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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 2 of 2 residents (Residents #43 and #57) reviewed. Specifically, Resident #43 did not have medication-specific interventions for the use of anticoagulants (blood thinner), and Resident #57 did not have a comprehensive care plan for the use of a chair alarm. Findings include: The facility policy, Care Plans-Specific Writing Guidelines, last revised 11/2017, documented the facility would develop a care plan specifically tailored to each individual based on person-centered care. Care plans would be updated and reviewed quarterly, annually, and after any significant change in condition. The facility policy, Alarm Use, effective in 2000 documented if alarms were determined to be an appropriate intervention an individualized person-centered care plan would be implemented and would be communicated on the certified nurse aide information sheets. The facility policy, Care Plans-General Development, last reviewed in 2023, documented baseline care plans included instructions needed to provide effective person-centered care and standard care and included medications. Each care plan would consist of four parts: focus details/problem/potential problem, goals, interventions/approaches/preferences, and notes/evaluation/reviews. 1) Resident #57 had [DIAGNOSES REDACTED]. The 1/3/2025 Minimum Data Set assessment documented the resident had intact cognition, required partial/moderate assistance with bed mobility and transfers, had no falls, and did not use a chair alarm. The 8/5/2024 Comprehensive Care Plan documented the resident was at risk for falls related to impaired mobility and balance deficit. Interventions included anticipate resident needs, use appropriate assistive device and level of assistance as recommended, and provide education on wheelchair safety. Interventions did not include the use of a chair alarm. The resident's undated certified nurse aide information sheet did not document the use of a chair alarm. During an observation and interview on 1/6/2025 at 12:57 PM, the resident was sitting in their wheelchair with a chair alarm attached to their shirt. They stated they had never had a fall. They stated staff attached a chair alarm to them when they were in their wheelchair. During an interview on 1/13/2025 at 9:32 AM, Certified Nurse Aide #21 stated they looked at residents certified nurse aide information sheets to know how to care for a resident. It was the nurse's responsibility to keep the information sheet updated with accurate information and if they noticed it was not accurate, they would notify the nurse manager. Residents who forgot to ask for assistance or had a lot of falls would use bed or chair alarms which were listed on the certified nurse aide information sheet and the care plan. They cared for Resident #57 during the day shift on 1/6/2025 and did not recall the resident using a chair alarm. It was not in their care plan or on their certified nurse aide information sheet so the resident should not have one in place. They stated it was important for care plans to be updated with accurate information so Resident #57 received proper care and were safe. During an interview on 1/13/2025 at 9:50 AM, the Director of Education/Infection Control Nurse #22 stated they passed medications on unit F on 1/6/2024 during the day shift. Staff should look at a resident's certified nurse aide information sheet or care plan to know how to care for a resident, and both had the same information. The Registered Nurse Managers were responsible for reviewing and updating resident care plans with accurate information and they were reviewed quarterly and as needed. Chair alarms were used for residents who forgot to ask for assistance or were high fall risks. They did not recall Resident #57 having a chair alarm on 1/6/2025 and they should not have been using one because it was not on their care plan. It was important to keep care plans updated with accurate information so Resident #57 received proper care and was safe. During an interview on 1/13/2025 at 10:15 AM, Registered Nurse Manager #23 stated staff would look at resident's care information sheets or care plans to know how to care for them. They contained their activities of daily living, transfer status, diet, toileting schedule, and safety information like bed and chair alarms. They were responsible for reviewing and updating care plans quarterly and as needed. Chair alarms were used for fall safety and for residents who forgot to ask for assistance and required a physician order. Resident #57's care plan did not include a chair alarm so they would have expected their staff to not initiate one without coming to them first and were not aware Resident #57 had a chair alarm in place on 1/6/ 2024. It was important to keep care plans updated with accurate information so Resident #57 received proper care. 2) Resident #43 had [DIAGNOSES REDACTED]. The 10/29/2024 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for all activities of daily living, did not have any skin conditions, and did not receive an anticoagulant medication. Physician orders [REDACTED]. 2. 5 milligrams, 1 tablet two times daily for [MEDICAL CONDITION]. The Comprehensive Care Plan initiated 1/7/2023 documented Resident #43 had cardio-vascular disorders with [DIAGNOSES REDACTED]. Interventions included take medications as prescribed by physician: Eliquis (a blood thinner). There were no interventions for the use of a blood thinning medication. The Comprehensive Care plan initiated 1/24/2023 documented the resident was at risk for falls and was at risk for impaired skin integrity. During an observation on 1/6/2025 at 12:27 PM, Resident #43 was sitting on a mechanical lift pad in their wheelchair in the dining room waiting to be assisted with lunch. During an interview on 1/10/2025 at 8:42 AM, Licensed Practical Nurse #27 stated the Nurse Managers were usually responsible for care plans and some licensed practical nurses also completed them. They did not know what needed to be included. During an interview on 1/10/2025 at 8:50 AM, Registered Nurse Unit Manager #22 stated they were responsible for reviewing the resident care plans and updating them as needed. Care plans were updated when new physician orders [REDACTED]. When they added an intervention or medication to the care plan, a library of interventions populated and should have populated for the anticoagulant medication. Resident #43 received an anticoagulant medication, and it should be on their care plan with interventions such as monitor for bleeding. The resident's anticoagulant medication was only listed under cardio-vascular disorders with no interventions. Anticoagulants should be care planned so the resident was monitored for bleeding or bruising. During an interview on 1/13/2025 at 10:56 AM, the Director of Nursing stated Minimum Data Set Coordinator #28 completed the initial comprehensive care plans on admission and established a baseline care plan. Care plans were updated on day 14 of admission with the Interdisciplinary Team and family, when there was a change in a resident's condition, when there were new physician orders, and quarterly. Resident #43 received an anticoagulant medication, and it should be listed under cardiovascular medications. The resident's care plan did not have interventions documented for their anticoagulant medications. It was important to have interventions for anticoagulant medication so the resident could be monitored for bleeding or bruising. | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F656- Develop/Implement Comprehensive Care Plan: Crouse Community center will ensure the development and implementation of a person-centered Comprehensive care plan. Corrective action: Resident #43 anti-coagulant use was identified and implemented into the Comprehensive Care plan for risk of bleeding or bruising on (MONTH) 14, 2025 Resident #57 has been determined not at risk for falls, therefore chair alarm was removed and staff was educated on his plan of care on (MONTH) 6, 2025. Other residents: All other residents were reviewed for Anti-coagulant use and the Comprehensive Care plan was updated for all of those residents to include at risk for bleeding or bruising complications to be monitored. All other residents in the facility will have a fall risk assessment completed and have appropriate interventions implemented and added to their Comprehensive person-centered Care plan. Systemic Changes: All new residents admitted on Anti-coagulant therapy or any other resident with a new order for Anti-coagulant therapy will have a Comprehensive Care plan implemented or updated to include at risk for bleeding or bruising complications to be monitored. This will also be communicated to the CNA staff utilizing the CNA information sheets. Moving forward fall risk assessments will determine appropriate interventions and will be updated on the CNA information sheets and the Comprehensive person-centered Care plan. All staff educated on following the CNA information sheets and the Comprehensive person-centered Care plan. Monitoring: Audits will be conducted by the Director of Nursing monthly on Care planning for Anti-coagulants with 100% compliant threshold. This audit will be presented to QAPI monthly. Audits will be conducted by Director of Nursing to include Alarm use and Care planning. This will be done by checking physician orders [REDACTED]. This audit will be done monthly with 100% compliant threshold and reported monthly to QAPI. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure all alleged violations including injuries of unknown origin, were thoroughly investigated to rule out abuse or neglect for 1 of 5 residents (Resident #25) reviewed. Specifically, staff identified a skin tear on Resident #25's left arm and there was not a timely investigation completed to rule out abuse or neglect. Additionally, the resident's skin tear was not assessed by a qualified professional and the medical provider was not notified of the injury. Findings include: The facility Registered Nurse Job Description dated 2019, documented the responsibilities of the registered nurse were to recognize and report changes in resident condition to the physician and follow through with an appropriate assessment, nursing measures, and documentation. The facility policy, Reporting of Alleged Physical or Verbal Abuse, dated 2/2000 documented: - All alleged violations involving mistreatment, neglect, abuse, and misappropriation of property, including injuries of unknown source were reported immediately to the President and Chief Executive Officer of the facility and when required by law to the New York State Department of Health. - The alleged violation would be reported immediately, and the Registered Nurse Manager would be responsible for initiating the accident/incident form. - The Supervisor shall begin an investigation immediately when a report of an alleged violation is received. A thorough investigation should include the date and time of the incident, who discovered the incident, how the incident was discovered, and the log should include staff interviews including dated and timed statements, a resident statement and a physician and family representative should be notified in a timely manner. Resident #25 had [DIAGNOSES REDACTED]. The 12/25/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had functional limitation in range of motion in both arms and legs, had no skin impairments, had no behavioral symptoms, did not reject care, and used a wheelchair. The Comprehensive Care Plan effective 2/28/2023 documented: - the resident required assistance with activities of daily living. Interventions included extensive assistance of 2 for bed mobility, and total assistance for transfers and toileting, and half side rails as enablers for bed mobility. - the resident was at risk for inappropriate behaviors related to [MEDICAL CONDITION]. Interventions included remove resident from situation and reapproach as needed. - the resident was at risk for falls. Interventions included investigate cause of fall immediately, bed in lowest position, ensure call bell is in reach, and maintain a safe environment. - the resident was at risk for impaired skin integrity related to impaired mobility, friction and shearing, and incontinence. Interventions included certified nurse aide evaluation of skin daily during care and report any skin abnormalities to the nurse. An additional note dated 10/16/2024 documented the resident had multiple skin tears due to fragile skin. The 1/2025 resident care instructions documented Resident #25 required extensive assistance with activities of daily living, required assistance of 2 and a mechanical lift for transfers into a geriatric lounge chair, was alert and oriented with forgetfulness and disorientation, and requested no male caregivers. The 1/2/2025 at 1:59 PM Licensed Practical Nurse #2 progress note documented the resident was hitting, pinching, and slapping staff. Staff noticed an open area on the resident's left upper arm, it looked like a bruise that had opened, and they cleansed and wrapped it with a bandage. There was no documented evidence the skin impairment Licensed Practical Nurse #2 found on 1/2/2025 was assessed by a qualified professional. The 1/2/2025 24-hour report had no documented evidence the resident had a skin tear to their left arm. The untimed Resident Incident Report initiated by Licensed Practical Nurse #2 and prepared by Registered Nurse Unit Manager #7 on 1/2/2024 documented the resident had a bruise/soft tissue contusion/swelling of their left arm that was discovered on 1/2/ 2025. The incident was unobserved. The area was cleansed, and [MEDICATION NAME] (a non-adhesive bandage) and kling wrap (an outer bandage) was applied. The physician signed the report on 1/9/ 2025. There was no documented evidence the injury to the left arm was investigated timely to rule out abuse and neglect. The Resident Incident Investigation Report dated 1/8/2025 and signed by the Director of Nursing documented the resident had been agitated during care. Staff (unidentified) had just completed hygiene care after transferring the resident into bed (no time documented). The analysis of the incident documented the resident had a history of [REDACTED]. There were no symptoms exhibited which may have contributed to the incident. The plan was to use Geri sleeves (protective skin covering) to aid with protection of fragile skin. The Director of Nursing concluded there were no indications of abuse or neglect through the investigation. A 1/8/2025 (6 days after the incident) staff statement from Registered Nurse Unit Manager #7 documented the resident stated they were not harmed by staff. There was no documented evidence a thorough investigation was completed to rule out abuse or neglect related to the injury of unknown origin identified on 1/2/ 2025. There was no documented evidence the medical provider was notified timely. During an observation and interview on 1/6/2025 at 10:26 AM, Resident #25 was sitting in their room in a geriatric lounge chair. A medium sized bruise was observed on the resident's left forearm and a small bandage near their elbow. The resident was unable to explain the cause of the bruise. During an observation on 1/10/2025 at 10:47 AM with Licensed Practical Nurse #2 the resident had multiple bruises on their left forearm. There was no bandage on their left elbow. There was a half-moon shaped open skin tear with a flap of skin covering it approximately 1-1/2 inches long and ?é½ inches wide, approximately ?é½ inch down from the bend of the resident's elbow. During an interview on 10/10/2025 at 10:11 AM Certified Nurse Aide #16 stated the resident had behaviors with care, they would ask the resident questions and try to distract them. The resident required assistance of 2 with a mechanical lift for transfers. They thought the resident had sores on their arms and was unsure why their left arm had a bandage. During an interview on 1/10/2025 at 10:36 AM Licensed Practical Nurse #2 stated Resident #25 scratched and hit staff during care. Staff had reported the resident had an open area on their arm and they wrote a nursing progress note. They were unsure which staff reported it. They stated the resident had a skin tear, it was initially bleeding, and they placed a bandage on it. Treatments required a physician order, and they did not have a treatment order. Licensed Practical Nurse #2 stated they thought they reported the incident on the 24-hour report, did not recall telling anyone, and a registered nurse did not assess the wound. They determined it was not abuse because the staff told them the resident had an open area. During an interview on 1/13/2025 at 9:18 AM Certified Nurse Aide #15 stated the resident was combative with care, they pinched and scratched the staff and required 2 staff to provide care. They stated they knew the resident had a skin tear to their left arm, they obtained it from pinching and scratching the staff and was not sure when it happened. They did not care for the resident often. Certified Nurse Aide #15 stated if the resident was combative, they would stop care and reapproach them and if they noticed a skin tear, they would tell the medication nurse. During a telephone interview on 1/13/2025 at 10:03 AM Certified Nurse Aide #13 stated they worked per diem (as needed) and worked o | Plan of Correction: ApprovedMarch 3, 2025 F610-Investigate/Prevent/Correct Alleged Violation: Crouse Community Center will ensure that allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. This includes measures to prevent further abuse, neglect, exploitation, or mistreatment while investigation is in progress and the incident is reported to the Administrator/Director of Nursing within 2 hours to ensure appropriate corrective actions are taken if alleged violation is verified. Corrective Action: Incident report and investigation was completed for Resident # 25. Upon investigation of the incident, root cause analysis and witness statements have determined it to be non-reportable. The bruising/skin tear was considered accidental secondary to Dementia with behaviors and fragile skin. Plan of correction includes continued application of arm protectors, use of 2 CNAs with all cares. Medication management will be reviewed to increase dose of Anti-Anxiety and Pain medication due to her behaviors. Other Residents: All licensed staff will be re-educated with our policy and procedures for reporting injuries of unknown etiology. All residents with an injury of unknown origin will have a skin assessment completed by a registered nurse with provider notification directly following assessment to obtain a treatment order if indicated, the RN will then initiate an Incident report with investigation if needed. Systemic Changes: Incident reporting of injuries of unknown origin will be included in facility orientation and annual Inservice training with Residents Rights and Abuse Reporting. Incident reports of injuries of unknown etiology must be reported immediately to the RN Nurse manager or RN Supervisor on duty to initiate the investigation, notify provider, and implement a treatment if indicated. After thorough investigation is complete, If abuse or serious bodily injury is suspected, the Director of Nursing will be notified and report the incident to the appropriate agency within 2 hours. Monitoring: Audits will be conducted by the Director of Nursing monthly on investigations of injuries of unknown origin. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not consult with the physician when there was a significant change in the resident's physical status for 1 of 3 residents (Resident #30) reviewed. Specifically, Resident #30 had a continued, unplanned weight loss and the medical provider was not notified. Findings include: The undated facility policy, Change in Condition-Notification, documented the facility would notify and inform the resident's physician, and if known, their legal representative when there was a significant change in the resident's physical, mental or psycho-social status in either life-threatening conditions or clinical complications. Resident #30 had [DIAGNOSES REDACTED]. The 11/10/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial/maximum assistance of 1 for all activities of daily living, did not have weight loss or a swallowing disorder, had no loose or broken teeth, and did not receive a therapeutic diet. The Comprehensive Care Plan initiated 9/22/2023 documented a focus area of nutritional status. Interventions included follow physician diet order, regular diet with mechanical soft/ground consistency, weights per physician order, labs as ordered, dietitian consult as needed, and observe for signs and symptoms of poor nutrition/hydration status like dry mouth, cracked lips, sunken eyes, dark urine, frequent vomiting, diarrhea, or fever. Care plan updates documented the following: - on 9/27/2023, regular diet. - on 3/12/2024- provide whole milk with meals for calorie intake. - on 12/30/2024- Ensure Plus high protein (nutritional supplement) three times a day with meals. Resident #30's monthly weight report documented the following weights: - 10/2/2024-160 pounds. - 10/7/2024 reweight- 157 pounds. - 11/3/2024- 157 pounds. - 12/3/2024- 143 pounds ( 8. 9% weight loss in 1 month) - 1/2025 (no date)- 139 pounds ( 13. 1% weight loss in 3 months) The 11/7/2024 Dietetic Technician #12 quarterly nutritional assessment documented the resident had a recent decline in food and fluid intake and required staff to assist them with eating. The plan was to follow the resident's intake and adjust their meal/fluid patterns and follow the (MONTH) weight. The 12/11/2024 Acute Visit list (a list of residents that needed to be seen by the provider) documented Resident #30 was to be seen for an acute visit. The list did not include the reason the resident needed to be seen. There was no documented evidence the physician was notified of the resident's significant weight loss. The 12/11/2024 Physician #10 progress note documented the resident had a slow decline cognitively and physically since the last visit. There was no documentation regarding the 8. 9% weight loss from 11/3/2024-12/3/ 2024. The 12/30/2024 at 12:07 PM Dietetic Technician #12 progress note documented the resident's (MONTH) weight was 141 pounds and was a 16-pound weight loss from 11/2024, following an illness with decline. The resident had variable intakes despite increased feeding assistance. Eight ounces of Ensure Plus Hi Protein three times a day with meal was added. Follow up in 1/2025 when weights become available. The Acute Visit list dated 1/3/2025-1/13/2025 did not include Resident # 30. There were no documented physician progress notes [REDACTED]. Resident #30 was observed: - on 1/8/2025 at 8:58 AM, sitting at the dining room table with their breakfast tray that consisted of an egg/cheese biscuit, potatoes, cold cereal, 4 ounces of orange juice, 8 ounces of milk and 8 ounces of a nutritional shake. The resident was partially assisted with eating and consumed 25% of their meal and drank half of their shake. - on 1/10/2025 at 9:12 AM, the resident had just finished eating their breakfast and the tray had been removed. The resident intake form documented they had consumed less than 50% of their meal and drank 240 cubic centimeters (8 ounces) of fluids. During an interview on 1/10/2025 at 10:11 AM, Certified Nurse Aide #16 stated the resident required additional assistance with eating, but they were unsure why they needed extra assistance or if the resident had lost weight. During an interview on 1/10/2025 at 2:41 PM, Dietetic Technician #12 stated they completed the quarterly nutritional assessments for the residents and gave the information to Registered Dietitian #11 who completed the nutritional assessment. Resident #30 had a 16 pound weight loss between 11/2024-12/2024 and they did not notify the physician of the loss. Dietetic Technician #12 stated they only conducted the nutritional assessments and entered progress notes. They filled out a weight change sheet that indicated a resident had a weight loss of 5 pounds or more. The weight change sheet was given to Registered Nurse Unit Manager #7 for review, who gave it to the Director of Nursing. They stated the Director of Nursing was responsible for notifying the physician of the weight change. They had always communicated weight changes that way and they trusted it worked. During an interview on 1/13/2025 at 10:30 AM Registered Nurse Unit Manager #7 stated certified nurse aides were responsible for obtaining the resident's weights every month and if there was a 5-pound weight loss or gain, a re-weight should be done. They did not notify the physician of weight changes. The Director of Nursing reviewed the weight change sheets documented if the resident had a significant weight loss. The notified the registered dietitian and the physician. Registered Nurse Unit Manager #7 stated they were aware Resident #30 had a significant weight loss of 16 pounds. They would not have documented the weight loss anywhere but should have written a nursing note in the resident's chart. It was important to document a significant weight loss, so staff were aware, and treatment was not delayed. During an interview on 10/10/2025 at 10:56 AM the Director of Nursing stated resident weights were obtained by certified nurse aides by the 10th of each month. If there were a significant weight change, the Nurse Managers should request a re-weight. If a resident had a significant weight loss, Dietetic Technician #12 would assess the resident and add supplements. They stated they received weight change sheets monthly from the Nurse Managers, reviewed them, and passed them to Minimum Data Set Coordinator #20 to make changes on the resident's assessment. They were aware Resident #30 had a significant weight loss but did not document in a progress note until 1/4/ 2025. They stated Registered Nurse Unit Manager #7 would know if the physician was notified. During an interview on 10/13/2025 at 12:40 PM, Physician #10 stated they were unsure if they were notified about Resident #30's significant weight loss. Weight changes were communicated by staff verbally when they did medical rounds and should be listed on their Acute Visit list. They documented in a progress note for acute issues. They expected staff to notify them of a significant weight loss. Treatment might consist of either an appetite stimulant or a review of the Resident's Medical Orders for Life-Sustaining Treatment record for a feeding tube. 10 NYCRR 415. 3(2)(ii)(a) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F580- Notify of Changes: Crouse Community Center will ensure that the physician is notified when there is a Significant change in the residents physical, mental, or psychosocial status with, potentially, the need to alter treatment. Corrective action: The facility will ensure that the physician is notified with any significant change in condition with a focus on unplanned weight loss. For resident #30, the physician was notified of the weight loss by the nurse manager. A significant change in status assessment was initiated due to the residents change in status in order for the IDT and family to establish appropriate goals of care. Diet consistency and level of assist with eating was changed as the immediate intervention with high protein supplements added by dietary. Resident transitioned to comfort care and expired on ,[DATE]/ 25. Other residents: The physician has reviewed and documented on all residents who had significant weight changes (5%/month or 10%/6months) in order to ensure adequate treatment. Systemic changes: All licensed staff will be re-educated on our Change in Condition-Notification policy, and Weight policy. Focus will be on significant weight loss and timely notification. The facility will ensure that the physician is notified with any significant change in condition with focus on unplanned weight loss. Monitoring: Audits will be conducted by Director of Nursing monthly with a 100% compliance threshold and reported to QAPI monthly. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility failed to ensure that pain management was provided to residents who required such services consistent with professional standards of practice for 2 of 3 residents (Residents #30 and #53) reviewed. Specifically, Resident #30 did not have pre and post pain evaluations completed when as needed pain medication was administered; and Resident #53's pain associated with transfers was not addressed. Findings include: The facility policy, Pain Assessment and Management, revised 12/2024, documented pain would be assessed on all residents during admission, quarterly, during any significant changes, and annually prior to the completion of their Minimum Data Set assessment. Pain interviews could be conducted at any time as needed. Numerical pain scaled from 0 to 10 would be used to assess the degree of pain with 0 describing no pain and 10 describing the worst pain. A face scale could be utilized if the resident could not understand the numerical scale with a happy face representing no pain to a face crying would represent worse pain. Residents who complained of moderate pain above 5 who had pain indicators would be asked about pain every shift and as needed while awake. Nursing would document on the Medication Administration Record, [REDACTED]. The pain flow assessment record would be reviewed after pain medication had been initiated or until the resident achieved optimal pain control. 1) Resident #30 had [DIAGNOSES REDACTED]. The 11/10/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial/maximum assistance of 1 for all activities of daily living, received a scheduled pain medication regimen, received as needed pain medications, received non-medication interventions for pain, and frequently had pain. The Comprehensive Care Plan initiated 11/5/2023 documented Resident had potential for pain related to vertebral stenosis (a narrowing of the bone spaces in the spinal column). Interventions included administer medications per physician order, routine, or as needed [MEDICATION NAME] (Tylenol, a medication to relieve pain or fever), [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication to relieve pain) as ordered, and on-going assessment of the resident's pain with emphasis on the onset, location, description, intensity of pain, and aggravating and alleviating factors. The physician orders [REDACTED]. - Tylenol 325 milligrams, 2 tablets (650 milligrams) by mouth twice a day at 2:00 PM and 8:00 PM, - [MEDICATION NAME] (Tylenol) 325 milligrams, 2 tablets (650 milligrams) by every 4 hours as needed for pain. - [MEDICATION NAME] ([MEDICATION NAME]) 7. 5 milligrams, 1 tablet by mouth every morning at 8:00 AM for [MEDICAL CONDITION]. The 1/2025 Medication Administration Record [REDACTED] - [MEDICATION NAME] 325 milligrams 2 tablets (650 milligrams) by mouth at 2:00 PM and 8:00 PM. - [MEDICATION NAME] ([MEDICATION NAME]) 7. 5 milligrams, 1 tablet by mouth at 8:00 AM. During an observation and interview on 1/6/2025 at 11:07 AM, Resident #30 was sitting in their recliner in their room holding a call bell cord. The resident displayed facial grimacing, was moaning, and yelling for help. They stated they hurt all over and had pain in their head. The 1/6/2025 at 8:57 PM Licensed Practical Nurse #30 progress note documented the resident was stiff, observed whimpering, and calling for help. Resident #30 stated they hurt all over and routine Tylenol was given. During an observation and interview on 1/10/2024 at 9:35 AM, the resident was sitting in the recliner in their room, had facial grimacing, was moaning and was restlessness. They stated they had [MEDICAL CONDITION] with chronic pain. They received pain medication and it helped sometimes and other times it didn't help. The 12/2024 and 1/2025 pain flow sheets (located in the front of Resident #30's medication administration record) included instructions that documented: record the following data when implementing an intervention for pain. Data included date, time, location of pain, type, intensity (non-verbal/verbal), non-medication interventions, medication/dose, initials, intensity of pain after interventions, and side effects. The pain flow sheets were blank and did not include data on the resident's pain. During an interview on 1/10/2025 at 10:11 AM Certified Nurse Aide #16 stated they were unsure if Resident #30 had pain with care but had observed they needed more assistance with their activities of daily living and eating and had to be fed. They were unsure why. They would tell a nurse if a resident had pain. During an interview on 1/10/2025 at 10:36 AM Licensed Practical Nurse #2 stated the purpose of the pain flow sheet in the Medication Administration Record [REDACTED]. They stated Resident #30 received routine and as needed pain medicine. They sometimes had pain and other times did not and they relied on the resident to tell them if they were in pain. They did not document a numerical pain scale in the Medication Administration Record [REDACTED]. Licensed Practical Nurse #2 stated Resident #30 was cognitively intact at times and could verbalize pain. They stated they did not document a post pain evaluation and thought the resident would tell them if they still had pain and the medication was not effective. It was important to document pain to know if the medication was effective. 2) Resident #53 had [DIAGNOSES REDACTED]. The 12/19/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, received routine pain medication, did not receive as needed pain medication, received non-medication interventions for pain, had pain that occasionally limited participation in rehabilitation therapy sessions and day to day activities. The Comprehensive Care Plan, last reviewed 10/19/2023, documented the resident had potential for pain related to hernia repair. Interventions included on-going assessment of the resident's pain with emphasis on the onset, location, intensity, and alleviating and aggravating factors. The 12/21/2024 physician order [REDACTED]. The 11/2024 Medication Administration Record [REDACTED]. There was no documented evidence of pre or post pain evaluations. There was no nursing progress note documenting indications for administering as needed Tylenol. The 1/2025 Medication Administration Record [REDACTED]. There was no documented evidence of pre or post pain evaluations. The 1/4/2025 at 9:38 PM Licensed Practical Nurse #30 progress note documented the resident refused to get out of bed for dinner with complaints of a headache. As needed Tylenol was given at 5:30 PM with some effect. The note did not include pre and post administration pain levels. During an observation on 1/10/2025 at 9:31 AM, Resident #53 was assisted from their wheelchair back to bed with use of the sit to stand lift by Certified Nurse Aides #25 and # 26. They applied the lift sling to the resident then directed them to lean forward. The resident said they were unable to do so. When staff attempted to move the resident forward to reach the lift handles | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F697- Pain Management: Crouse Community Center will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive centered care plan, and the residents goals and preferences. Corrective action: For resident # 30, a new pain assessment and a therapy referral were completed. Medications were adjusted and is due for a review with provider. Care plan interventions updated. Resident #53 was transitioned to comfort care upon review of her MOLST with the family members and medication changes were made, she expired on ,[DATE]/ 25. Other residents: All licensed staff will be re-educated with the pain management policy which includes emphasis on pre and post pain evaluation and pain management documentation to ensure that pain management is appropriate and effective for all residents. All non-licensed staff will be re-educated on change in condition communication, pain identification, and reporting. Systemic changes: Pain Assessment and Management policy was updated and training will include accurate pain flow assessment record documentation and staff communication to ensure referrals to appropriate sources (i.e. therapy, psychosocial, medical, outside agencies referrals) were made. Monitoring: Audits will be conducted by the Director of Nursing monthly on pain flow sheet completion, and resident specific comprehensive care plan interventions. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure resident rights to privacy and confidentiality of their personal and medical records for 2 of 2 residents (Resident #3 and 13) reviewed. Specifically, Residents #3 and #13 had their dietary status [REDACTED]. Findings include: The facility policy, Patient Bill of Rights Procedures, dated 6/26/1997, documented the residents of the facility were assured their medical and personal records would be kept in confidence. All staff were educated to respect the dignity and individuality of each patient with attention to privacy during the treatment and care of the resident's personal needs. 1) Resident #3 had [DIAGNOSES REDACTED]. The 11/22/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent for all activities of daily living, and had a feeding tube (gastrostomy, a tube surgically inserted into the stomach) for more than 51% of their daily total calories. The 12/30/2024 physician order [REDACTED]. 1. 5 (tube feeding formula) continuously at 50 cubic centimeters per hour, and the resident's medications could be mixed to administer via the resident's gastrostomy tube. The follow observations were made: - on 1/06/2025 at 11:35 AM, there was a sign documenting NPO next to their name plaque on the outside of their room. - on 01/07/2025 at 9:08 AM, NPO was handwritten on a folded pink piece of paper taped above their name on the door plaque. - on 01/08/2025 at 8:56 AM, there was NPO next to the resident's name on their door. - on 01/10/2025 at 11:31 AM, there was a sign on pink paper documenting NPO above the resident's name on the door plaque. 2) Resident #13 had [DIAGNOSES REDACTED]. The 12/21/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for all activities of daily living, and had a feeding tube for more than 51% of their daily total calories. The 12/30/2024 physician order [REDACTED]. 1. 5 (tube feeding formula) at 50 cubic centimeters per hour via their jejunostomy tube (feeding tube inserted into the small intestine.) The following observations were made: - on 1/06/2025 at 11:56 AM, the resident's name plaque outside their room had an NPO sign next to it. - on 1/07/2025 at 9:15 AM, the resident had NPO printed on paper next to their name on their name plaque. - on 1/08/2025 at 9:01 AM, the resident had NPO above their name on the door. - on 1/08/2025 at 2:45 PM, there was an NPO sign above the resident's name on their door plaque. - on 1/10/2025 at 11:33 AM, there was a small sign with NPO next to resident's name on the door plaque. During an interview on 1/10/2025 at 11:39 AM, the Social Services Director stated staff was educated on what classified as resident personal information. A resident's diet and liquid texture were classified as resident's personal health information. A resident's personal health information should not be posted where visitors and non-pertinent staff could see it. The nothing by mouth directive outside a resident's door was a violation of the resident's privacy. During an interview on 1/10/2025 at 2:06 PM, Certified Nurse Aide #18 stated the NPO sign outside the resident's door indicated the resident was to have nothing by mouth. The signs were placed there so no one accidentally gave the resident food or anything to drink. A resident's liquid and/or diet texture was classified as personal health information. It was a violation of the resident's privacy to have NPO posted next to the residents' names on their doors. During an interview on 1/10/2025 2:38 PM, Licensed Practical Nurse #19 stated the NPO sign outside Resident #13's door indicated the residents could not have anything by mouth and alerted unit helpers to not bring them snacks or drinks. Resident health information should not be posted where unauthorized persons or staff could view it. They stated they were undecided if posting the information outside the resident's door was a violation of privacy as they did not want a well-meaning visitor or volunteer to give the resident food or fluids they could not have. During an interview on 1/10/2025 at 2:43 PM, Registered Nurse Unit Manager #6 stated liquid and diet texture were classified as personal health information. The NPO signs for Resident #3 and Resident #13 should not have been posted outside their rooms and was a violation of the resident's privacy. During an interview on 1/13/2025 at 12:02 PM, the Director of Nursing stated staff was educated on what classified as resident personal information at least once a year. A resident's diet and liquid texture were classified as personal health information. A resident's diet and/or liquid texture should not be posted in areas visible to other residents and visitors. They stated a resident who had an NPO sign posted outside their room next to their name was not a violation as it was an abbreviation and non-medical personal would not know what it meant. They stated they did not think about visitors or other residents with a medical background being aware of it. It was a violation of the resident's privacy to have their diet order posted outside their room next to their name. 10NYCRR 415. 3(d)(1)(ii) | Plan of Correction: ApprovedMarch 3, 2025 F583- Personal Privacy/Confidentiality of Records: Crouse Community Center will ensure all residents their right to privacy and confidentiality. Corrective action: For resident # 3 and resident # 13, NPO signage was removed from the residents door and replaced with a water drop symbol with an ?ôX?Ø through it on (MONTH) 13, 2025 Other residents: Thickened Liquids-Swallowing eval policy was updated to include new symbol for NPO. All other residents on an altered fluid consistency were reviewed to ensure that the appropriate symbol was on their door as per policy. Discrete facility approved signage will be utilized to ensure privacy and confidentiality to all residents. Medical abbreviations will not be placed on residents door, only discrete symbols. Systemic Changes: Thickened liquids policy was updated with staff education on the new symbol utilized for NPO residents. Discrete facility approved signage will be used as a communication tool for staff, medical abbreviations will not be utilized. Residents' diet, diagnosis, and or conditions will not be displayed as to protect their privacy and confidentiality. Monitoring: Audits will be conducted by the Director of Nursing to ensure confidentiality and privacy are not violated by using medical signage. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not provide pharmaceutical services to meet the need of each resident for 4 of 4 residents (Residents #1, #88, #208, and #209) reviewed. Specifically, the facility used Resident #88's [MEDICATION NAME] (a narcotic pain reliever) to administer to Residents #1, #208, and #209 when they did not have the medication available. Findings include: The facility policy, Medication Administration, Handling and Storage, revised 12/2024, documented a resident's controlled drug package was to be fully labeled with the name, drug, and directions and put in the double locked drawer of the medication cart during the medication pass. The facility policy, Controlled Substances; Ordering, Storage, and Handling, last reviewed 2019, documented at the beginning of each shift, all controlled substances were physically counted for accuracy of the number remaining according to the controlled drug sheet compared to the actual number in the unit dose container. The individual resident's narcotic record is completed with the count. Administration of controlled substances was performed with appropriate nursing procedure. The facility did not have a documented policy on borrowing medications. The A Unit controlled substance record documented Resident #88 had an order for [REDACTED].#88's [MEDICATION NAME] was documented as borrowed for Resident #1 a total number of 20 times between 12/6/2024-12/26/2024; for Resident #208 on 12/23/2024; and for Resident #209 on 1/6/2025 and 1/7/ 2025. Resident #1's 11/24/2024 physician order [REDACTED]. Resident #208's 12/23/2024 physician order [REDACTED]. Resident #209's 1/7/2025 physician order [REDACTED]. 10. During an observation and interview on 1/07/2025 at 12:59 PM, Licensed Practical Nurse #29 stated Resident #209's last name was written next to the count on the controlled medication sheet for Resident #1's [MEDICATION NAME] 5 milligram tablets because Resident #209 was out of their [MEDICATION NAME], so they borrowed a dose from Resident # 1. They stated it was facility policy to borrow medications from another resident if a resident was out and needed the dose. During an interview on 1/13/2025 at 10:08 AM, Registered Nurse Unit Manager #6 stated controlled substances had to be ordered through a physician prescription. They were unaware Resident #209 ran out of their [MEDICATION NAME]. They stated the resident had just been readmitted from the hospital so that was likely why their prescription was not renewed. When residents were readmitted or newly admitted from the hospital without written prescriptions for controlled substances, they borrowed medications until the facility provider could write the prescription and the medication was received. They stated it was in the facility policy to borrow medications. There was an emergency supply of medications in the facility, but they just borrowed medications from other residents. If the resident they were borrowing from started to run low on the medication, they would get a new prescription for that resident. During a follow up interview on 1/13/2025 at 11:04 AM, Registered Nurse Unit Manager #6 stated they were unsure why the nurses had borrowed 20 doses of Resident #88's [MEDICATION NAME] for Resident # 1. They had to call the pharmacy to find out as Resident #1's prescription was sent in on 12/5/2024 but was not delivered until 12/26/ 2024. On 1/13/2025 at 11:08 AM, they called the pharmacy and was informed there were issues with the original prescription not having a quantity on it, so it was returned to the facility. They were unaware of this and was unsure why it took so long for the prescription to be corrected and filled. During an interview on 1/13/2025 at 12:02 PM, the Director of Nursing stated the pharmacy provided the facility with a formulary for the emergency medication supply system, but they did have the opportunity to change the list. All nurses were able to access the emergency medication supply system with a fingerprint or a code. They stated since [MEDICATION NAME] was the only narcotic pain medication in the emergency medication supply system, if a resident ran out of a different narcotic pain medication the nurses probably borrowed the dose from another resident. The emergency medication supply system was supposed to have other narcotic pain medications added but the process was never completed. They stated the nurses were not supposed to borrow narcotic medications from one resident to give to another. They stated it used to be the facility policy to borrow medications prior to obtaining the emergency medication supply system. They were unaware Resident #88 had over 23 tablets of their 5 milligram [MEDICATION NAME] medication borrowed from 12/5/2024 to 1/13/ 2025. Medications should not be borrowed. During an interview on 01/13/2025 at 12:16 PM, Pharmacist #42 stated the emergency medication supply system was stocked based on what the facility needed and requested. For controlled substances, the facility sent the order, it was processed, billed, and then sent on the next scheduled run to the facility. If a medication was needed from the emergency medication supply system, the facility called the pharmacy, they confirmed the patient and the order, and an approval code was given to dispense the medication. If a medication was needed that was not in the emergency medication supply system, there was a courier service was that was used that delivered to the facility within two to four hours for a stat run. Nighttime deliveries could take longer and depended on availability. If controlled medications were needed, they should be obtained through the emergency medication supply system or through a stat run. Borrowing controlled substances was not appropriate and could lead to diversion and billing issues. During an interview on 1/13/2025 at 1:25 PM, the Medical Director stated if a resident needed medication and they did not have it, nursing should contact them to send an electronic prescription to the pharmacy for an immediate fill. They stated the facility still utilized paper prescriptions, but they were allowed to send electronic prescriptions if necessary. They stated it was not an acceptable practice to borrow medication from one resident to give to another. They were unaware Resident #88 had 23 doses of their [MEDICATION NAME] borrowed from 12/5/2024 to 1/13/2025 and stated that should not have happened. 10NYCRR 415. 18(e)(2) | Plan of Correction: ApprovedMarch 3, 2025 F755- Pharmacy Services/Procedures/Pharmacist/Records: Crouse Community Center will ensure medications are available for residents when needed. Corrective action: Resident # 1, #208, #209 had new prescriptions obtained with their own sufficient, designated supply of medications received. Resident # 88 has a sufficient supply of medications. Other residents: All other residents with orders for controlled substances were reviewed to ensure sufficient supply of medication. Systemic Changes: Crouse Community Center will ensure that all residents with controlled substances will have a sufficient supply of medications. Licensed staff was educated on the modifications made to the facility Stat Safe. Pharmacy was consulted, and the facility Stat Safe medication emergency supply system was updated with additional emergency controlled substances added. Monitoring: Audits will be conducted weekly by the Director of Nursing to ensure sufficient supply of controlled substances. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 13, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey conducted 1/6/2025-1/13/2025, the facility did not ensure that it promoted and facilitated resident self-determination including the resident's right to make choices about aspects of daily life that are significant to the resident for 1 of 3 residents (Resident #4) reviewed. Specifically, there was no documented evidence Resident #4's informed consent was obtained prior to initiating a chair alarm (a device that detects pressure changes to alert staff of resident position changes) and the care plan was not revised to include the use of a chair alarm. Findings include: The facility policy, Resident Bill of Rights, effective 6/26/1997, documented residents had the right to refuse treatment after being fully informed of and understanding the consequences of such action. The facility policy, Care Plans-Specific Writing Guidelines, last reviewed 2023, documented care plan approaches should include resident preferences and should be resident specific. The facility policy, Alarm Use, effective 2000, documented all residents were assessed/evaluated by the interdisciplinary team for fall prevention measures including alarms. If alarms were determined an appropriate intervention, an individualized person-centered care plan would be implemented. Residents had the right to decline or refuse alarms. The facility policy, Fall Prevention for High-Risk Residents, revised 7/2024, documented residents at high risk for falls would have a fall prevention care plan; staff would round when the resident was in bed; and the call bell would be kept in reach. Additional measures to be considered on an individual basis would include a bed and/or chair alarm. Resident #4 had [DIAGNOSES REDACTED]. The 11/19/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not exhibit behavioral symptoms, required substantial/maximal assistance with sitting to standing and chair/bed-to-chair transfers, had a fall prior to admission, did not have any falls since admission, and used a bed and chair alarm daily. The Comprehensive Care Plan, initiated 11/12/2024, documented the resident was at risk for falls related to high risk for falls, frequent falls, impaired mobility, and balance deficit. Interventions included bed in the lowest position, evaluate pattern of falls, and anticipate resident needs. There was documented evidence of use of a bed or chair alarm. The 12/30/2024 Physician order [REDACTED]. The resident care instruction sheet, updated 1/8/2025, documented the resident was alert and oriented and had bed and chair alarms. Nursing progress notes dated 12/30/2024-1/8/2025 did not include the use of a bed or chair alarm or discussions with the resident or resident representative regarding the use of a bed and chair alarm. Resident #4 was observed sitting in their wheelchair with a chair alarm clipped to their back: - on 1/6/2025 at 11:39 AM, Resident #4 stated the chair alarm bothered them and they had never fallen from the chair. - on 1/8/2025 at 9:03 AM. Resident #4 stated they recalled one time the chair alarm activated. They were not sure why it activated as they had not fallen. The alarm was very loud, and it took a long time for someone to respond to turn it off. No one had asked them if they wanted the alarm and if they had been asked, they would have declined. - on 1/10/2025 at 8:44 AM. During an interview on 1/10/2025 at 2:46 PM, Certified Nurse Aide #4 stated resident rounds were performed on all residents minimally every 2 hours to check such things as positioning, need for bathroom use, and to ensure alarms were in place. Alarms were usually used on someone who fell . Resident #4 was rounded on minimally every 2 hours, they used their call bell appropriately, was able to voice their needs, and did not attempt to get up unassisted. They thought the resident's alarms were put in place on admission as a precaution. If a resident had an alarm but did not need one it could be undignified. Alarms were noticeable to others so even reducing from two to one could help with dignity. They stated, residents had the right to fall. During an interview on 1/10/2025 at 2:57 PM, Licensed Practical Nurse #5 stated alarms required a physician order [REDACTED]. Residents identified as high risk for falls on admission had alarms initiated. Within two weeks, if there were no attempts to get up unassisted, the alarms would be taken off. If a resident was using their call bell safely, was not self-transferring or falling they would suggest the alarms be removed. Resident #4 was soft spoken, did not like to complain, used their call bell, was able to make their needs known, was able to understand others, did not attempt to self-transfer, had not fallen, and had intact cognition. The resident had both a chair and bed alarm since admission. They stated removing unnecessary alarms was important for dignity reasons and that use of alarms took some independence away from the residents and residents had the right to fall. During an interview on 1/10/2025 at 3:15 PM, Registered Nurse Unit Manager #6 stated bed and chair alarms were used on residents that did not understand the call bell concept, tried to get up alone, had late-stage dementia, and had a history of [REDACTED]. A high fall risk assessment alone should not trigger the need for an alarm. Resident #4 used their call bell, was able to make their needs known, was able to understand others, did not attempt to self-transfer, had not fallen, and was rounded on every hour. The ongoing need for the resident's alarms had not been reevaluated since admission but should have been. Asking permission for alarm use was important so it was not considered against the resident's will. The use of alarms could cause anxiety, dignity issues, impair independence, and make a resident feel less free. Discontinuing an alarm was important because if a resident used the call bell effectively and no longer was a risk for falls alarms could be considered a restraint. During an interview on 1/13/2025 at 2:30 PM, the Director of Nursing stated the use of alarms was determined on admission. They went higher on alarm use initially and would drop back down if indicated. Use of alarms was reassessed during the first care plan meeting, quarterly, and with any significant change. The use of alarms was discussed with the resident during their care plan meetings. Resident #4 scored high on their fall assessment and therefore needed an alarm. The use of the alarm was discussed with the resident at their care plan meeting. The Interdisciplinary Care Plan Meeting sign-in sheet, dated 11/27/2024, did not document the resident was present for the meeting. 10 NYCRR 415. 5(b)(3) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F561- Self-determination: Crouse Community Center will ensure that the facility is promoting and facilitating resident self-determination through support of resident choice, focusing on significant aspects of his/her life in the facility. Corrective action: Resident #4 was re-interviewed by Nurse Manager and declined the use of alarms. Alarms were discontinued and Care plan and CNA notification sheet updated on (MONTH) 10, 2025. Other residents: All residents in the facility were reviewed for fall risk. If alarm use is determined to be an appropriate fall alert intervention, consent forms will be completed by resident or designated representative and comprehensive care plan will be implemented. Systemic changes: The facility will promote self-determination with focus on alarm use and resident choice. Consent forms were created and all staff educated on obtaining consent prior to alarm use. Monitoring: Audits will be conducted by Director of Nursing to include Alarm use and Care planning. This will be done by checking physician orders [REDACTED]. This audit will be done monthly with 100% compliant threshold and reported monthly to QAPI. Responsible Party: Director of Nursing |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure cooking facilities were maintained in accordance with National Fire Protection Association 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations for 1 of 1 main kitchen fire suppression systems. Specifically, a 2024 semi-annual fire suppression system inspection had not been completed; and there were deficiencies identified on the 7/5/2024 semi-annual kitchen fire suppression system inspection report that had not been corrected timely. Findings include: 1. Semi-annual Testing Not Completed The facility could not provide documentation that the main kitchen fire suppression system had a semi-annual inspection for the first half of 2024. During an interview on 1/10/2025 at 12:38 PM, the Maintenance Director stated they were aware that the main kitchen fire suppression system was required to be inspected semi-annually, and they thought that two inspections had been completed in 2024, but found their vendor had not scheduled an inspection for the first half of 2024. The Maintenance Director stated it was important that all required inspections were completed to verify that all fire suppression system components were functional for the safety of staff. 2. Deficiencies Not Corrected Timely The main kitchen fire suppression system inspection report dated 7/5/2024, documented the need to replace seven tin type scissor links with steel scissor links, and to replace two nozzles for the next inspection. During an interview on 1/10/2025 at 12:38 PM, the Maintenance Director stated they had not reviewed the comment section of the 7/5/2024 semi-annual kitchen fire suppression system inspection report prior to this federal survey. They stated these deficiencies identified had not been corrected. The Maintenance Director stated it was important that all required fire suppression system components were functional, and the deficiencies should have been corrected. 2012 NFPA 101 19. 3. 2. 5. 1, 9. 2. 3 2011 NFPA 96 11. 2 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 5, 2025 On 1/20/2025 the Fire Suppression System was inspected, and all repairs were made at the same time. Going forward the Director of Environmental Services will have calendar reminders on when semi-annual inspections are due and ensure they are completed timely. Vendor committed to comply with strict semi-annual inspections. All Maintenance staff has been educated on the importance of hood inspections, including the aspect of why repairs need to be done immediately following the inspection. Director of Facilities also reviewed hood inspection schedules. The Director of Environmental Services will monitor compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure corridor doors were maintained for 1 room. Specifically, the E-Unit pantry had an unsealed hole through the door. Findings include: During an observation on 1/8/2025 at 11:25 AM, the E-Unit pantry access door had an unsealed hole near the door handle. During an interview on 1/10/2025 at 12:48 PM, the Maintenance Director stated the E-Unit pantry access door lock set had been replaced in June 2023. They were not aware that a hole was left from the previous door lock set until it was identified during the survey. The Maintenance Director stated it was important that all corridor doors were properly sealed for the safety of the residents and staff. 2012 NFPA 101 19. 3. 6. 3 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 10, 2025 Door was repaired on 1/14/ 2025. Maintenance staff no longer employed. Education of Maintenance staff on importance of filling holes in doors when completing any work. The Director of Environmental Services will monitor compliance with a door audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure electrical installations were properly maintained and installed for 4 rooms. The 2012 edition of NFPA 99, Health Care Facilities Code, required all adaptors, extension cords, and attachment plugs to be listed for their purpose. The survey and certification letter 14-46-LSC issued by the Centers for Medicare and Medicaid Services required power strips used in conjunction with non-patient care related electrical equipment to be UL-1363 (relocatable power taps). Specifically, resident room A6 and resident room B11 had electrical items plugged into unapproved adapters; resident room A9 and resident room B2 had electrical items plugged into unapproved extension cords. Findings include: The Use of Extension Cords policy, last revised 1/30/2022, documented the following: - the resident admission packets would discuss in writing the prohibited use of non UL rated cords and power strips; and - the maintenance department would need to inspect all incoming cords and power strips to ensure compliance. On 1/8/2025 the following was observed: - at 9:35 AM, resident room A6 had two resident owned electrical picture frames plugged into an unapproved 3-prong adapter; - at 9:30 AM, resident room A9 had a television plugged into an unapproved extension cord; - at 9:52 AM, resident room B2 had a television plugged into an unapproved extension cord; and - at 10:02 AM, resident rom B11 had a resident owned string of lights plugged into an unapproved 3-prong adapter. During an interview on 1/10/2025 at 1:31 PM, the Maintenance Director stated they were not aware of the unapproved adapters and extension cords in the resident rooms. They stated any electrical items brought in by a family member were required to have been checked by the maintenance department for electrical safety, and that 3-prong adapters were not allowed. The Maintenance Director stated it was important that proper electrical adapters were used for the safety of the residents and staff. 2012 NFPA 99: 10. 2. 4 10NYCRR 415. 29(a)(2), 711. 2(a)(1) CMS S&C: 14-46-LSC | Plan of Correction: ApprovedMarch 5, 2025 All unapproved extension cords and adapts were removed. Updated form in place for new admissions so resident and families understand regulation and memo to all staff to help police building from unauthorized cords and adapters. All Staff have been educated on the importance of regular room checks to ensure that there are no uninspected extension cords in any room. Families are informed upon admission, in the admission agreement, of our policy. The Director of Environmental Services will monitor compliance with extension cord an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure electrical equipment was maintained in accordance with National Fire Protection Association 99 for 1 of 1 non-patient care related electrical equipment reviewed and 2 of 3 patient care related electrical equipment reviewed. Specifically, the resident room B6 electric tree, the beauty salon curling iron, and the C-Unit shower room hair dryer all lacked electrical inspection labels. Findings include: The facility's Electrical Equipment Safety Checks policy, last revised 1/3/2025, documented the following: - all electrical equipment needed to be inspected and maintained to ensure resident safety. This included facility medical electrical equipment and resident personal electronic equipment. - annual preventative maintenance was conducted based on initial assessment and in conjunction with the manufacturer's guidelines. 1. Non-Patient Care Related Electrical Equipment During an observation on 1/8/2025 at 10:00 AM, resident room B6 had an electric plastic tree that lacked an electrical inspection label. During an interview on 1/10/2025 at 3:45 PM, the Maintenance Director stated as per policy all electrical equipment was required to have been inspected by the maintenance department prior to entering resident rooms. They stated all staff had been in-serviced initially and annually that non-patient care related electrical equipment was required to have been electrically inspected. The Maintenance Director stated that the maintenance department staff would enter resident rooms monthly and would check the electrical equipment within these rooms, but that equipment was not currently tracked. The Maintenance Director stated it was important that all electrical equipment was maintained for the safety of the residents and staff. 2. Patient Care Related Electrical Equipment A. Curling Iron During an observation on 1/8/2025 at 10:15 AM, the beauty salon had a curling iron that lacked an electrical inspection label. During an interview on 1/10/2025 at 3:31 PM, the Maintenance Director stated they were not sure when the beauty salon curling iron had entered the facility, but if it had been inspected, then there would have been an electrical inspection label on it. B. Hair Dryer During an observation on 1/8/2025 at 10:30 AM, the C-Unit shower room had a hair dryer with an electrical inspection label dated 5/ 2022. During an interview on 1/10/2025 at 3:35 PM, the Maintenance Director verified the C-Unit shower room hair dryer did not have an electrical inspection label for 2023 or 2024. They stated there was no other documentation that this device had been electrically inspected in 2023 or 2024 as required in the Electrical Equipment Safety Checks policy. 2012 NFPA 99: 10. 5. 3 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 5, 2025 Small electric tree was removed, and both the curling iron and hair dryer were inspected. A revised quarterly inspection tracking sheets were implemented and a memo for staff to help the maintenance staff identify any new electrical equipment brought into the facility. All Maintenance Staff were educated on the importance of inspecting all electrical equipment within the building. The Director of Environmental Services will monitor compliance with an Electrical Device Audit quarterly, with 100% threshold, compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure that 1 of 1 diesel emergency generators were properly maintained in accordance with National Fire Protection Association (NFPA) 99. Specifically, the transfer time from main power to the 500-kilowatt diesel generator had not been documented; an annual fuel test had not been completed for 2023 and the 2024 fuel test failed; the three-year four-hour load test had not been completed; and an annual load bank test had not been completed for 2023 and 2024. Findings included: 1. Generator Transfer Time Not Documented The monthly generator test log, from 4/2023 to 7/2024, did not document the transfer time from the main power to the 500-kilowatt diesel emergency generator. During an interview on 1/10/2025 at 2:15 PM, the Maintenance Director stated they were not aware that documentation of the transfer time from main power to the generator was required until they had reviewed the generator testing regulations in (MONTH) of 2024, and their log was revised at that time to include the transfer time. 2. Annual Fuel Test The facility could not provide documentation the 2023 annual fuel test was completed for the 500-kilowatt diesel emergency generator. The 9/13/2024 fuel test report documented the sample failed and did not conform to the requirements. During an interview on 1/10/2025 at 2:30 PM, the Maintenance Director stated they were not aware that the diesel for the 500-kilowatt generator was required to have been tested annually until they reviewed the generator testing regulations in 9/ 2024. They stated it was important that water and other contaminants did not mix with the fuel because this would cause generator failure. 3. Three-Year Four-Hour Load Test Not Completed The facility's Generator Test Log documented on 3/4/2024 the generator ran for 4 hours and 15 minutes during a scheduled outage. However, the actual load on the generator could not be calculated from the information recorded on their form. During an interview on 1/10/2025 at 2:45 PM, the Maintenance Director stated a three-year four-hour load test had been completed on 3/4/2024 and they assumed the load was 30 percent or greater. They were not aware of what the amperage value had to be to for the 500-kilowatt diesel generator to achieve a 30 percent load value. The Maintenance Director stated they were not aware that the amperage value had to be 226 or greater and therefore the amperage value of 200 that was recorded on their form was not 30 percent load or greater. They stated it was important to know the correct values while calculating generator load values, so they ensured the proper testing was completed. 4. Annual Load Bank Test Not Completed The monthly generator test log, from 4/2023 to 11/2024, documented the monthly load tests for the 500-kilowatt diesel emergency generator were under 30 percent. The facility did not have documentation for the required annual 1. 5-hour load bank test for 2023 and 2024. During an interview on 1/10/2025 at 2:55 PM, the Maintenance Director stated they had assumed all of the monthly load tests that were completed had been 30 percent or greater. They were not aware of what the amperage value had to be to for the 500-kilowatt diesel emergency generator to achieve a 30 percent load value. They were not aware that if monthly load values were under 30 percent the facility, then an additional annual 1. 5-hour load bank test was required. 2012 NFPA 101: 9. 1. 3. 1, 19. 5. 1 2012 NFPA 99: 6. 5. 3. 1, 6. 4. 3. 1 2010 NFPA 110: 8. 3. 8, 8. 4. 2. 3, 8. 4. 9. 5. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Generator Transfer Time Transfer times are now being recorded on the generator log since 1/13/ 2025. All Maintenance staff were educated on the importance of properly recording generator transfer times. 2. Annual Fuel Test In discussing with the fuel testing company, our fuel did not ?ôfail?Ø because of hi [MEDICATION NAME]. It showed ?ôfailed?Ø because the test measures for [MEDICATION NAME] due to an EPA regulation for ?ôon-the-road?Ø fuel. Our generator takes residential fuel that is ?ôlow [MEDICATION NAME]Ø and will never meet the ?ôon the road?Ø standard with an ?ôultra-low?Ø formula. This part of the report is NOT-APPLICABLE since the generator and the ?ôlow [MEDICATION NAME]Ø fuel it uses is not for an ?ôon the road?Ø use. 3. Three-Year Four-Hour Load Test Crouse Community Center has scheduled a load bank test with the generator vendor on 3/19/2025 to ensure proper load requirement and will conduct the four-hour load test on 3/19/2025 once proper load is confirmed. 4. Annual Load Bank Test Crouse Community Center has scheduled a load bank test on 3/19/2025 to ensure compliance with proper load requirement. All Maintenance Staff were educated on the importance of accurate readings to reflect that the generator is running at 30%. They were also educated on the importance of the four-hour load test as well as the annual load bank testing. The Director of Environmental Services will monitor compliance with a generator testing that includes transfer time and load amount during testing, both with a 100% threshold, and report the results to the Quality Assurance Committee quarterly |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure that the emergency lighting was tested and maintained for 1 of 1 emergency lights (basement generator room). Specifically, the annual 90-minute run test for the battery-operated emergency light in the generator room had not been completed in 2023 and 2024; and the monthly 30-second run test was not documented from (MONTH) 2023 to December 2024. Findings include: The facility could not provide documentation that the basement generator room battery-operated emergency light annually 90-minute run test had been completed in 2023 and 2024, or that the monthly 30-second run tests were completed from (MONTH) 2023 to December 2024. During an observation on 1/8/2025 at 12:10 PM, the basement generator room had a battery-operated emergency light. During an interview on 1/8/2025 at 12:10 PM, the Maintenance Director stated the basement generator room battery operated emergency light had not been tested monthly for 30-seconds or annually for 90-minutes. During an interview on 1/10/2025 at 1:05 PM, the Maintenance Director stated they were not aware that basement generator room battery operated emergency light was required to be tested monthly for 30-seconds and annually for 90-minutes. 2012 NFPA 101: 19. 2. 9. 1, 7. 9 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 5, 2025 The Maintenance staff was trained on the importance of emergency lighting in the generator room and the importance of monthly and annual testing of the emergency lighting and correctly documenting it on a newly revised form. Ninety Minute test run on (MONTH) 9, 2025, 30 second tests were run on (MONTH) 12, 2025 & 3/3/ 2025. The Director of Environmental Services will monitor compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure fire drills were completed as required for 1 of 3 shifts. Specifically, the evening shift fire drill was not completed for the first quarter of 2024. Findings include: The facility could not provide documentation that an evening shift fire drill had been completed for the first quarter of 2024. During an interview on 1/10/2025 at 1:00 PM, the Maintenance Director stated the evening shift fire drill for the first quarter of 2024 was missed. They stated they were aware that fire drills were required to be completed quarterly for each shift, and it was important that all fire drills were completed for the safety of the residents and staff. 2012 NFPA 101: 19. 7. 1 10NYCRR 415. 29(a)(1&2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 5, 2025 Fire drills are up to date. Maintenance Director will preplan quarterly fire drills to ensure no shift is every missed going forward. All Maintenance Staff have been educated on the importance of fire drills, including maintaining the quarterly schedule per shift. The Director of Environmental Services will monitor compliance with a fire drill audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on record review, observation, and interview during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure that the medical gas and vacuum system was inspected and maintained in accordance with the National Fire Protection Association (NFPA) 99: Health Care Facilities code. Specifically, the medical gas and vacuum system had deficiencies that had not been corrected. Findings include: The 2/1/2024 annual medical gas and vacuum system inspection report documented the following deficiencies: - the vacuum source system had inadequate electrical controls and was missing hour meters; and - the vacuum source system did not have a lag alarm. During an interview on 1/10/2025 at 1:45 PM, the Maintenance Director stated they were not aware of the deficiencies identified in the 2/1/2024 annual medical gas and vacuum system inspection report. They stated these deficiencies had not yet been repaired because they were never told by the third-party vendor that there was deficient equipment. They stated it was important that all components of the medical gas and vacuum system were maintained so the system could properly function when needed. During an observation on 1/10/2025 at 3:07 PM, the basement medical gas system did not have any label that documented it had failed the 2/1/2024 annual testing. 2012 NFPA 99 5. 1. 14. 2. 3 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 5, 2025 The vacuum system will be decommissioned on 2/20/2025 Additional Portable suction devices were ordered and received. All Staff have been educated on the decommissioning of previous vacuum system and the implementation of the portable suction machines to be used in it's place. The Director of Environmental Services will monitor all vendor reports to ensure no repairs are recommended in the notes of any section and complete an audit, with 100% threshold, to report to the Quality Assurance Committee Quarterly. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure their automatic sprinkler system was maintained properly. Specifically, a quarterly sprinkler system inspection was not completed for the third quarter of 2024; the basement upper device backflow prevention device failed and had not been repaired; the A-Unit janitor's closet had a missing ceiling tile; and the main kitchen had open holes through the ceiling tiles. Findings include: 1. Quarterly Sprinkler Inspection Not Completed The facility could not provide a sprinkler system inspected for the third quarter of 2024. During an interview on 1/10/2025 at 1:55 PM, the Maintenance Director stated they had not realized the third quarter of 2024 inspection had not been completed until the fourth quarter had already started. They stated that after the fourth quarter of 2024 sprinkler system inspection had been scheduled with the sprinkler vendor, the vendor had verified the third quarter inspection was skipped. The Maintenance Director stated it was important that all quarterly sprinkler system inspections had been completed for the safety of the residents and staff. 2. Failed Backflow Prevention Device The 2/8/2024 backflow prevention device testing report for the basement upper device documented that this device did not meet the requirements of an acceptable containment device at the time of the testing. During an interview on 1/10/2025 at 1:55 PM, the Maintenance Director stated they were not aware the basement upper backflow prevention device had failed during its annual testing on 2/8/ 2024. The Maintenance Director stated that the basement upper backflow prevention device had not been repaired. They stated it was important that all backflow devices were properly functioning for the safety of the residents and staff. During an observation on 1/10/2025 at 3:05 PM, the basement upper backflow prevention device did not have any label that documented it had failed the 2/8/2024 annual testing. 3. Ceiling Tiles Not Maintained During an observation on 1/8/2025 at 9:25 AM, the A-Unit janitor's closet ceiling was missing 6-inch by 18-inch ceiling tile. During an observation on 1/8/2025 at 11:28 AM, the main kitchen ceiling by the dish machine area had three small holes in it. There was a 1/2-inch circular hole, a 1-inch by 2-inch hole, and 2-inch by 2-inch hole. During an interview on 1/10/2025 at 1:55 PM, the Maintenance Director stated they were not sure why there was a missing ceiling tile in the A-Unit janitor's closet because they had not received any work orders letting them know there was a problem, and all staff members were trained how to submit work orders. They were not sure how long it had been missing because this room was not usually checked during daily building checks. They stated the daily building checks included checking the main kitchen for any issues, but they had not been notified about the holes in the main kitchen ceiling tiles. The Maintenance Director stated it was important that all ceiling tiles were smoke tight so smoke would not spread to other areas. 2012 NFPA 101: 19. 3. 5. 1, 9. 7. 5 2011 NFPA 25: 5. 1 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedMarch 5, 2025 Sprinkler system inspections are up to date in 2025. The backflow devices were inspected and repaired on 2/5/ 2025. A third backflow is now decommissioned. Missing ceiling tile was replaced. Going forward the Director of Environmental Services will have calendar reminders on when quarterly inspections are due and ensure they are completed timely. New Vendor has been selected to inspected and repair backflows immediately if necessary. Ceiling tile visual inspections will be added to the daily tour logs to ensure no tiles are damaged or missing. All Maintenance staff have been educated on the importance of complying with quarterly sprinkler inspections. Director of Facilities also educated staff on why it is important to review inspection report prior to signing report repairs. The Director of Environmental Services will monitor compliance with audits that tracks scheduled quarterly sprinkler inspections, backflow inspections, and ceiling tile visual inspections with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code recertification survey conducted 1/8/2025-1/10/2025, the facility did not ensure smoke barrier doors were properly maintained for 2 of 6 smoke barriers. Specifically, the F-Unit smoke barrier and the D-Unit smoke barrier had unsealed wire penetrations. Findings include: On 1/10/2025, between 10:13 AM and 10:23 AM, the following was observed: - at 10:13 AM, the F-Unit smoke barrier had an unsealed cable wire that passed through the wall; and - at 10:23 AM, the D-Unit smoke barrier had an unsealed data wire that passed through the wall. During an interview on 1/10/2025 at 12:51 PM, the Maintenance Director stated they were not aware of the unsealed smoke barrier penetrations. They stated the facility smoke barriers were checked quarterly, but they had not followed up behind the smoke barrier check that was completed on 12/20/ 2025. They stated the cable wire that passed through the F-Unit smoke barrier had been installed in July 2024. The Maintenance Director stated it was important that all smoke barriers were properly sealed to prevent the spread of smoke and fire into other areas of the facility. The facility's Smoke Wall Checks documented the D Wing and F Wing were good. The form was only dated in line with the A Wing and last completed on 12/20/ 2024. 2012 NFPA 101 19. 3. 7. 3 10NYCRR 415. 29(a)(2), 711. 2(a)(1) | Plan of Correction: ApprovedFebruary 10, 2025 Wall penetrations were repaired on 1/14/2025 Maintenance Staff was inserviced on the importance of sealing any wall penetrations when completing work The Director of Environmental Services will monitor compliance with a smoke wall penetration audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly. |