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Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review conducted during an extended Standard survey completed on 2/3/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure abuse and neglect reporting policies and procedures were updated and consistently implemented. This has the potential to affect all residents residing in the facility. The findings are: REFER TO: F 600 - Free from Abuse and Neglect F 607 - Develop/Implement Abuse/Neglect Polices F 609 - Reporting Alleged Violations Review of the policy and procedure titled Abuse/Neglect - Reporting Process dated 12/2015 documented at any time when a visitor or staff member witnesses or is made aware of possible resident abuse or neglect, the following procedure must be implements: The employee will report the incident to the Nursing Supervisor immediately and will initiate an Incident/Accident Report. The Nursing Supervisor will notify the Administrator and Nursing Director. The Administrator and/or Nursing Director will take responsibility for notifying the State Health Department within five working days that resident abuse/neglect has occurred. During an interview on 1/30/25 at 10:21 AM, the Director of Nursing stated the most recent Abuse/Neglect - Reporting Process policy and procedure was last revised in December 2015. During an interview on 2/3/25 at 9:36 AM, the Director of Nursing stated they rely on the Risk Management Team to do the investigation and rule out abuse or neglect when staff were involved. They stated policies were reviewed a couple time of month during a meeting that included the Director of Nursing, Administrator, Medical Records, Inservice Coordinator/Infection Preventionist and sometimes the Assistant Director of Nursing. Policies were reviewed and updated based on Quality Assurance projects. They stated they were unaware of the updated regulations for reporting allegations of suspected abuse/neglect and expected a big email or a Dear Administrator Letter would have been sent to the Administrator or themselves During an interview on 2/3/25 at 1:31 PM, the Administrator stated they would usually get updated on new and changes in regulations through letters posted in the secure online system that allows New York State health department, providers, and facilities to share health information and there were a lot of changes between 2020 and 2024. They believed the change in the regulation for reporting was in 2022 and they must have missed that specific letter. Their policy was last reviewed in (YEAR) and should have been updated by the Policy and Procedure Team. The Policy and Procedure Team were responsible for updating policies and procedures included the Administrator and Director of Nursing. They stated the policy should have been updated so the facility could stay within compliance of state guidelines. During an interview on 2/3/25 at 3:28 PM, County Legislature #1 stated they were part of the governing board that oversees the facility. They stated they believed the Administrator was updating their policies and procedures, as expected. County Legislature #1 stated it was expected all policies and procedure were reviewed and updated because they should be up to date with the current regulations. 10 NYCRR 415. 26 | Plan of Correction: ApprovedFebruary 26, 2025 Administration has updated the abuse and neglect reporting policies and procedures to reflect current regulatory language. This updated policy will be consistently implemented so that the facility is administered in a manner that enables it to use its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. Special attention will be paid to reporting time-frames to assure information in conveyed within guidelines set forth. An audit of all policies and procedures related to reporting incidents to the New York State Department of Health will be reviewed to assure they reflect the most current guidance. Administration will review state and federal guidance released within the past six months, as well as new guidance as it is released to assure any changes are implemented as directed and that additional staff are educated. The facility has hired a healthcare consultant to assist in establishing methodologies for ensuring compliance with state and federal regulations. The policy related to reporting abuse and neglect has been updated to reflect the most current guidance and to provide clear language of the procedures to be followed so they specifically align with regulations and reporting time-frames. Administrative staff will subscribe to state and federal long term care list serves, and monitor industry organization updates, like those sent by LeadingAge NY, of which the facility is a member. Administrative staff will receive in-service training on this policy and procedure to assure understanding. Audits of incidents reported to the state department of health will be completed as they occur to assure immediate compliance with reporting guidelines. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Administrator will be responsible for ongoing compliance with these corrective measures. |
Scope: N/A
Severity: N/A
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey completed on 2/3/25, the facility did not meet the requirements of the New York State Department of Health Criminal History Record Check. Specifically, the facility did not have continuing documentation for the weekly supervision of employees that were subject to the New York State Department of Health Criminal History Record Check and had not yet received a determination letter from the Criminal History Record Check Legal Review Unit. This affected, two (Employee #6, agency Certified Nurse Aide and Employee #7, Food Service Helper) of two employees reviewed for Criminal History Record Check negative determination findings did not have continuing documentation for their weekly supervision in their personal files. The findings are: Review of the facility policy and procedure titled Criminal History Record Check dated 9/2021 documented, it is the policy of this facility to: Require a Criminal History Record Check on all new non-licensed employees hired or used after (MONTH) 6, 2006, who will provide care or supervision to residents. The provisional employee may be approved for work while the results of the Criminal History Record Check are pending. A direct supervision sheet will be completed by the provisional employee's direct supervisor for each day of work until the Criminal History Record Check results have returned. This provisional employee is monitored by the authorized person and the Nursing Supervisor. 1a. Review of the employee file for Employee #6, (Certified Nurse Aide) revealed the employee was hired on 1/26/24 and the file contained a Criminal History Record Check Direct Supervision Dates of Provisional Period sheet dated 1/31/24 and 2/1/ 24. Further review of the file revealed it contained a Criminal History Record Check Legal Review Unit negative determination letter (Hold in Abeyance) for the employee dated 2/9/24 and a time sheet that documented the employee worked at the facility on 2/11/24 from 1:59 PM to 10:51 PM. During an interview on 1/30/25 at 12:44 PM the Infection Control/ In-service Coordinator (Authorized Person for Criminal History Record Check) stated the only supervision documentation the facility had for Employee #6 was the Criminal History Record Check Direct Supervision Dates of Provisional Period sheet dated 1/31/24 and 2/1/ 24. The Infection Control/ In-service Coordinator (Authorized Person for Criminal History Record Check) further stated they were not an Authorized Person for Criminal History Record Check when Employee #6 was hired, and they were not involved with the Criminal History Record Check process at that time. 1b. Review of the employee file for Employee #7, (Food Service Helper) revealed the employee was hired on 11/7/23 and the file contained a Criminal History Record Check Direct Supervision Dates of Provisional Period sheet dated 11/7/23, 11/8/23, 11/9/23, 11/13/23, 11/15/23, 11/28/23, and 12/2/ 23. Further review of the file revealed it contained a Criminal History Record Check Legal Review Unit negative determination letter (Pending Denial) for the employee dated 2/15/24 and Time and Attendance sheets that documented the employee worked at the facility on: -2/15/24 from 10:00 AM to 3:03 PM. -2/17/24 from 10:04 AM to 7:52 PM. -2/18/24 from 8:30 AM to 7:48 PM. -2/20/24 from 10:01 AM to 6:30 PM. -2/21/24 from 10:07 AM to 8:07 PM. During an interview on 1/30/25 at 12:55 PM the Infection Control/ In-service Coordinator (Authorized Person for Criminal History record Check) stated the only supervision documentation the facility had for Employee #7 was the Criminal History Record Check Direct Supervision Dates of Provisional Period sheet dated 11/7/23, 11/8/23, 11/9/23, 11/13/23, 11/15/23, 11/28/23, and 12/2/ 23. The Infection Control/ In-service Coordinator (Authorized Person for Criminal History Record Check) further stated they were not an Authorized Person for Criminal History Record Check when Employee #7 was hired, and they were not involved with the Criminal History Record Check process at that time. During an interview on 1/30/25 at 12:57 PM the Administrator stated the only supervision documentation the facility had for Employee #6 and Employee #7 were the Criminal History Record Check Direct Supervision Dates of Provisional Period sheets that were previously provided by the facility. 402. 6(d) | Plan of Correction: ApprovedMarch 3, 2025 The employees found to have been missing their criminal history record check weekly supervision documentation have since been cleared for employment and no longer require weekly supervision or documentation of supervision. A review of the last three months of new hires will be completed to determine if any other employees were missing their criminal history record check weekly supervision documentation. Those identified as missing supervision will be noted, and if they continue to lack final criminal history record check clearance for employment, supervision will resume as required by state regulation. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for employee supervision when record check results are pending. A supervision sheet for each employee is created and held within the department providing supervision to the new employee. When final criminal history record check results are received, the supervision document will marked complete and filed. Staff will be educated to ensure documentation for the weekly supervision of employees that were subject to the New York State Department of Health Criminal History Record Check and had not yet received a determination letter from the Criminal History Record Check Legal Review Unit. All supervisory staff will be educated on these procedures. An audit of criminal history record check supervision documents will be completed weekly for eight weeks to assure that new employees are being supervised weekly per state regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures. |
Scope: N/A
Severity: N/A
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey completed on 2/3/25, the facility did not meet the requirements of the New York State Department of Health Criminal History Record Check. Specifically, the facility did not immediately remove an employee from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. This affected one (Employee #7, Food Service Helper) of two employees reviewed for Criminal History Record Check negative determination findings. The finding is: According to New York State Regulations Part 402 Criminal History Record Check, employee in direct care and supervision is defined as any unlicensed person employed by or used by a nursing home, licensed pursuant to Article 28 of the Public Health Law, who has physical access to a resident's living quarters, or any unlicensed person providing face-to-face care following the resident's care plan. Review of the facility policy and procedure titled Criminal History Record Check (CHRC) dated 9/2021 documented, it is the policy of this facility to: Require a Criminal History Record Check on all new non-licensed employees hired or used after (MONTH) 6, 2006, who will provide care or supervision to residents. Upon email notification, Criminal History Record Check letters will be viewed and appropriate actions are taken as directed in the letters. If a disapproval letter for an employee is received, the provisional employee will be removed immediately from direct care or supervision of residents and will be notified that the Criminal History Record Check information is the reason for disapproval. Review of the employee file for Employee #7, (Food Service Helper) revealed the employee was hired on 11/7/23 and the file contained a Criminal History Record Check Legal Review Unit negative determination letter (Pending Denial) for the employee dated 2/15/ 24. Review of Time and Attendance sheets provided by the facility revealed Employee #7 had worked in the facility on: -2/15/24 from 10:00 AM to 3:03 PM. -2/17/24 from 10:04 AM to 7:52 PM. -2/18/24 from 8:30 AM to 7:48 PM. -2/20/24 from 10:01 AM to 6:30 PM. -2/21/24 from 10:07 AM to 8:07 PM. Review of the Food Service Helper job description revised date 1/9/23 documented: distinguishing features of this class: This is routine manual work performed under the immediate supervision in connection with preparation of a service in a cafeteria and cleaning of kitchen equipment, silver, and dishes. Food Service Helper does related work as required. Typical work activities: Sets tables, service food from steam tables in a cafeteria-type dining hall, clears tables and dirty dishes, cleans tables, chairs, serving tables, and other equipment. During an interview on 1/29/25 at 3:11 PM the Administrator stated the facility's Criminal History Record Check Authorized Person at the time Employee #7 was hired was only checking for Criminal History Record Check information in the morning and not in the afternoon, and they had missed the employee's Pending Denial letter. 402. 7(a)(2)(i) | Plan of Correction: ApprovedMarch 3, 2025 The employee not immediately removed for direct contact or supervision of residents upon receiving New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter (Pending Denial) was removed from direct contact once the determination letter was viewed and has since been cleared to return to employment at the facility. A review of the last three months of new hires will be completed to determine if any other employees were not immediately removed for direct contact or supervision of residents upon receipt of New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter documentation. No other employees were found. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for frequently checking the criminal history check result reports to assure that any negative determination letters are acted upon immediately, without delay. Additionally, systems will be place for alternate authorized users of the New York State Department of Health Criminal History Record Check (NYSDOH CHRC) to check for results in the absence of the primary user. Staff be educated to ensure employees are immediately removed from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. Authorized persons and supervisory staff will be educated on this procedure. An audit of criminal history record check online results will be completed weekly for eight weeks to assure that any negative determination letters are viewed and acted upon the day of receipt. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures. |
Scope: N/A
Severity: N/A
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review during a Standard survey completed on 2/3/25, the facility did not meet the requirements of the New York State Department of Health Criminal History Record Check. Specifically, the facility did not immediately remove an employee from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. This affected one (Employee #6, Certified Nurse Aide) of two employees reviewed for Criminal History Record Check negative determination findings. The finding is: According to New York State Regulations Part 402 Criminal History Record Check, employee in direct care and supervision is defined as any unlicensed person employed by or used by a nursing home, licensed pursuant to Article 28 of the Public Health Law, who has physical access to a resident's living quarters, or any unlicensed person providing face-to-face care following the resident's care plan. Review of the facility policy and procedure titled Criminal History Record Check (CHRC) dated 9/2021 documented, it is the policy of this facility to: Require a Criminal History Record Check on all new non-licensed employees hired or used after (MONTH) 6, 2006, who will provide care or supervision to residents. Upon email notification, Criminal History Record Check letters will be viewed and appropriate actions are taken as directed in the letters. If a disapproval letter for an employee is received, the provisional employee will be removed immediately from direct care or supervision of residents and will be notified that the Criminal History Record Check information is the reason for disapproval. Review of the employee file for Employee #6, (Certified Nurse Aide) revealed the employee was hired on 1/26/24 and the file contained a Criminal History Record Check Legal Review Unit negative determination letter (Hold in Abeyance) for the employee dated 2/9/ 24. Review of a time sheet provided by the facility revealed the employee worked on 2/11/24 from 1:59 PM to 10:51 PM. During an interview on 1/29/25 at 3:11 PM the Administrator stated the facility's Criminal History Record Check Authorized Person at the time Employee # 6 was hired was only checking for Criminal History Record Check information in the morning and not in the afternoon, and they had missed the employee's Hold in Abeyance letter. 402. 7(a)(4) | Plan of Correction: ApprovedMarch 3, 2025 The employee not immediately removed for direct contact or supervision of residents upon receiving New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter (Hold in Abeyance) was removed from direct contact once the determination letter was viewed and has since been cleared to return to employment at the facility. A review of the last three months of new hires will be completed to determine if any other employees were not immediately removed for direct contact or supervision of residents upon receipt of New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter documentation. No other employees were found. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for frequently checking the criminal history check result reports to assure that any negative determination letters are acted upon immediately, without delay. Additionally, systems will be place for alternate authorized users of the New York State Department of Health Criminal History Record Check (NYSDOH CHRC) to check for results in the absence of the primary user. Staff be educated to ensure employees are immediately removed from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. Authorized persons and supervisory staff will be educated on these procedures. An audit of criminal history record check online results will be completed weekly for eight weeks to assure that any negative determination letters are viewed and acted upon the day of receipt. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review conducted during an a Complaint investigation (#NY 289, #NY 807, #NY 814, #NY 482, #NY 719, #NY 779, #NY 581, and #NY 961) during the extended Standard survey completed on 2/3/25, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. In addition the facility did not ensure their abuse reporting policy and procedures were updated to include current regulations and guidance. Specifically, the facility did not ensure their policy for abuse reporting was current. This affected 10 (Residents #17, 30, 42, 47, 68, 71, 72, 75, 95, and #161) of 12 residents reviewed. Additionally, one (Employee #4, agency Licensed Practical Nurse) of seven employees that worked in the facility and were subject to the New York State Nurse Aide Registry Verification, was not reviewed through the New York State Nurse Aide Registry prior to their employment as required. This resulted in no actual harm with the potential for more than minimal harm with the likelihood to affect all residents and is substandard quality of care. The findings are: REFER TO: F 609 - Reporting of Alleged Violations Review of the policy and procedure titled Abuse/Neglect - Reporting Process dated 12/2015 documented at any time when a visitor or staff member witnesses or is made aware of possible resident abuse or neglect, the following procedure must be implements: The employee will report the incident to the Registered Nurse Nursing Supervisor immediately and will initiate an Incident/Accident Report. The Nursing Supervisor will notify the Administrator and Nursing Director. The Administrator and/or Nursing Director will take responsibility for notifying the State Health Department within five working days that resident abuse/neglect has occurred. Review of the policy and procedure titled Abuse Prevention and Reporting dated 9/2023 documented, all facility applicants will be screened by the hiring manager or their designee for abuse by checking the on-line New York Nurse Aide Registry Prometric.com and printing a copy of the report for submission with all new hire paperwork prior to the first day of employment. All non-licensed staff will be finger-printed per New York State Department of Health regulations via the Criminal History Check module of the New York State Health Commerce System (HCS). The policy did not include a timeline of when the New York State Department of Health was to be notified. 1. Review of the State Operational Manuals issued 11/22/2017 and 8/8/2024 documented to Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. During an interview on 1/30/25 at 10:21 AM, the Director of Nursing stated the most recent Abuse/Neglect - Reporting Process policy and procedure was last revised in December 2015. They stated the policies were reviewed at the facility. During an interview on 2/3/25 at 9:36 AM, the Director of Nursing stated they rely on the Risk Management Team to do the investigation and rule out abuse or neglect when staff were involved. They stated policies were reviewed a couple time of month during a meeting that included the Director of Nursing, Administrator, Medical Records, Inservice Coordinator/Infection Preventionist and sometimes the Assistant Director of Nursing. Policies were reviewed and updated based on Quality Assurance projects. They stated they were unaware of the updated regulations for reporting allegations of suspected abuse/neglect and expected a big email or a Dear Administrator Letter would have been sent to the Administrator or themselves. During an interview on 2/3/25 at 1:31 PM, the Administrator stated they would usually get updated on new and changes in regulations through letters posted in the secure online system that allows New York State health department, providers, and facilities to share health information and there were a lot of changes between 2020 and 2024. They believed the change in the regulation for reporting was in 2022 and they must have missed that specific letter. Their policy was last reviewed in (YEAR) and should have been updated by the Policy and Procedure Team. The Policy and Procedure Team were responsible for updating policies and procedures included the Administrator and Director of Nursing. They stated the policy should have been updated so the facility could stay within compliance of state guidelines. 2. Review of the employee file for Employee #4's (agency Licensed Practical Nurse) revealed the employee was hired on 12/15/ 24. Review of the timesheets provided by the facility revealed Employee #4 had worked in the facility on: - 12/15/24 from 1:30 PM to 10:45 PM. - 12/21/24 from 1:45 PM to 10:30 PM. - 12/22/24 from 2:00 PM to 10:30 PM. - 12/25/24 from 2:00 PM to 10:30 PM. - 12/28/24 from 2:00 PM to 10:30 PM. - 12/29/24 from 2:00 PM to 10:30 PM. - 1/1/25 from 2:00 PM to 10:30 PM. - 1/4/25 from 2:00 PM to 10:30 PM. - 1/5/25 from 2:00 PM to 10:30 PM. - 1/11/25 from 2:00 PM to 10:30 PM. - 1/12/25 from 2:00 PM to 10:30 PM. - 1/18/25 from 2:00 PM to 10:30 PM. - 1/19/25 from 2:00 PM to 10:30 PM. - 1/25/25 from 2:00 PM to 11:15 PM. During an interview on 1/29/24 at 2:20 PM, the Administrator (Authorized Person for Criminal History record Check) and the Infection Control/ In-Service Coordinator (Authorized Person for Criminal History record Check) stated employee #4 was hired to work at the facility as a Licensed Practical Nurse. The New York State Department of Health will be notified by the Nursing Director and/or Administrator when there is reasonable cause to believe that abuse has occurred. During an interview on 1/30/25 at 9:16 AM the Administrator stated the facility had no documentation that a New York State Nurse Aide Registry Verification report had been completed for Employee #4 prior to their employment at the facility. 10 NYCRR 415. 4(b) | Plan of Correction: ApprovedFebruary 26, 2025 F- 607 ÔÇ£ Develop/Implement Abuse/Neglect Policies I. Per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: Resident #17: o Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents o An assessment by a Registered nurse was completed on each altercation. No injuries were identified. o Resident #17s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging o A Social Services assessment completed to ensure there were no negative psychosocial impact due to the altercations and subsequent room changes. Resident #30: o An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice o A Social Services assessment completed to ensure there were no negative psychosocial impact. o Certified Nursing Assistant #5 will be re-educated on their role to review the care plan prior to providing care. Resident #42: o An assessment by a Registered nurse was completed. No additional injuries were identified o A Social Services assessment completed to ensure there were no negative psychosocial impact. o Certified Nursing Assistant #4 is no longer employed by the facility. Resident #47: o An assessment by a Registered nurse was completed. No injuries were identified o A Social Services assessment completed to ensure there were no negative psychosocial impact. o An investigation was conducted and allegation unfounded for sexual abuse. o Certified Nursing Assistant #9 was re-educated, was re-assigned from providing care to resident # 47. Resident #68: o Assessments by a Registered Nursing and Physician were completed. No injuries were identified. o A Social Services assessment will be completed to ensure there were no negative psychosocial impact. o Additional signage will be placed on the residents door to deter others from wandering into the residents room. Resident #71: o Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. o The residents care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. o A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident Resident #72 o Assessments by a Registered Nursing were completed. No injuries were identified. o A Social Services assessment will be completed to ensure there were no additional negative psychosocial impacts related to the incident. Resident #75: o Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. o An assessment by a registered nurse was completed following each altercation. No injuries were identified. o The resident was moved to a different unit on 12/11/24 o Resident #75s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due possessiveness. o A Social Services assessment will be completed to ensure there were no negative psychosocial impact related to the resident to resident altercations and the subsequent room change. Resident #95: o Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. o A Social Services assessment completed to ensure there were no negative psychosocial impact Resident #161: o The resident was discharged from the facility on 7/26/ 24. o A review of the residents medical record indicate no additional injuries or negative psychosocial impact o Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. o Certified Nursing Assistant #4s employment was terminated. A New York State Nurse Aide Registry Verification report was obtained for the Employee Licensed Practical Nurse # 4. No findings were noted. The Administrator, Director of Nursing and Assistant Director of Nursing, were educated on the State Operations Manual timeframe reporting requirements for abuse reporting by the consultant The Administrator, Director of Nursing, Assistant Director of Nursing and the Infection Control/In-Service Coordinator were educated on the requirement for pre-employment screening for all regular and agency staff via the New York Nurse Aide Registry by the consultant II. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. o All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect or mistreatment. The care plan of any identified resident will be reviewed and updated accordingly for risk Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness and ensure interventions are initiated in an effort to prevent abuse. o Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. o All regular and agency staff personnel records will be reviewed to ensure the Nurse Aide Registry screening has been completed. III. Per the Directed Plan of Correction the following system changes will be implemented to ensure continuing compliance with regulations: The policy titled ?ôAbuse/Neglect - Prevention and Reporting Process?Ø has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. The facility hiring policy will be reviewed by the consultant with administration and nursing leadership and a check list provided to ensure all pre-employment procedures including Nurse Aide Registry Checks are completed prior to starting work. As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address: o Abuse Identification, Prevention and Reporting: ?é- All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing staff immediately to prevent further abuse and implementation of interventions to prevent recurrence. o State and Federal Regulations on Incident and Abuse Reporting: ?é- The Administrator and Director of Nursing and facility leadership (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence and immediate removal of any staff alleged to be involved, o Nurse Aide Registry. All facility leadership staff will be educated by the consultant on the updated hiring policy/process and check list specifically to ensure the nurse aide registry is reviewed prior to hiring both regular and agency staff. o Regulatory Changes: All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. o All training components will be added to initial orientation and annual education for facility and agency staff. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Co |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during a Complaint investigation (#NY 814, #NY 482, #NY 961) during an extended Standard survey completed on 2/3/25, the facility did not ensure that all residents care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for three (Residents # 30, 42, & 161) of three resident's reviewed. Specifically, care plan interventions were not followed by staff. Issues included: protective sleeves (#30), and shorts (#42) were not provided as planned, and a side rail was left in the up position when care was not being provided (#161) all breaks in implementation resulted in minor injuries. The findings are: The policy and procedure titled Comprehensive Care Plans last revised 10/23 documented it is the responsibility off all staff that are providing hands on care to consult and follow the Comprehensive Care Plan and Kardex. All staff are trained upon orientation and annually that compliance with all directives on a resident's care plan/Kardex are expected to be followed at all times. 1. Resident #30 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 7/29/24 documented Resident #30 was moderately cognitive impaired, was sometimes understood and sometimes understands. They required partial/moderate assistance with upper body dressing. The comprehensive care plan dated 7/23/24 documented Resident #30 had fragile skin and had the potential for impaired skin integrity. The planned interventions included one assist for dressing and bilateral arm (protective sleeves) while out of bed. The Kardex Report (a guide used by staff to provide care) with an as of date of 9/16/24 documented bilateral (both) arm (protective sleeves) on in the morning and off at bedtime. Review the facility accident and incident investigation dated 9/13/24 completed by Registered Nurse #4 documented at 10:00 AM, Resident #30 was not wearing the (protective sleeves) and sustained a skin tear to their right forearm while repositioning themselves in their wheelchair. Review of the nursing progress notes dated 9/13/24, Registered Nurse #4 documented at 10:29 AM Resident #30 rearranged themselves in their wheelchair, hit their right upper arm on the arm rest, and sustained a skin tear. Review of the Risk Management Nursing Home Investigation dated 9/16/24 documented Certified Nurse Aide #5 did not provide Resident #30's (protective sleeves) on 9/13/ 24. The care plan violation resulted in a skin tear to Resident #30's right upper arm. During an observation and interview on 1/28/25 at 9:50 AM, Resident #30 was wearing (protective sleeves) on both arms with long sleeves and stated the sleeves protected their skin so if they bumped into things, the skin protectors prevented their skin from splitting as their skin was frail. During an interview on 1/31/25 at 12:36 PM, Certified Nurse Aide #5 stated they were aware Resident #30's care plan reflected the (protective sleeves) to protect their skin from injury and checked the care plan prior to care for resident safety. They provided personal care on 9/13/24 for Resident # 30. The (protective sleeves) were not in Resident #30's room, then got pulled to another unit during care and putting the (protective sleeves) on slipped my mind. During an interview on 2/3/25 at 12:19 PM, Registered Nurse #4 stated following the care plan prevented injuries to the residents. Certified Nurse Aide #5 should have informed the nurse the (protective sleeves) were missing. Having the (protective sleeves) on may have prevented the skin tear. All staff were responsible for following the care plan. 2. Resident #42 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #42 had severe cognitive impairments, was rarely understood and rarely understands. Resident #42 was dependent on staff assistance for dressing. The comprehensive care plan revised on 3/9/22 documented Resident #42 had an activity of daily living self-care deficit. Interventions included one staff assist for turning and repositioning, shorts on at all times and one staff assistance for lower body dressing. The Kardex Report dated 12/6/24 documented Resident #42 was to have shorts on at all times, under both bed mobility and dressing categories. Review of the self-inflicted injury report dated 12/6/24, Registered Nurse Supervisor #1 documented there were three scratches to the Resident #42's left hip. The scratches were cleansed, and shorts were applied to protect the resident's skin from self-inflicting wounds. Resident #42 had a long history of scratching themselves and was care planned to wear shorts in bed for prevention; the shorts were not placed on Resident #42 during the shift prior. Review of the Risk Management Nursing Home Investigation with a received date of 12/6/24 documented that on 12/6/24 Resident #42 was found to have three linear self-inflicted scratches on their left hip, and they were not wearing their shorts at that time. Investigator #1 documented an interview with Certified Nurse Aide #4 on 12/10/ 24. Certified Nurse Aide #4 gave a statement they were not familiar with Resident #42, were overwhelmed, and did not review the care plan prior to providing nightly care. They did not place shorts on Resident # 42. Investigator #1 documented Certified Nurse Aide #4 did not follow the care plan. During an observation on 1/29/25 at 3:44 PM, Resident #42 was sitting up in their chair. They were holding onto the bottom of their shirt in one hand and their sweatpants with the other hand. While holding their clothes, they were moving their fingers and feeling their clothing. During an observation and interview on 1/30/25 at 9:10 AM, Certified Nurse Aide #8 provided incontinent care to Resident # 42. They placed shorts back on Resident #42 after completion. They stated the care plan included that Resident #42 should always wear shorts and Resident #42 wears the shorts because they had a tendency of scratching themselves. During a telephone interview on 1/31/25 at 10:19 AM, Certified Nurse Aide #2 stated they were not familiar with Resident #42 but looked at the care plan that night (12/6/24) to see what type of assistance they needed. They noticed Resident #42 did not have their shorts on, but soon after both Licensed Practical Nurse #3 and Registered Nurse Supervisor #1 went to check on Resident # 42. During a telephone interview on 1/31/25 at 1:24 PM, Registered Nurse Supervisor #1 stated they were supervising the night Resident #42 was found without their shorts on and scratch marks on their left hip (12/6/24). They stated Resident #42 had a history of [REDACTED]. When they arrived at the unit to assess Resident #42, they were digging at their left leg and that was where the scratch marks were. They were superficial marks, were cleansed, shorts were applied, and the administration were notified via electronic mail. During a telephone interview on 2/3/25 at 9:08 AM, Licensed Practical Nurse #3 stated Resident #42 was always moving their hands, grabbing, and scratching wherever they could reach. They stated on 12/6/24 they remembered going into the room with Registered Nurse Supervisor #1, Resident #42 did not have on their shorts like care planned and there were scratch marks on their left hip. They stated there was a break in the care plan at that point and the shift prior should have placed the shorts on Resident #42 for their safety. During a telephone interview on 2/3/25 at 9:16 AM, Certified Nurse Aide #3 stated they assisted Certified Nurse Aide #2 with their rounds, noticed Resident #42 did not have shorts on, had scratches to their hip, and then notified Licensed Practical Nurse #3 immediately after care. They stated the care plan showed that Resident #42 should have shorts on at all times and the shift prior must n | Plan of Correction: ApprovedFebruary 26, 2025 F- 656 ÔÇ£ Develop/Implement Comprehensive Care Plan I. Per the Directed Plan of Correction, the following actions were accomplished for the residents identified in the sample: Resident #30: o An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice o A Social Services assessment completed to ensure there were no negative psychosocial impact. o Certified Nursing Assistant #5 was re-educated on their role to review the care plan prior to providing care Resident #42: o At Risk for Skin Integrity Impairment care plan due to self-inflicted scratching and the need to wear shorts as an intervention will be implemented. o An assessment by a Registered nurse was completed. No additional injuries were identified o A Social Services assessment completed to ensure there were no negative psychosocial impact. o Certified Nursing Assistant #4 is no longer employed by the facility Resident #161: o The resident was discharged from the facility on 7/26/ 24. o An assessment by a Registered nurse was completed at the time of the incident. No additional injuries were identified. o A review of the residents medical record indicated no additional negative impacts from the deficient practice o Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. II. Per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify potential incidents related to a failure to follow the care plan. Any incidents will be investigated, reported accordingly and staff re-educated as appropriate. III. Per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: The policy titled ?ôComprehensive Care Plans?Ø has been reviewed by the consultant with administration and nursing leadership and no changes were indicated. As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program. o All facility nursing staff (Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides) will be educated by the consultant on the Comprehensive Care Plans policy and ensuring that care plans be reviewed prior to providing care and followed as documented. o All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. An audit tool will be developed, and all incidents will be reviewed daily by the Director of Nursing/Designee for 1 month then weekly for 2 months to ensure all incidents of failure to follow the care plan are identified, reported timely and staff educated as appropriate. o Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. Audit results will be reported to the Quality Assessment & Assurance Committee monthly for three months. o Frequency of on-going audits will be determined by the Committee based on audit results. The consultant will participate in Quality Assessment & Assurance Committee Meeting monthly x 3 months. Responsibility: Director of Nursing or Designee |
Scope: Isolated
Severity: Actual harm has occurred
Citation date: February 3, 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 Complaint investigation (#NY 779, and #NY 581) during an Extended Standard survey completed on 2/3/2025, the facility failed to protect residents from abuse by other residents for three (3) (Resident #17, #71, and #75) of 12 residents reviewed. Specifically, on 11/4/2024, Resident #68 struck Resident #71 in the face with their walker, resulting in a laceration across the bridge of Resident #71's nose, and skin tears to their right cheek and chin. Additionally, on 12/5/2024, 12/10/2024, and 12/11/2024, physical altercations occurred between Residents #17 and #75, who were roommates and remained roommates until after the third altercation on 12/11/ 2024. This resulted in actual harm to Resident # 71. The findings are: The policy titled Abuse/Neglect - Reporting Process, last revised 12/15, documented it is the policy of the facility to treat all residents with kindness, dignity, and consideration. They ensure all residents are free from verbal, sexual, physical, and mental abuse. The policy titled Abuse Preventing and Reporting, last revised 9/23, documented an abusive act is defined as any act of commission or omission that causes potential or actual physical or emotional harm or injury to a resident. Physical abuse is defined as any act or omission which may cause or causes physical pain, harm or injury to the resident or where it is reasonable to believe that pain, harm or injury would result. Physical abuse may include, but is not limited to slapping, pinching, kicking, pushing or rough handling, and/or failure to intervene in a resident altercation that results in physical harm to a resident. 1. Resident #68 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/9/2024 documented Resident #68 was severely cognitively impaired, was usually understood, and usually understands. The Kardex (a guide used by staff to provide care) dated 1/31/2025 documented Resident #68 was independent with ambulation on the unit, using a rolling walker. The facility could not provide a Kardex for the time of the abuse 11/4/ 2024. The comprehensive care plan dated 6/18/2021 documented Resident #68 had a history of [REDACTED]. Staff were to assess and anticipate resident's needs, intervene before agitation escalates, guide away from source of distress, and allow to share feelings. On 2/2/2024 a Velcro stop sign was added across entry doorway as needed and the door to their room was to be closed. Resident #71 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #71 was severely cognitively impaired, sometimes understands, was sometime understood, continuously had disorganized thinking and wandered occasionally. The Kardex dated 1/31/2025 documented Resident #71 was independent with wheelchair mobility on the unit. The facility could not provide a Kardex for the time of the abuse 11/4/ 2024. The comprehensive care plan identified as current, dated 6/12/2023, documented Resident #71 had impaired cognitive function related to dementia and to cue, reorient and supervise as needed. The comprehensive care plan documented Resident #71 had a communication problem related to a hearing deficit. Staff were to anticipate and meet needs and to be conscious of Resident #71's position when in groups, activities, and dining room to promote communication with others. The comprehensive care plan did not document that Resident #71 wandered into unsafe places or displayed behaviors directed towards others. Review of the resident-to-resident incident reports for Resident #71 and Resident #68 completed by Registered Nurse #1, and the facility's investigation report completed by the Director of Nursing dated 11/4/2024, revealed at 2:45 PM, Resident #71 was propelling their wheelchair down the hallway when they opened Resident #68's room door and started to enter. Resident #68 met Resident #71 in the doorway, lifted their walker to Resident #71's face, and began pushing them out of their room. Resident #71 began yelling, which alerted staff, who then immediately intervened and separated the two (2) residents. Resident #71 sustained a skin tear to their right cheek and chin and a laceration across the bridge of their nose with a moderate amount of bloody drainage. Bruising was also noted across their nose. Resident #71 was visibly upset and showed moderate signs of pain and discomfort. Tylenol was given, the wounds were cleansed, and steri-strips (thin, sticky bandages applied to skin to help cuts or wounds stay closed) were applied to their right cheek and nose, along with a dry clean dressing to their chin. X-rays were obtained and were negative for any fractures. Resident #68 became aggressive towards staff and was sent to the emergency room for evaluation. The reports documented Resident #68 had a history of [REDACTED]. The resident-to-resident reports and the facility investigation report did not document the stop sign was in place across Resident #68's door at the time of the abuse on 11/4/ 2024. Interdisciplinary progress notes dated 11/4/2024 through 11/11/2024 documented staff monitored and treated Resident #71's facial injuries (bruising, swelling, laceration, scratches) and administered Tylenol as needed for visible signs of pain. The Medication Administration Record [REDACTED]# 68. Prior to 11/4/2024, Resident #71 had not been receiving pain medication. During observations on 1/27/2025 between 9:42 AM and 10:01 AM, both Residents #71 and #68 were in their rooms, directly across the hall from each other. Resident #68's door was closed and had a stop sign across their doorway. During an interview on 1/29/2025 at 11:44 AM, Licensed Practical Nurse #1 stated Resident #68 did not like people in their personal space and most incidents involving this resident on the unit involved other people entering their room. They stated that if someone got too close to Resident #68, they would become provoked and would attempt to hit the other person. Licensed Practical Nurse #1 stated they did not know if the stop sign was in place on Resident #68's door on 11/4/2024 at the time of the attack. Additionally, they stated Resident #71 had difficulty hearing, so other residents get frustrated when they tried to talk to them. During an interview on 1/29/2025 at 11:51 AM, Certified Nurse Aide #1 stated they were at the nurse's station on 11/4/2024 when they saw Resident #71 wheel down the hallway to Resident #68's room, open the door and enter. They then heard yelling and started to walk down the hallway when they saw Resident #68 push Resident #71 out of their room with their walker. Resident #68 had already closed the door and returned to their room when Certified Nurse Aide #1 arrived at the incident. They stated Resident #71 was bleeding from areas on their face that corresponded with where the walker had hit them. Certified Nurse Aide #1 stated they did not recall if the stop sign was across Resident #68's door on 11/4/ 2024. The unit had a lot of wanderers who would remove stop signs across doors, and staff did their best to redirect residents. During an observation on 1/30/2025 at 11:18 AM, Resident #68 was in their room, the door was closed and there was no stop sign across the entry way. Resident #71 was in their room across the hall watching television. During an interview on 1/30/2025 at 11:23 AM, Licensed Practical Nurse #1 stated Resident #71 had swelling, bruising to their face and showed signs o | Plan of Correction: ApprovedMarch 5, 2025 I. As per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: Resident #71: o Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. o The residents care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. o A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident. Resident #68: o Assessments by a Registered Nursing and Physician were completed. No injuries were identified. o A Social Services assessment will be completed to ensure there are no ongoing negative psychosocial impact. o Additional signage will be placed on the residents door to deter others from wandering into the residents room. Certified Nursing Aide #1, Social Worker #1, Registered Nurse Head Nurse #2 and Licensed Practical Nurse #1 will receive educational counseling on their role to identify potential for abuse and prevent abuse from occurring including ensuring that preventative measures such as stop signs were in place per plan of care. Resident #17 o An assessment by a Registered nurse was completed on each altercation between resident #17 and # 75. No injuries were identified. o Resident #17s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging. o A Social Services assessment will be completed to ensure there were no negative psychosocial impact due to the altercations and the subsequent room changes. Resident #75: o An assessment by a registered nurse was completed upon each altercation with resident # 17. No injuries were identified. o Resident #75s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due possessiveness. o Resident # 75 was moved to a private room on a different unit o A Social Services assessment will be completed to ensure there were no negative psychosocial impact related to the resident to resident altercations. o Licensed Practical Nurse #1 and Certified Nursing Aide #1 will be educated on their role to report resident issues including resident to resident verbal altercations immediately. o Registered Nurse # 1 will be educated on their role to put interventions into place to prevent/ reduce risk of abuse and prevention of recurrence. o The Director of Nursing and Assistant Director of Nursing were educated on their role to investigate reports of verbal altercations between residents as potential incidents of abuse and institute measures to prevent recurrence. II. As per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. o All resident progress notes and incident reports for the past 60 days will be reviewed to identify any incidents of actual or potential abuse, neglect or mistreatment. o The care plan of any identified resident will be reviewed and updated accordingly for risk Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness and ensure interventions are initiated in an effort to prevent abuse. o Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. III. As per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: The policy titled ?ôAbuse/Neglect ÔÇ£ Prevention and Reporting Process?Ø has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. The facility Comprehensive care planning policy was reviewed and updated by the consultant with administration and nursing leadership to include the requirement to revise the care plan with interventions to prevent recurrence of incidents including abuse. As per the Directed Plan of Correction, the Consultant has developed and will implement an In-service Program to address: o Abuse Identification, Prevention and Reporting: ?é- All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing any staff alleged to be involved immediately to prevent further abuse and implementation of interventions to prevent recurrence. o State and Federal Regulations on Incident and Abuse Reporting: ?é- The Administrator, Director of Nursing and facility leadership staff (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence and immediate removal of any staff alleged to be involved, o Regulatory Changes: All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. o Care Planning: All nursing leadership and social work staff will be educated by the consultant on the care plan policy updates specific to identifying Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, initiating interventions prevent or reduce the risk of abuse and revising care plan with interventions to prevent recurrence of abuse. The facility will monitor for increase resident - resident altercations and or inj of unknown origin that may signal or alert staff that a problem is potentially evolving o All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facilitys compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assurance Committee meeting was held on (MONTH) 24, 2024, to examine this deficiency. An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plan updated accordingly. Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. Audit results will be reported to the Quality Assurance Committee monthly for three months. The consultant will participate in Quality Assurance for three months. Frequency of on-going audits will be determined by the Committee based on audit results. Consultant will participate in the Quality Assurance Committee Meeting monthly x 3 months. The administrator will be responsible to ensure corrective action is implemented |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a Complaint investigations (#NY 289, #NY 779, #NY 581, #NY 814, #NY 482, #NY 807, #NY 719, #NY 961) completed during an extended Standard survey on 2/3/25, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to administrator of the facility and to other officials (including to the State Survey Agency) for 10 (#17, #30, #42, #47, #68, #71, #72, #75, #95 and #161) of 12 residents reviewed. Specifically, allegations of resident abuse (#47, #68, #71, #17, #75, #72, and #161) and injuries of unknown origin (# 95) were not reported within 2 hours to State Agency. Additionally, resident neglect (#30, #42 and #161) was not reported within 24 hours to the State Agency. This resulted in no actual harm with the potential to affect all residents that is substandard quality of care. The findings are: The policy and procedures titled Abuse/Neglect - Reporting Process dated 12/2015, documented it is the policy of the facility to comply with all State and Federal regulations with regards to abuse and neglect. The New York State Department of Health will be notified of any resident abuse or neglect, whether suspected or confirmed. The Nursing Supervisor will notify the Administrator and Nursing Director. The Administrator will notify the Social Worker. The Administrator and/or Nursing Director will take responsibility for notifying the State Health Department within five working days that abuse/neglect has occurred. a. Resident #47 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 10/17/24 documented Resident #47 was cognitively intact. The nursing home facility investigation report submitted successfully to the State Agency competed by the Administrator documented that Resident #47 reported to Social Worker #1 that Certified Nurse Aide #9 had touched them inappropriately during incontinent care a couple days prior. The incident was documented to have occurred on 10/15/24 at 2:00 PM, staff was first made aware on 10/17/24 at 3:00 PM, the Administrator was first made aware on 10/17/24 at 3:00 PM and reported the allegation to the State Agency on 10/18/24 at 1:46 PM. During a telephone interview on 2/3/25 at 8:26 AM, Investigator #1 stated they were notified of Resident #47's allegation on 10/17/ 24. They considered this allegation to be one of sexual abuse and should have been reported to the State Agency within two hours. During an interview on 2/3/25 at 9:33 AM, the Director of Nursing stated being inappropriately touched was considered sexual abuse. They stated the facility investigative report documented the incident was submitted to the State Agency on 10/18/24 at 1:46 PM and it should have been reported sooner because it was a potential abuse allegation. b. Resident #68 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #68 was severely cognitively impaired Resident #71 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #71 was severely cognitively impaired. Review of the resident-to-resident incident reports for Resident #71 and Resident #68 completed by Registered Nurse #1, and the facility's investigation report completed by the Director of Nursing dated 11/4/2024, revealed at 2:45 PM Resident #71 was propelling their wheelchair down the hallway when they opened Resident #68's room door and started to enter. Resident #68 met Resident #71 in the doorway, lifted their walker to Resident #71's face, and began pushing them out of their room. Resident #71 began yelling, which alerted staff, who then immediately intervened and separated the two (2) residents. Resident #71 sustained a skin tear to their right cheek and chin and a laceration across the bridge of their nose with a moderate amount of bloody drainage. Bruising was also noted across their nose. Resident #71 was visibly upset and showed moderate signs of pain and discomfort. Tylenol was given, the wounds were cleansed, and steri-strips (thin, sticky bandages applied to skin to help cuts or wounds stay closed) were applied to their right cheek and nose, along with a dry clean dressing to their chin. X-rays were obtained and were negative for any fractures. Resident #68 became aggressive towards staff and was sent to the emergency room for evaluation. The reports documented Resident #68 had a history of [REDACTED]. The resident-to-resident reports and the facility investigation report did not document the stop sign was in place across Resident #68's door at the time of the abuse on 11/4/ 2024. The nursing home facility investigation report was submitted successfully to the State Agency on 11/6/24 at 3:18 PM by the Director of Nursing. During an interview on 1/29/25 at 1:56 PM, the Director of Nursing stated the facility had 48 hours to submit a report so that is why this incident was reported and submitted on 11/6/24. c. Resident #95 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #95 was severely cognitively impaired. Review of a facility report titled, Incident-by-Incident Type, dated 12/20/23 at 12:21 PM submitted by the Director of Nursing documented Resident #95 had an injury of unknown source (acute fracture of fourth finger right hand) identified on 12/19/23 at 11:29 AM. The nursing home facility investigation report submitted successfully to the State Agency on Wednesday 12/20/2023 at 2:31 PM by the Director of Nursing for allegations of injury of unknown source (acute fracture of fourth finger right hand). The report documented the incident occurred was on Tuesday 12/19/23 at 11:29 AM. The Administrator was first made aware of the incident on Wednesday 12/20/23 at 12:13 PM. d. Resident #17 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #17 was moderately cognitively impaired. Resident #75 had [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #75 was severely cognitively impaired. The nursing home facility investigation report submitted successfully to the State Agency dated 12/5/24, completed by Administrator, documented Resident #75 observed Resident #17 going through their belongings and slapped Resident #17 on the face. Resident #17 slapped Resident #75 back, also on the face. The incident was reported to Licensed Practical Nurse #1 by Resident #17, and while they were talking to Licensed Practical Nurse #1 about the incident, Resident #75 approached to tell their side of the story. Residents are new roommates, and both are able to ambulate independently. Resident #17 indicated they did not like their living arrangement. Both residents were placed on 15-minute checks to monitor their whereabouts and avoid further altercations. During an interview on 2/3/25 at 10:29 AM, the Director of Nursing stated the incident between Resident #17 and Resident #75 occurred on 12/5/24 at 7:45 AM, they were made aware at 8:30 AM. They stated they reported the incident to the State Agency on 12/6/24 at 2:06 PM, over 48 hours from when the incident occurred. They stated the incident should have been reported within 24 hours. Review of resident-to-resident incid | Plan of Correction: ApprovedFebruary 26, 2025 I. Per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: Resident #17: o Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents o An assessment by a Registered nurse was completed on each altercation. No injuries were identified o Resident #17s care plan was reviewed and updated to include Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging care plan with appropriate interventions to prevent recurrence. o A Social Services assessment completed to ensure there were no negative psychosocial impact. Resident #30: o An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice o A Social Services assessment completed to ensure there were no negative psychosocial impact. o Certified Nursing Assistant #5 will be re-educated on their role to review the care plan prior to providing care. Resident #42: : o An assessment by a Registered nurse was completed. No additional injuries were identified o A Social Services assessment completed to ensure there were no negative psychosocial impact. o Certified Nursing Assistant #4 is no longer employed by the facility. Resident #47: o An assessment by a Registered nurse was completed. No injuries were identified o A Social Services assessment completed to ensure there were no negative psychosocial impact. o An investigation was conducted and allegation unfounded for sexual abuse. o Certified Nursing Assistant #9 was re-educated, was re-assigned from providing care to resident # 47. Resident #68: o Assessments by a Registered Nursing and Physician were completed. No injuries were identified. o The residents care plan will be reviewed and updated to include risk for Physically/Verbally Aggressive behaviors and appropriate interventions to reduce risk. o A Social Services assessment will be completed to ensure there were no negative psychosocial impact. Resident #71: o Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. o The residents care plan will be reviewed and updated to include wandering risk, risk for victimization due to wandering and behaviors directed at others. o A Social Services assessment will be completed to ensure there were no additional negative psychosocial impacts related to the incident. Resident #75: o Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. o An assessment by a registered nurse was completed upon each altercation with resident # 17. No injuries were identified. o Resident #75s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due possessiveness. o Resident # 75 was moved to a private room on a different unit o A Social Services assessment will be completed to ensure there were no negative psychosocial impact related to the resident to resident altercations. Resident #95: o Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. o A Social Services assessment completed to ensure there were no negative psychosocial impact Resident #161: o The resident was discharged from the facility on 7/26/ 24. o A review of the residents medical record indicate no additional injuries or negative psychosocial impact o Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. o Certified Nursing Assistant #4s employment was terminated. . The Administrator, Director of Nursing and Assistant Director of Nursing, were educated by the consultant on the State Operations Manual timeframe reporting requirements for abuse reporting by the consultant II. Per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. o All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect or mistreatment by the Director of Nursing/designee. The care plan of any identified resident will be reviewed and updated accordingly for risk Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness and ensure interventions are initiated in an effort to prevent abuse. o Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. III. Per the Directed Plan of Correction the following system changes will be implemented to ensure continuing compliance with regulations: The policy titled ?ôAbuse/Neglect ÔÇ£ Prevention and Reporting Process?Ø has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address: o Abuse Identification, Prevention and Reporting: ?é- All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing any staff alleged to be involved immediately to prevent further abuse and implementation of interventions to prevent recurrence. o State and Federal Regulations on Incident and Abuse Reporting: ?é- The Administrator, Director of Nursing and facility leadership staff (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence and immediate removal of any staff alleged to be involved, o All training components will be added to the initial orientation and annual education for facility and agency staff IV. The facilitys compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. o An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plan updated accordingly o Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. Audit results will be reported to the Quality Assessment & Assurance Committee monthly for three months. o Frequency of on-going audits will be determined by the Committee based on audit results. The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly x 3 months. Responsibility: Director of Nursing |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 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 Complaint investigation (#NY 814) during an extended Standard survey completed on 2/3/25, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (1) (Resident #161) of one (1) reviewed for dignity. Specifically, the certified nurse aide provided care despite the resident's refusal and resulted in Resident #161 feeling ashamed and humiliated. The finding is: The policy and procedure titled Resident Choice and Rights last revised 1/2023 documented it is the policy of this facility to provide and encourage resident choices in all aspects of their care and daily routines to maintain their dignity, individualism and customary routines. Your Rights as A Nursing Home Resident in New York State dated 2022 documented as a resident in this facility, you have rights guaranteed to you by state and federal laws. This facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have a right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of your self-worth. You have the right to accept or refuse care and treatment. Resident #161 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 5/10/24 documented that Resident #161 was cognitively intact, was understood and understands. The comprehensive care plan dated 5/3/24 documented Resident #161 had bladder incontinence related to impaired mobility. The care plan included incontinence checks as needed. The Kardex Report (guide used by staff to provide care) dated 5/9/24 documented Resident #161 required the assistance of two staff members for toileting and did not reflect incontinence care. The Risk Management Investigation dated 7/1/24 documented at approximately 3:00 AM on 7/1/24, Certified Nurse Aide #4 touched Resident #161 in the genital area without announcing their presence. When Resident #161 told Certified Nurse Aide #4 to remove their hand, Certified Nurse Aide #4 continued touching Resident #161 and stated to Resident #161 they were checking their brief to ensure they were dry. Later that morning at approximately 5:30 AM, Certified Nurse Aide #4 provided personal hygiene care to Resident #161, despite Resident #161 wanting to complete their own care. While washing Resident #161's genital area, Certified Nurse Aide #4 told Resident #161 they were checking for disease. Resident #161 told Registered Nurse #6 they were sleeping and startled by Certified Nurse Aide #4's grabbing and tugging at their brief at 3:00 AM and told Certified Nurse Aide #4 to get their hand out of there. Certified Nurse Aide #4 continued to move their hand around on their private area. Later that same morning at approximately 5:30 AM, Certified Nurse Aide #4 assisted Resident #161 with morning care and stated Certified Nurse Aide #4 was insistent in trying to get Resident #161's clothing off. Resident #161 repeatedly told Certified Nurse Aide #4 that I do that myself, please stop, but Certified Nurse Aide #4 kept insisting. Certified Nurse Aide #4 then spread Resident #161's legs apart and told them that they were looking for disease and looked at Resident #161's peri area. Registered Nurse #6 reported Resident #161 was crying, was very embarrassed. Resident #161 required assistance for transferring but preferred to be independent for most things and will ring the bell when they required assistance to use the toilet. During an interview on 1/31/25 at 11:43 AM, Certified Nurse Aide #7 stated Licensed Practical Nurse # 5 requested they go and check on Resident #161 on the morning of 7/1/ 24. Resident #161 was sobbing and felt offended that Certified Nurse Aide #4 would treat them like that. It was Resident #161's right to refuse care. Certified Nurse Aide #7 stated the resident felt disrespected, ashamed and expressed that Certified Nurse Aide #4's treatment towards Resident #161 was undignified. During a telephone interview on 1/31/25 at 12:19 PM, Licensed Practical Nurse #5 stated providing care when they don't want the care was demeaning. Resident #161 had the right to refuse care. During a telephone interview on 1/31/25 at 1:57 PM, Registered Nurse #6 stated Certified Nurse Aide #4's actions on 7/1/24 were inappropriate and they should have stopped care on both occasions. During an interview on 2/3/25 at 8:52 AM, Social Worker #1 stated they would have expected that Certified Nurse Aide #4 to have stopped care right away, report to the nurse, and reapproach later. Certified Nurse Aide #4's violated Resident #161's choice not to have care and it was undignified. During an interview on 2/3/25 at 9:33 AM, the Director of Nursing stated placing your hands on someone inappropriately without talking to them even after they told you to stop was a dignity concern. Resident #161 felt reluctant to discuss the care they had received on the morning of 7/1/ 24. Certified Nurse Aide #4 violated Resident 161's rights to be treated with dignity and respect. During a telephone interview on 2/3/25 at 1:45 PM, Certified Nurse Aide #4 denied the allegations and stated they would not force care on a resident that didn't want it. Certified Nurse Aide #4 stated that would be disrespectful. 10NYCRR 415. 3 (2)(f)(ii) | Plan of Correction: ApprovedMarch 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The resident noted to be adversely affected by an employees action which denied them their right to be treated with respect and dignity was assured that employee would no longer provide them care. The resident was seen by the social worker post incident but declined to discuss the incident further. The resident has since discharged . The employee cited in the deficient practice was immediately removed from duty upon notification of the event, did not return to work post incident and is no longer employed at the facility. All residents have the potential to be affected.All resident pr ogress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect or mistreatment. Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. The facility policy for Resident Rights has been reviewed and remains appropriate. Resident Rights in-servicing is mandatory yearly for all facility staff and is part of the orientation program for new hires. Printed versions of the New York State Resident Rights Handbook are readily available on all units and in common areas, The facility completes satisfaction surveys quarterly with responsible parties and monthly with a random selection of long term residents and new admissions. All facility will receive additional in-service training, specific to the residents right to refuse care, and to always be treated with dignity and respect. These corrective actions will be monitored via random unannounced resident-care audits to assure all physical care interactions and verbal communications are conducted in a manner that affords the resident dignified, respectful care. Ten compliance audits will be completed nurse managers/their designees, weekly for six weeks. These audits will include completion with families or responsible parties of those cognitively impaired to ensure treatment of [REDACTED]. These audit results will be placed on the agenda of both the monthly (for next three months) and the quarterly Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Nursing will be responsible for ongoing compliance with these corrective measures. |
Scope: N/A
Severity: N/A
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard survey completed on 2/3/25, the facility did not meet the requirements of the New York State Department of Health Criminal History Record Check. Specifically, the 105 Termination Form was not submitted to the New York State Department of Health Criminal History Record Check (CHRC) program within thirty days of an employee being reassigned from the direct care or supervision of residents, and no longer had access to residents and their belongings. This affected one (Employee #6, Certified Nurse Aide) of two employees reviewed for Criminal History Record Check negative determination findings. The finding is: During an interview on 1/29/25 at 3:11 PM the Administrator stated the facility had found some issues with the Criminal History Record Check paperwork from the facility's previous Infection Control/ In-Service Coordinator (Authorized Person for Criminal History record Check), the facility had done some audits of the paperwork, and the facility did not have documentation of the audits. Review of the facility policy and procedure titled Criminal History Record Check (CHRC) dated 9/2021 documented, it is the policy of this facility to: Require a Criminal History Record Check on all new non-licensed employees hired or used after (MONTH) 6, 2006, who will provide care or supervision to residents. Upon email notification, Criminal History Record Check letters will be viewed and appropriate actions are taken as directed in the letters. The Criminal History Record Check program will be notified no later than 30 days following a prospective employee withdrawing an application for employment or a current employee, who has underwent Criminal History Record Check, has left employment. Criminal History Record Check Termination Form 105 will be electronically submitted via Health Provider Network by the authorized person (AP). Review of the employee file for Employee #6 revealed the employee was hired as a Certified Nurse Aide on 1/26/24 and a time sheet that documented the last day the employee had worked at the facility was on 2/11/ 24. Further review of the file revealed a Criminal History Record Check Termination Form 105 for the employee dated 10/4/ 24. 402. 9(b)(2) | Plan of Correction: ApprovedMarch 3, 2025 The employee whose 105 Termination Form was not submitted to the New York State Department of Health Criminal History Record Check program within thirty days of terminations has had that termination form since submitted. The facility no longer has them as an active employee in our New York State Department of Health Criminal History Record Check roster. A review of the last three months of terminations will be completed to determine if any other employees were missing their 105 Termination Form. Those identified as missing the form will be noted, and will have it submitted as required by state regulation. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for terminating employees, via a 105 Termination Form, out of the system when they are no longer employed by the facility. Staff be educated to ensure the 105 Termination Form will be submitted to the New York State Department of Health Criminal History Record Check (CHRC) program within thirty days of an employee being reassigned from the direct care or supervision of residents, and no longer had access to residents and their belongings. Authorized persons and supervisory staff will be educated on these procedures. An audit of criminal history record check documents will be completed weekly for six weeks to assure that terminated employees have been removed from the New York State Department of Health Criminal History Record Check system per state regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 2/3/25, alcohol-based hand rub (ABHR) was not properly stored. Specifically, storage of alcohol-based hand in aggregated quantities greater than 10 gallons were stored in a single smoke compartment outside of a flammable liquids storage cabinet. The requirements of the 2012 edition of National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code were not met. This affected one of one Basement. The finding is: Observation in the Basement on 1/27/25 at 3:21 PM revealed 73 liters (equal to 19. 28 gallons) of alcohol based hand sanitizer was stored in the Supplies storage room outside of a flammable liquids storage cabinet. Further observation revealed the alcohol based hand sanitizer was stored on open shelving in the Supplies storage room located across from the Boiler room. During an interview at the time of the observation the Maintenance Supervisor stated the facility stored the alcohol based hand sanitizer in the Supplies room and they were not aware of the regulations for the storage of alcohol based hand sanitizer in quantities greater than 10 gallons needing to be stored in a flammable liquids storage cabinet. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2. 6, 8. 7. 3, 8. 7. 3. 1 2012 NFPA 30: 9. 6, 9. 6. 2, 9. 6. 2. 1, Table 9. 6. 2. 1, 9. 6. 2. 2 2012 NFPA 30: 9. 1, 9. 1. 1, 9. 1. 4, 9. 7, 9. 7. 1, 9. 7. 2, Table 9. 7. 2 2012 NFPA 30: 9. 3, 9. 3. 6, 9. 7, 9. 7. 3 | Plan of Correction: ApprovedFebruary 26, 2025 The excess (greater than 10 gallons) volume of alcohol based hand sanitizer noted during survey has been removed and redistributed to meet life safety code standards. An audit of other housekeeping storage areas has been be completed to identify any other areas that had quantities beyond those allowed by regulation. No other areas were identified to be in violation of this life safety code standards. A review of the facilities storage procedures has been completed to assure proper storage of alcohol-based hand sanitizers. The facility will also be reduce on-site inventory of hand sanitizer to avoid the potential for excess storage in potentially hazardous areas. All maintenance and housekeeping staff will receive education and in-servicing on this new policy and procedure. Random audits of housekeeping storage areas will be completed weekly, for six months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 2/3/25, the kitchen hood extinguishment system was not maintained. Specifically, the kitchen hood extinguishment system was not inspected every six months and the manual pull station for the kitchen hood extinguishment system was not inspected monthly. This affected one of one basement. The findings are: 1. During an interview on 1/30/25 at 3:56 PM the Maintenance Supervisor stated the contractor that inspected, tested , and maintained the Kitchen's kitchen hood extinguishment system was scheduled to inspect the system in (MONTH) of 2023. The contractor's company was taken over by another company and the new contractor did not complete an inspection of the facility's kitchen hood extinguishment system in (MONTH) of 2023, due to the transition between the companies. Review of review of Pre-Engineered Restaurant Fire Suppression System Reports from the contractor that inspected, tested , and maintained the facility's kitchen hood suppression system revealed the system was inspected on 3/9/23 and 10/6/ 23. Issues cited on 10/6/23 report were corrected, and the system was re-inspected on 10/16/ 23. 2. Observation in the basement on 1/27/24 at 3:42 PM in the Kitchen revealed the Kitchen was equipped with a kitchen hood extinguishment system. Further observation of the tag attached to the kitchen hood extinguishment system's manual pull station revealed the system was inspected by a contractor in (MONTH) of 2024. This tag had no documentation for the monthly inspections of the manual pull station for October, November, and (MONTH) of 2024. During an interview at the time of the observation the Maintenance Supervisor stated they were not aware the kitchen hood extinguishment system's manual pull station had to be inspected monthly, and the facility had no documentation for the monthly inspections of the kitchen hood extinguishment system's manual pull station. Review of monthly Fire Extinguisher Monthly Checklist dated 2/22/23 through 12/26/24 revealed they contained no documentation for the monthly inspections of the kitchen hood extinguishment system's manual pull station. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2. 5, 19. 3. 2. 5. 1, 9. 2. 3 2011 NFPA 96: 2. 1, 2. 2, 11. 2, 11. 2. 1 2009 NFPA 17A: 7. 2, 7. 2. 1, 7. 2. 2, 7. 2. 5 | Plan of Correction: ApprovedFebruary 26, 2025 The hood extinguishment system identified during survey as having not been inspected every six months, has had timely inspections since the occurrence in 2023, per life safety code standards. The manual pull station for the hood extinguishment system pull station identified as lacking the required monthly inspection has been inspected and is working properly The facility has only one hood extinguishment system, so there is nothing further affected by the deficient practice. An audit of the facilities pull-stations will be completed to identify any others that may lacked monthly inspections. Any identified as having been missed will be inspected per life safety code standards. A review of the policy related to inspections of the hood extinguishment system and pull stations has been completed with updates made to specify frequency and documentation of inspections All maintenance staff will receive education and in-servicing on this new policy and procedure. Audits of the monthly pull-station inspection will be completed to assure all pull-stations are inspected, including the hood extinguishment system, for three months to assure ongoing compliance. Audits of the hood extinguishment systems six-months inspections will occur via electronic calendar reminders to the maintenance supervisor and administration, as a mechanism to assure scheduled inspections are not missed. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 2/3/25, extension cords, power strips, and an electrical adapter were not maintained. Specifically, extension cords, powers strips that were plugged into powers strips (daisy chained) and an electrical adapter were being used to supply a permanent supply of power to various equipment. This affected two (first and second floors) of two resident use floors. The findings are: 1a. Observation on the second floor on 1/27/25 at 11:29 AM revealed a power strip plugged that was into a second power strip and was supplying power to two computer tablets in the Medical Records office. During an interview at the time of this observation the Maintenance Supervisor stated they were not aware the two power strips were plugged together. 1b. Observation on the first floor in the Cypress Unit on 1/27/25 at 2:25 PM revealed an electrical adapter was supplying power to two phone charges in the Nursing Supervisor's office. During an interview at the time of this observation the Maintenance Supervisor stated they were not aware the electrical adapter was being used in the office. 1c. Observation on the first floor in the Cypress Unit on 1/28/25 at 1:02 PM revealed an extension cord was supplying power to two phone charges in Resident Room 153. During an interview at the time of the observation the Maintenance Supervisor stated they were not aware the extension cord was being used in the room. 1d. Observation on the first floor in the Cypress Unit on 1/28/25 at 1:05 AM revealed an extension cord was supplying power to a holiday tree in Resident Room 154. 1e. Observation on the first floor in the front lobby revealed an extension cord was supplying power to a string of lights that were wrapped around the handrail of the open staircase that served the first and second floors. During an interview on 1/30/25 at 2:18 PM the Maintenance Supervisor stated the residents' rooms were inspected for extension cords and power strips during monthly bed inspections. Review of monthly Bed Inspections logs revealed the last time the residents' rooms were inspected was (MONTH) of 2024 and the logs contained no documentation that the residents' rooms were inspected for extension cords and power strips. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 99: 2. 1, 2. 2, 10. 2. 3. 6, 10. 2. 4, 10. 2. 4. 2, 10. 2. 4. 2. 1, 10. 2. 4. 2. 3, 10. 2. 3, 10. 2. 3. 1, 10. 2. 3. 1. 1 2011 NFPA 70: 110. 3(A)(1)(8), 400. 3, 400. 8(1), 590. 3 | Plan of Correction: ApprovedMarch 1, 2025 The power strips, extension cords and adapter found during survey were immediately removed from use. An audit of the entire facility to include resident rooms, offices and common areas will be conducted to assure no other power strips, extension cords and adapter are being utilized with exception to those found to meet the UL and life safety code standards. Any found to be non-compliant will be removed A review of the facilities policy related to use of power strips, extension cords and adapter has been completed and found to be in compliance with the standards set forth by life safety codes. Maintenance staff will receive education and in-servicing to review this policy and procedure. Random audits of resident rooms, offices and common spaces for non-approved power strips, extension cords and adapters will be completed weekly, for six week, to assure ongoing compliance. A new audit form that includes bed inspections, and inspections for extension cords, power strips, and electrical adapters, will be created to document these audits. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 2/3/25, the emergency generator was not maintained. Specifically, the facility did not continuously conduct monthly load tests, did not conduct an annual inspection of the main and feeder circuits breakers, did not conduct monthly and annual testing of emergency lighting associated with emergency power supply equipment, and emergency lighting associated with emergency power supply equipment was not functioning. This affected two (first and second floors) of two resident use floors and the basement. The findings are: 1a. Observation in the Basement on 1/27/25 at 3:01 PM revealed the transfer switch for the facility's emergency generator was in the Electrical room. Further observation revealed that when the emergency battery backup lighting fixture in the room was tested by the Maintenance Supervisor the light did not illuminate. During an interview at the time of the observation the Maintenance Supervisor stated they were not aware the battery backup lighting fixture in the Electrical room was not working and they were not aware that the battery backup lighting fixture had to be tested monthly for 30 seconds and annually for 90 minutes. Review of Review of emergency generator weekly inspection and monthly load test logs dated 1/31/23 through 12/30/24 revealed they contained no documentation that the battery backup lighting fixture in the basement Electrical room had been tested monthly for 30 seconds and annually for 90 minutes in 2023 and 2024. 2a. During an interview on 1/29/25 at 9:08 AM the Maintenance Supervisor stated the facility had no documentation that the main and feeder circuits breakers had been inspected in 2023 and 2024. The Maintenance Supervisor further stated they had spoken with a representative of the contractor that inspected, tested , and maintained the facility's emergency generator and the contractor did not conduct as inspection of the main and feeder circuits breakers in 2023 and 2024. Review of Review of emergency generator weekly inspection and monthly load test logs dated 1/31/23 through 12/30/24 revealed they contained not documentation that the main and feeder circuits breakers had been inspected in 2023 and 2024. Review of Planned Maintenance reports from the contractor that inspected, tested , and maintained the facility's emergency generator dated 3/21/23, 4/28/23, 12/21/23, 4/16/24, and 10/29/24 revealed they contained no documentation that the main and feeder circuits breakers had been inspected in 2023 and 2024. 3a. During an interview on 1/29/25 at 9:12 AM the Maintenance Supervisor stated the facility emergency generator was usually run under load on the overnight shift, there had been some issues with staff in (MONTH) of 2024, and the emergency generator was not run under load in (MONTH) of 2024. Review of emergency generator weekly inspection and monthly load test logs revealed the emergency generator was not run under load and the transfer switch for the emergency generator was not exercised in (MONTH) of 2024. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 5, 19. 5. 1, 19. 5. 1. 1, 9. 1, 9. 1. 3, 9. 1. 3. 1 2010 NFPA 110: 2. 1, 2. 2, 4. 2, 4. 4, 4. 4. 1, 4. 4. 2, 7. 3, 7. 3. 1, 8. 3, 8. 3. 3, 8. 3. 4, 8. 3. 4. 1, 8. 4, 8. 4. 1, 8. 4. 2. 4, 8. 4. 6, 8. 4. 6. 1 2012 NFPA 99: 6. 5, 6. 5. 1, 6. 4. 1, 6. 4. 1. 1. 6. 1, 6. 5. 4, 6. 5. 4. 1. 1. 2, 6. 4. 4, 6. 4. 4. 1. 1. 3, 6. 4. 4. 1. 1. 4, 6. 5. 4. 1. 2, 6. 4. 4. 1. 2, 6. 4. 4. 1. 2. 1 2012 NFPA 101: 19. 2. 9, 19. 2. 9. 1, 7. 9, 7. 9. 2, 7. 9. 2. 4, 7. 9. 3, 7. 9. 3. 1, 7. 9. 3. 1. 1 | Plan of Correction: ApprovedMarch 4, 2025 The following items noted during survey as being deficient: conducting monthly generator load tests, annual inspection of the main and feeder circuits breakers, monthly and annual testing of emergency lighting associated with emergency power supply equipment, and proper function of emergency lighting associated with emergency power supply equipment have all been completed and repaired to meet the life safety code standards. The emergency light fixture is scheduled to be replaced. The facility will complete a facility-wide audit to ensure there are no other battery-powered emergency light fixtures that require testing. The 30 second and 90 minute testing of the emergency light fixtures will occur with the routinely scheduled generator load tests. A contractor has been hired to complete the inspection of the main and feeder circuits breakers and annually going forward. An audit of all generator inspection documents will be completed to assure that routine load tests are completed within the standards of the life safety code. These inspections will be added to existing schedules. A review of the facilities policy related to generator inspections will be completed to assure it contains language that outlines the procedures for proper inspection. The audit documents used for generator inspections will also include the language specific to the monthly generator load tests and testing of the emergency light fixtures. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of generator inspection documents to include the main and feeder circuits breakers, the annual testing of emergency lighting associated with emergency power supply equipment, and emergency lighting associated with emergency power supply equipment, monthly generator load tests, and the monthly 30-second testing, will be completed and documented monthly, for three months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 3, 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 Life Safety Code survey completed on 2/3/25, the facility's fire alarm system was not maintained. Specifically, smoke detectors were not inspected and tested annually, heat detectors and smoke detectors located in elevator shafts were not inspected and tested every 18 months, batteries associated with the fire alarm panel and fire alarm system were not load voltage tested semiannually, and a Notification Appliance Control Panel (NACP) batteries failed load testing. This affected two (first and second floors) of two resident use floors and the basement. The findings are: 1a. Observations on 1/27/25 between 9:39 AM and 3:58 PM revealed a fire alarm system was installed throughout the facility, the system was equipped with a fire alarm control panel located in the Maintenance Shop, and the facility had two elevators. (Elevator #1 and Elevator #2). 1b. During an interview on 1/29/25 at 9:26 AM the Maintenance Supervisor stated the contractor that inspected, tested , and maintained the facility's fire alarm system inspected and tested the system annually and the facility had not documentation that the batteries associated with the fire alarm system had been load voltage tested semiannually. Review of fire alarm system inspection and testing reports from the contractor that inspected, tested , and maintained the facility's fire alarm system dated 4/25/23 and 4/22/24 revealed they contained no documentation that batteries associated with the fire alarm panel and fire alarm system had been load voltage tested semiannually. 1c. During an interview on 1/29/25 at 9:35 AM the Maintenance Supervisor stated the issues documented on the of fire alarm system inspection and testing report from the contractor that inspected, tested , and maintained the facility's fire alarm system dated 4/22/24 were not addressed and the contractor did not come back to the facility to correct any of the issues. Review of the of fire alarm system inspection and testing report from the contractor that inspected, tested , and maintained the facility's fire alarm system dated 4/22/24 revealed the following was documented on the report: -The batteries in the Notification Appliance Control Panel (NACP) failed the load test. -There were several resdients rooms that were not tested due to COVID restrictions. -The elevator shaft devices were unable to be tested without the elevator company onsite. They were simulated for the purpose of functionality only. Further review of the report revealed one smoke detector, and one heat detector were located at the top of the shaft of Elevator #1, and one heat detector was located at the pit of the shaft of Elevator # 1. Continued review of the report revealed one smoke detector, and one heat detector were located at the top of the shaft of Elevator #2 and one heat detector was located at the pit of the shaft of Elevator # 2. The smoke detectors and heat detectors located in the shafts of Elevator #1 and Elevator #2 were inspected and tested on [DATE] and had not been retested as of 1/31/ 25. (The smoke detectors and heat detectors located in the shaft of Elevator #1 and the shaft of Elevator #2 had not been tested in 21 months.) According to 2010 Edition National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code: Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, [MEDICAL CONDITION], and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction. Extended intervals shall not exceed 18 months. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 9. 6, 9. 6. 1, 9. 6. 1. 3 2010 NFPA 72: 14. 2. 2, 14. 2. 2. 1, 14. 3, 14. 3. 1, Table 14. 3. 1, 14. 3. 2, 14. 3. 3, 14. 4, 14. 4. 5, Table 14. 4. 5, 14. 5. 1 | Plan of Correction: ApprovedMarch 2, 2025 The smoke detectors missed on the annual inspection will be inspected per life safety code standards. The heat and smoke detectors in the elevator shaft not inspected and tested within the last 18 months will be inspected This test will be coordinated with the vendors who provide elevator service and fire detection services The batteries associated with the fire alarm panel and fire alarm system that were not load voltage tested semiannually have been tested per life safety code standards. The Notification Appliance Control Panel batteries that failed the load testing have been replaced and now operate per life safety code standards An audit of the most recent inspection reports has been completed to assure no other heat or smoke detectors were missed and require inspection. Any areas identified as lacking inspection has been inspected per life safety code standards. A review of the facilities policy related to routine testing of building systems, to include fire systems, has been reviewed and updated to include language that clearly outlines the frequency and scope of inspections, as well as who is to complete them . The facility maintenance and administrative staff will utilize electronic calendar reminders to assist in assuring that inspection dates are occurring within the regulatory time frames. All maintenance staff will receive education and in-servicing on this new policy and procedure. An audit of the inspection reports, will occur monthly, for any vendor-provided services related to smoke head testing and related fire system tests, for three months, to assure no areas are missed or that vendors return to address any missed items. The maintenance supervisor, or designee, will complete the audits. These audits will be reviewed for proper completion by the maintenance director. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 2/3/25, a hazardous area was not maintained. Specifically, a hazardous areas door did not self-close and latch into its door frame. This affected one of one basement. The findings are: Observation in the basement on 1/27/25 at 3:15 PM revealed the door to the clean linen storage room did not self-close and latch into its door frame. Further observation revealed the room was greater than 50 square feet in size and contained seven, five foot all by four foot long by two foot wide clean linen carts full of clean linen, two, three foot tall by three foot long by two foot wide clean linen carts full of clean linen, and six, five foot tall by four foot long by one foot wide shelving units full of clean linen. During an interview at the time of the observation the Maintenance Supervisor stated the door's self-closing device had been replaced a couple times and the top hinge on the door was broken. The Maintenance Supervisor further stated the door and the door's frame needed to be replaced. During an interview on 1/29/25 at 3:54 PM the Maintenance Supervisor stated the Maintenance staff audited the facility's hazardous areas doors, and the facility did not have documentation for the audits. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 2, 19. 3. 2. 1, 19. 3. 2. 1. 3 | Plan of Correction: ApprovedFebruary 26, 2025 The door identified during the survey as not self-closing and latching into its door frame has been repaired to and is currently working properly and per regulation. The facility is in the process of obtaining quotes to ultimately replace the door, which will occur post survey compliance date. An audit and review of all facility self-closing doors has been completed to assure that they are also closing and latching fully into their frames. Any other doors found to be malfunctioning will be repaired to assure they self-close and latch fully into the door frame A review of the facilities policy related to the routine inspection of self-closing and latching doors has been completed to assure it contains language specifying the frequency and scope of such checks. Door audits will be documented and maintained in a binder within the maintenance department. All maintenance staff will receive education and in-service training on this updated policy and procedure. An audit of all self-closing and latching doors will be completed weekly for six weeks to assure all doors are operating per regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 3, 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 Life Safety Code survey completed on 2/3/25, the facility's automatic sprinkler system was not maintained. Specifically, sprinkler heads were not free of foreign materials due to being loaded and covered with debris, lint, and dust. Sprinkler heads were corroded, rusted, and needed to be replaced. An escutcheon was missing from a sprinkler head. Sprinkler piping and sprinkler pipe hangers were exposed to external loads. The facility did not have documentation that verified quarterly inspections, testing, and maintenance of the automatic sprinkler system had been completed. The post indicator valve was seized in open position. This affected two (first and second floors) of two resident use floors and the basement. The findings are: 1a Observation on the second floor on 1/27/25 at 10:01 AM revealed one sprinkler head in the Cedar Unit Tub room was loaded and covered with lint and dust. During an interview at the time of the observation the Maintenance Supervisor stated sprinkler heads were checked and cleaned quarterly and Maintenance staff on the third shift checked and cleaned the sprinkler heads. 1b. Observation on the second floor on 1/27/25 at 10:20 AM revealed two sprinkler heads in the Cedar Unit dining room and one sprinkler head in the lounge/ television area were loaded and covered with lint and dust. 1c. Observation on the second floor on 1/27/25 at 11:16 AM revealed two sprinkler heads in the Therapy Suite were loaded and covered with lint and dust. 1d. Observation on the second floor on 1/27/25 at 11:37 AM revealed two sprinkler heads in the Cedar Unit Tub room were loaded and covered with lint and dust. 1e. Observation on the second floor on 1/27/25 at 11:47 AM revealed a three sprinkler heads in the Juniper Unit dining room and two sprinkler heads in the lounge/ television area were loaded and covered with lint and dust. 1f. Observation on the first floor on 1/27/25 at 1:33 PM revealed one sprinkler head located in the corridor near Resident room [ROOM NUMBER] on the Evergreen Unit was loaded and covered with lint and dust. 1g. Observation on the first floor on 1/27/25 at 2:20 PM revealed one sprinkler head located in the corridor near Resident room [ROOM NUMBER] on the Cypress Unit was loaded and covered with lint and dust. 1h. Observation on the first floor on 1/27/25 at 2:20 PM revealed two sprinkler heads in the Cypress Unit Tub room were loaded and covered with lint and dust. 1i. Observation in the basement on 1/27/25 at 2:48 PM revealed on sprinkler head located in the Laundry room was loaded and covered with lint and dust. 1j. Observation in the basement on 1/27/25 at 3:52 PM revealed two sprinkler heads in the Kitchen were loaded/ covered with black debris and two other sprinkler heads were covered with lint and dust. Further observation revealed one sprinkler head in the produce cooler had rust colored stains on it. The escutcheon was missing from a sprinkler head in the walk-in freezer. 2a. Observation above the ceiling tiles on the second floor on 1/28/25 at 8:54 AM revealed temporary lighting including a light bulb in a plastic cage and electrical wiring was attached to and hung from sprinkler piping by a metal wire near Resident rooms [ROOM NUMBERS] on the Cedar Unit. During an interview at the time of the observation the Maintenance Supervisor stated the Maintenance staff checked sprinkler piping when they conducted work above the ceiling tiles and the facility did not have documentation for the checks. 2b. Observation above the ceiling tile on the second floor on 1/28/25 at 9:08 AM revealed an electrical junction box was attached to and hung from the sprinkler pipe hanger by a plastic tie near the smoke barrier doors that separated the second floor corridor from the Cedar Unit. 2c. Observation above the ceiling tile on the second floor on 1/28/25 at 9:40 AM revealed an electrical wire was attached to a sprinkler pipe hanger by a plastic tie near the Beauty Salon. 2d. Observation above the ceiling tile on the first floor on 1/28/25 at 9:48 AM revealed a one half inch flexible metal electrical wire was attached to a sprinkler pipe hanger by a metal wire near the smoke barrier doors that separated the first floor corridor from the Cypress Unit. 2e. Observation above the corridor ceiling tile on the first floor on 1/28/25 at 10:00 AM revealed seven electrical wires were attached to a sprinkler pipe by a plastic tie near Resident room [ROOM NUMBER] on the Cypress Unit. 2f. Observation above the ceiling tile on the first floor on 1/28/25 at 10:27 AM revealed an electrical wire was attached to a sprinkler pipe hanger by a plastic tie near the smoke barrier doors that separated the first floor corridor from the Evergreen Unit. 2g. Observation above the corridor ceiling tile on the first floor on 1/28/25 at 10:43 AM revealed a one half inch flexible metal electrical wire was attached to two sprinkler pipe hangers by metal wires near Resident room [ROOM NUMBER] on the Evergreen Unit. 2h. Observation above the corridor ceiling tile on the first floor on 1/28/25 at 10:59 AM revealed a one half inch flexible metal electrical wire was attached to a sprinkler pipe by a metal wire near the stairway exit door near Resident Room 195. 3a. During an interview on 1/29/25 at 4:03 PM the Maintenance Supervisor stated the facility had no documentation for the inspection and testing of the facility's automatic sprinkler system in the second quarter of 2023 and the third quarter 2024. The Maintenance Supervisor further stated the contractor that inspected, tested , and maintained the facility's automatic sprinkler system did not inspect and test the system in the second quarter of 2023 and the third quarter 2024. 4a. During an interview on 1/29/25 at 4:06 PM the Maintenance Supervisor stated the issues documented on the of sprinkler inspection reports from the contractor that inspected, tested , and maintained the facility's fire alarm system dated 10/7/24 and 1/10/25 were not addressed and the contractor did not come back to the facility to correct any of the issues. Review of a Sprinkler Inspection Report from the contractor that inspected, tested , and maintained the facility's automatic sprinkler system dated 10/7/24 revealed the following was documented on the report: Sprinkler heads in the kitchen are excessively dirty and showing rust and corrosion. Including the two walk-in coolers and one walk-in freezer. 21 heads that exclude the two office areas off of the kitchen will require replacement. Review of a Sprinkler Inspection Report from the contractor that inspected, tested , and maintained the facility's automatic sprinkler system dated 1/10/25 revealed the following was documented on the report: At least one sprinkler head is corroded in kitchen near hood/ steamer. Advise replacing sprinkler. At least two sprinklers are dust/ grease loaded in kitchen: to left of clock above reach in freezer, and above prep table in front of walk -in cooler. Advise replacing both sprinklers. At least one sprinkler head has rust stains in the kitchen walk-in produce cooler, advise replacing as it could not be confirmed if the rust was originated from the sprinkler or the pipe above. Sprinkler in kitchen walk-in freezer is missing its escutcheon. Advise replacing escutcheon for sprinkler. Post Indicator Valve is seized in the open position. Valve has a history of being difficult to operate. Advise repair. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2011 NFPA 101: 9. 7, 9. 7. 1, 9. 7. 1. 1, 9. 7. 5 2011 NFPA 25: 4. 1, 4. 1. 1, 4. 3, 4. 3. 1, 5. 1, 5. 1. 1, 5. 1. 1. 1, 5. 1. 1. 2, Table 5. 1. 1. 2, 5. 2, 5. 2. 1, 5. 2. 1. 1, 5. 2. 1. 1. 1, 5. 2. 1. 1. 2, 5. 2. 2. 2, 6. 2. 7, 6. 2. 7. 2, 2010 NFPA 13: 9. 1, 9. 1. 1. 7 | Plan of Correction: ApprovedFebruary 26, 2025 The sprinkler heads noted in the inspection to not be free of foreign materials were properly cleaned per life safety code standards. The sprinkler heads noted in the inspection to be corroded or rusted have been replaced per life safety code standards. The escutcheon noted in the inspection as missing has been replaced. The sprinkler piping and pipe hangers noted to have been exposed to external loads during inspection have had the loads removed. The quarterly inspection, testing and maintenance of the automatic sprinkler system noted as lacking has been verified and documented. The post indicator valve that was found during inspection to have been seized in the open position will be repaired to proper function. An audit of all of the facilities sprinkler heads will be completed to assure they are free of foreign materials, not corroded or rusted and have escutcheons to meet the life safety code standards. An audit of all ceiling areas containing sprinkler piping and pipe hangers will be completed to confirm they have not been exposed to external loads. There are not other post-indicator valves in the facility The quarterly inspection, testing and maintenance of the automatic sprinkler system will be audited for completion to assure the facility remains compliant with timely quarterly inspections. Any and all areas found during these audits to be non-compliant will be cleaned, repaired or replaced to assure compliance with life safety code standards. A review of the facilities policy related to sprinkler system inspections will be completed to assure it contains language that outlines the requirements of quarterly sprinkler inspections, to include frequency, scope, documentation, individuals responsible and follow-up procedures on identified issues. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of sprinkler inspection documents, as well as inspection of sprinkler heads and sprinkler piping will be completed monthly, for three months to assure ongoing compliance. These audits will include checking for lint/dust on sprinkler heads, corrosion on sprinkler heads, proper escutcheon placement, checking sprinkler piping for external load, and visual inspection of the post indicator valve. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the Life Safety Code survey completed on 2/3/25, smoke barrier walls were not maintained. Specifically, smoke barrier walls were not complete from floor to roof deck, not designed to have at least a 30-minute fire resistance rating, and not designed to resist the passage of smoke, due to penetrations through the smoke barrier walls. This affected two (first and second floors) of two resident use floors. The findings are: 1a. Observation above the ceiling tiles on the second floor in the Cedar Unit on 1/28/25 at 9:15 AM revealed a two inch long by one inch wide open unsealed penetration in the smoke barrier wall above the smoke barrier doors that separated the Cedar Unit from the second floor corridor. During an interview at the time of the observation the Maintenance Supervisor stated there had not been any recent work conducted on the smoke barrier wall in this area of the facility. 1b. Observation above the ceiling tiles on the first floor in the Evergreen Unit on 1/28/25 at 10:39 AM revealed a 16 inch long by three inch wide open unsealed penetration in the smoke barrier wall above the smoke barrier doors that separated the Evergreen Unit from the first floor corridor. During an interview at the time of the observation the Maintenance Supervisor stated there had not been any recent work conducted on the smoke barrier wall in this area of the facility. During an interview on 1/29/25 at 4:03 PM the Maintenance Supervisor stated the Maintenance staff inspected the facility's smoke barrier walls at least twice a year and the facility did not have documentation for the inspections. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7, 19. 3. 7. 3, 8. 5, 8. 5. 1, 8. 5. 2, 8. 5. 2. 1, 8. 5. 2. 2, 8. 5. 2. 3 | Plan of Correction: ApprovedFebruary 26, 2025 Q 1. Per the Directed Plan of Correction, the following actions were accomplished for the residents identified in the sample. No residents were negatively impacted. Penetrations were sealed in the smoke barrier wall above the smoke barrier doors separating Cedar Unit from the second floor corridor. Penetrations were sealed in the soke barrier wall above the smoke barrier doors separating the Evergreen Unit from the first floor corridor. Q 2. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. A visual inspection of the facility will be conducted to ensure all visible penetrations are properly sealed. Q 3. Per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: The facility fire protection policy was reviewed by the consultant with Administration and the Director of Maintenance without changes. As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address All maintenance staff will be re-educated on the policy specific to ensuring thorough inspection of the facility to ensure all areas of penetrations are identified and properly sealed by the consultant. All training components have been added to the initial orientation and annual education for facility maintenance staff Q 4. The facilitys compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. The Director of Maintenance will inspect any areas of contractor work for potential areas of penetrations immediately following the conclusion of scope of work. The Director of Maintenance will provide quarterly reports on contracted work and subsequent inspections to the Quality Assurance Performance Improvement committee for the next 12 months. Frequency of on-going audits will be determined by the Committee based on audit results The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly x 3 months Responsibility: The Director of Maintenance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 3, 2025
Corrected date: N/A
Citation Details Based on observation, interview, and record review during the Life Safety Code survey completed on 2/3/25, smoke barrier doors were not maintained. Specifically, smoke barrier doors did not close the opening between them, leaving only the minimum clearance necessary for proper operation and smoke barrier doors did not prevent the passage of smoke. This affected one (first floor) of two resident use floors. The finding is: Observation on the first floor in the Evergreen Unit on 1/27/25 at 1:18 PM revealed a greater than one quarter inch gap between the doors that separated the Evergreen Unit from the first floor corridor, when the doors were in a fully closed position. During an interview on 1/29/25 at 4:05 PM the Maintenance Supervisor stated the Maintenance staff checked the facility's smoke barrier doors during monthly security door checks and the facility had documentation for the checks. Review of monthly Security Door Checks logs revealed the smoke barrier doors that separated the Evergreen Unit from the first floor corridor were checked monthly from 2/14/23 through 1/6/25 and the logs contained no documentation for gap between the doors. 10 NYCRR 415. 29(a)(2), 711. 2(a)(1) 2012 NFPA 101: 19. 3. 7, 19. 3. 7. 6, 19. 3. 7. 8, 8. 5, 8. 5. 1, 8. 5. 4, 8. 5. 4. 1, 8. 5. 4. 4 | Plan of Correction: ApprovedFebruary 26, 2025 The unit smoke barrier doors found during survey not close the opening between them, leaving more than the minimum clearance necessary to prevent the passage of smoke have been repaired with vertical door seals to assure they meet life safety code standards. An audit of all facility smoke barrier double-doors will be completed to assure they do not contain vertical gaps that would allow passage of smoke. Any areas identified as not properly closing and allowing an opening between them will be repaired per life safety code standards. A review of the facilities policy related to door inspections will be completed to assure it contains language that outlines the procedures for proper inspection to include closing, latching, and not having a gap in the opening between them if they are double doors. The audit documents used for door inspections will also include the language specific to the procedure. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of smoke barrier doors will be completed monthly, as part of the security door check audits, for three months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures. |