monitored: Audits will be reviewed by administration and reported to the quality assurance committee. Plant operations director will be responsible for correction |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: N/A
Corrected date: N/A
Citation Details Details not available | Plan of Correction: N/A Plan of correction not approved or not required |