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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for three (3) (Resident #s 16, 22, and 25) of 36 residents reviewed. Specifically, (a.) Resident #22 was unable to make their needs known, and there were several dates with no documented activities. (b.) For Resident #s 16 and 25, there were no consistent activities planned to meet the resident's needs and/or preferences. This is evidenced by: The facility Policy and Procedure titled, Activities, effective 10/15/2021, documented: (a) the Residential Services Activities Departments provided ongoing programs of activities designed to meet, in accordance with the comprehensive resident assessment, the interest and the physical, mental and psychosocial well-being of each resident; (b) activities programs encouraged the resident's voluntary choice of activities and participation by offering a variety of programs throughout the day and week. The programming promotes and maintains the resident's sense of usefulness to self and others; (c) the coordinator of each program ensured that there was a written plan for individual, group and independent activities in accordance with the resident's needs, interests and capabilities. The plan recognized the resident's mental and physical needs and interests, as well as education and experiences. The plan was developed and prepared with the resident and their designated representatives when it was appropriate and communicated to team members; (d) a monthly activities schedule based upon individual and group needs, interactions and capabilities was developed by the coordinator; (e) upon request, the coordinator provided the Executive Director with a monthly report of the type, frequency of, and number of residents who participated in the activity programs. They also ensured that the resident's clinical record contained a quarterly assessment to the resident's degree of participation in, response to, and benefit from the activities program. Resident #22 Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had severe cognitive impairments, could be understood, and understand others. During observations on 3/26/2025 at 2:56 PM, 3/27/2025 at 10:00 AM, and 3/28/2025 at 11:30 AM, Resident #22 was noted to be the living room common area where a television was on. The resident was dozing on and off. The Comprehensive Care Plan for Activities revised 2/11/2025, documented Resident #22 would be able to participate in activities of their choice and the resident would maintain the highest quality of life possible. Record review revealed no documented evidence of activities for Resident #22 on the following dates in 2025: 1/03, 1/06, 1/08, 1/10, 1/13-1/17, 1/19-1/21, 1/23-1/25, 1/28-1/31, 2/05, 2/07, 2/08, 2/10-2/14, 2/19, 2/21, 2/22, 2/25-2/27, 3/03-3/08, 3/12-3/14, 3/19, 3/28, and 3/31/2025. Resident #25 Resident #25 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was understood, could understand others, and was severely cognitively impaired. The Comprehensive Care Plan for Activities, last revised on 3/09/2025, documented the resident would continue to participate in groups and activities of choice. During an observation on 3/25/2025 at 12:16 PM, Resident #25 was in their room alone. During an observation on 3/31/2025 at 10:15 AM, Resident #25 was in their room alone with no activities or interaction. There were personal craft supplies available in the room, but they were not in reach of the resident. Resident #16 Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 3/15/2025, documented the resident had moderate cognitive impairment, could be understood, and understand others. The Comprehensive Care Plan for Activities, last revised on 3/09/2025, documented the resident would continue to participate in groups and activities of choice. During an observation on 3/25/2025 at 12:50 PM, Resident #16 was observed to be in their room with no staff interaction. During an observation on 3/31/2025 at 10:09 AM, Resident #16 was observed to be sitting at the dining table with no interaction or activities. Interviews: During an interview on 3/26/2025 at 12:30 PM, Ombudsman #1 stated residents had requested more activities to take place in the houses; they wanted more personalized activities that included exercise and outside trips. During an interview on 4/03/2025 at 10:14 AM, Shahbaz (Certified Nurse Aide) #1 stated that each house had activities and that the activities depended on the Shahbaz. They stated they tried to follow the activity calendar but not all staff did. During an interview on 3/31/2025 at 1:56 PM, Recreational Therapy Manager #1 stated when there were three (3) Shahbaz in the house, one should have been conducting the activity. They stated the following: The Activity Calendar was posted in the houses. Activity attendance roster was documented in electronic medical records. One-to-One activities were documented for each elder receiving 1:1 activities. Recreational Therapy Manager #1 stated a staff member from dietary held exercise groups in the houses, although it was not on a regular basis. They also stated there had been two outside trips within their 2-year tenure--One to the mall and the other to see Christmas Lights. They stated the major barrier to outside trips was securing a driver to drive the van. During an interview on 3/31/2025 at 3:18 PM, Administrator #1 stated they were reviewing current activity programs and working with Recreational Manager #1 and house staff to improve activities. They stated that they were recently made aware of needing a driver for outside trips and looking into obtaining more drivers; families had volunteered to assist in coordinating and conducting activities, such as paint and sip. They further stated that a dietary employee conducted an exercise program each month for each house. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h | Plan of Correction: ApprovedMay 7, 2025 F679 Element 1 Resident #22 ?Çô Activities professionals updated the residents Activity Assessment and progress note addressing activities and individual preferences. Resident #25 ?Çô Activities professionals updated the residents Activity Assessment and progress note addressing activities and individual preferences. Resident #16 ?Çô Activities professionals updated the residents Activity Assessment and progress note addressing activities and individual preferences. Element 2 All residents that engage in the activities program could be affected by this deficient practice. Element 3 The Activities Policy was reviewed with no changes. In-services will be conducted to the Activities Director and the Activities Assistant regarding the expectation that activities be conducted daily in each of the homes, and that the activities are appropriate for the elders in the home. Activities Staff were in-serviced on the activity assessment process and the activity progress note. All residents will have updated Activity Assessments and Progress note to be completed at the rate of two houses per week. Activity Calendars will be reviewed and rewritten to address the needs and preferences of each of the houses to meet the interests of and support the physical, mental, and psychosocial well-being of each resident to promote independence and interaction in the community. One Community activity will be held per week at the Community Center for everyone to attend. Element 4 Activity Calendars will be posted in a prominent place with copies submitted at the Decline meeting on Thursdays. Activity staff will Audit that the scheduled activities are being conducted, according to the calendar schedule, at two houses per day for the next three months until 100% compliance is met. Audit results will be brought to the Quality Assurance Performance Improvement Committee monthly. The committee will make recommendations for the ongoing audits and frequency based on compliance. Committee will make recommendations for change in policy, plan or education based on results of the audits. Monitored by Director of Activities, or Designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure assessments were coordinated with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid for eight (8) (Resident #s 16, 22, 65, 70, 115, 130, 145, and 166) of 36 residents reviewed. Specifically, (a) Resident # ' s 22, 65, 70, and 145 received new [DIAGNOSES REDACTED].# ' s 16, 22, 115, 130, and 166 were admitted with [DIAGNOSES REDACTED]. This is evidenced by: The facility Policy and Procedure titled, Pre-Admission Screening and Resident Review (PASSAR), effective 9/10/2022, documented all individuals seeking admission would undergo a Pre-Admission Screening and Resident Review Level I screening prior to admission to determine if they have a mental illness or intellectual disability. Screening would be conducted in accordance with New York State Department of Health guidelines and Centers for Medicare and Medicaid Services regulations. Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation would be completed by a qualified mental health professional. The evaluation would assess the individual's needs, preferences, and the appropriateness of nursing facility placement. Resident #22 Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/15/2024, documented the resident had severe cognitive impairment, could be understood, and understand others. The Screen Form dated 12/29/2017, documented under Level I Review for Possible Mental Illness-question #23: Does this person have a serious mental illness - No. A Psychiatric consultation on 8/16/2022, documented medical history of [REDACTED]. Resident #130 Resident #130 was admitted to the facility with [DIAGNOSES REDACTED]. The Screen Form dated 7/24/2024, documented under Level I Review for Possible Mental Illness-question #23: Does this person have a serious mental illness - No. A Psychiatric consultation dated 9/05/2024, documented the following active Diagnosis: [REDACTED]. Recommendation: consider use of Galantamine for cognition and hallucinations. Continue [MEDICATION NAME] 100 milligrams daily for (depression/anxiety). Continue [MEDICATION NAME] 7.5 milligrams at bedtime for Appetite Enhancement/helps with [MEDICAL CONDITION]). Resident #166 Resident #166 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident was usually understood, could usually understand others, and was severely cognitively impaired. The Screen Form dated 10/22/2024 documented under Level I Review for Possible Mental Illness-question # 23: Does this person have a serious mental illness - No. During an interview on 4/01/2025 at 10:56 AM, Social Worker #3 stated the screen was completed prior to admission. They stated that a developmental disability, serious mental illness, or intellectual disability would warrant a Level II screen. They stated if a resident was diagnosed with [REDACTED]. During an interview on 4/01/2025 at 3:46 PM, Social Worker #1 stated resident #22 and resident #130 did not have any [DIAGNOSES REDACTED]. During an interview on 4/01/2025 at 11:06 AM, Social Worker #2 stated a Level II screen should be requested for conditions like [MEDICAL CONDITION] disorder. During an interview on 4/03/2025 at 10:10 AM, Admissions Coordinator #1 stated prior to admission all resident medical and financial information was gathered, including the DOH-695 Screen. They stated the information was reviewed for completeness then given to nursing staff for admission; any subsequent changes requiring level II screen was followed up by social work. 10 New York Codes, Rules, and Regulations 415.11(e) | Plan of Correction: ApprovedMay 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F644 Element 1 Level I screen will be completed for Residents 36, 22, 65, 70, 145, 16, 115, 130 and 166. Element 2 All residents with a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. This review will be completed by (MONTH) 13, 2025. Any resident with a [DIAGNOSES REDACTED]. The Pre-Admission Screening and Resident Review policy was reviewed, and no changes were made. Element 3 Inservice?ÇÖs will be conducted for the facility screeners, admission coordinator, social workers, nurse managers and nurse practitioners on the policy, including, but not limited to, the need to complete a level I screen with any new [DIAGNOSES REDACTED]. Element 4 Audits will be conducted weekly on all new admissions and for all residents seen by the psychiatrist by using the Progress Note Reports using the practitioner as the author. Progress Note Reports will be reviewed at the Decline meeting held on Thursdays. Audit results will be brought to the Quality Assurance Performance Improvement Committee monthly. Audits will continue until 100% compliance achieved. The committee will make recommendations for the ongoing audits and frequency based on compliance. Committee will make recommendations for change in policy, plan or education based on results of the audits. Monitored by Director of Nurses, or Designee. |
Scope: N/A
Severity: N/A
Citation date: April 3, 2025
Corrected date: N/A
Citation Details Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure criminal history record checks were performed as required by adopted regulations for one employee personnel record reviewed. Specifically, the facility did not immediately or as soon as possible, conduct criminal history record checks on persons reasonably expected to be hired or employed, as required by 10 New York Codes, Rules, and Regulations section 402.3. This is evidenced by: During observations on 3/27/2025 at 11:45 AM, Environmental Aide II #1, was observed working in House #12. There was no documented evidence that a Criminal History Background Check was conducted on Environmental Aide II #1. During an interview on 3/28/2025 at 10:51 PM, Administrator #1 stated that Environmental Aide II #1 was employed at a sister facility, was brought to this facility to help with environmental tasks, and that a background check should have been but was not conducted. 10 New York Codes, Rules, and Regulations 402.3 | Plan of Correction: ApprovedMay 12, 2025 Element 1 The employee that did not have a background check specifically for EVG, but did have one for the company, had her schedule cancelled and did not return to the community. A community is a facility with their own distinct operating certificate Human Resources will in-service Administrator, Director of Nursing, and Staffing Coordinators that any unlicensed staff that is shared between communities, a community is a facility with their own distinct operating certificate, will have a separate background check for each separate community. Element 2 The facility will ensure that any unlicensed staff that is shared between communities, a community is a facility with their own distinct operating certificate, will have a separate background check for each separate community. Payroll for the last 30 days will be reviewed to ensure that no staff have worked at the facility without a completed Criminal History Record Check. No staff identified. Element 3 Policy for Criminal History Record Check policy has been updated to reflect the necessity of having separate background checks for each community they work at. Current staff rosters will be audited to ensure that all staff working at the EVG community, a community is a facility with their own distinct operating certificate that work at other sister communities have separate background checks. Element 4 Results of audits with be reported at the Quality Assurance Performance Improvement Committee monthly for three months. The Quality Assurance Performance Improvement Committee will be responsible for recommending ongoing need and frequency of audits and if plan needs to be amended based on findings of audits and compliance with plan. Human Resources Authorized Person is responsible for on-going compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety for four (4) of 16 resident central kitchens. Specifically, (a.) bulk food items were not labeled for their contents; (b.) bulk food items and outside items were not date-labeled after opening or labeled with an expiration date; (c.) appliances were not cleaned and had dirt, grime, and unknown substances within them; and (d.) chicken was improperly being thawed. This is evidenced by: An undated policy titled Food Safety Labeling Procedure documented that all food or beverage items stored, opened, prepared, or leftover in our kitchens/storage areas and/or delivered to areas such as Nursing Stations or pantries would be clearly identified by the item name/product, the production or opened date, and the use-by date. A document titled Important Foodservice and Sanitation Guidelines described that any prepared food that was opened or stored must be labeled and dated for discard within three days. Any beverage or dairy product must be labeled with its opening date. Items must be discarded within seven days of being opened or by the manufacturer's use-by date, whichever comes first. Any condiment-type item that must be refrigerated after opening must be labeled with the opened date, and items must be discarded within 30 days of being opened. House #5 During an observation on [DATE] at 10:27 AM, uncooked chicken was in a Ziploc bag placed in a metal bowl in the kitchen sink, with water from the faucet running over it. The bag was labeled ,[DATE] dinner. At 11:23 AM, the same bag of chicken was observed in the metal bowl filled with water in the same sink. The bag of chicken was sitting in the bowl filled with water, and the faucet was turned off. During observations on [DATE] from 10:35 AM to 12:35 PM, the following was noted within the main kitchen area for Houses #10, 12, 14, and 16: House # 10 A) Eight (8) items did not have labels describing what they were or what they contained: ?? Frozen French fries located within a freezer ?? Frozen scones located within a freezer ?? Frozen cookies located within a freezer ?? Frozen sausage patties located within a freezer ?? Frozen fish fillets located within a freezer ?? Frozen peas located within a freezer ?? Frozen dinner rolls located within a freezer ?? Frozen broccoli located within a freezer B) Two (2) items lacked a label or writing of when they were opened: ?? A bag of Ruffles chips ?? Package of cookies C) The appliances had the following findings: ?? Seals on the freezer and refrigerator were covered with dirt and grime ?? The freezer had old fallen labels dating back to 2019 ?? The freezer bottom had substance on the bottom of the freezer ?? The interior of the oven had unknown substances on the glass doorway ?? The microwave oven was covered with an unknown substance within the appliance House # 12 A) Eight (8) items did not have labels describing what they were or what they contained: ?? Frozen waffle fries located within a freezer ?? Frozen hot dogs located within a freezer ?? Frozen hamburgers located within a freezer ?? Two (2) packages of frozen sausage patties located within a freezer ?? Four (4) packages of frozen sausage patties located within a freezer ?? Frozen fish fillets labeled as sausage located within a freezer ?? Frozen corn located within a freezer ?? Frozen cinnamon rolls labeled as dinner rolls located within a freezer ?? Frozen broccoli located within a freezer ?? Frozen berry mix located within a freezer B) Two (2) items lacked a label or writing of when they were opened: ?? Two (2) packages of wheat bread ?? Package of cookies C) The appliances had the following findings: ?? Seals on the freezer and refrigerator were covered with dirt and grime ?? The freezer had old fallen labels dating back to 2021 ?? The freezer bottom had substance on the bottom of the freezer ?? The interior of the oven had unknown substances on the glass doorway ?? The microwave oven was covered with an unknown substance within the appliance House #14 A) Eight (8) items did not have labels describing what they were or what they contained: ?? Frozen French fries located within a freezer ?? Frozen scones located within a freezer ?? Frozen cookies located within a freezer ?? Frozen sausage patties located within a freezer ?? Frozen fish fillets located within a freezer ?? Frozen peas located within a freezer ?? Frozen dinner rolls located within a freezer ?? Frozen broccoli located within a freezer B) Four (4) items lacked a label or writing of when they were opened: ?? A bag of Ruffles chips ?? Package of cookies ?? Package of Cinnamon Toast Crunch bars ?? Package of Oatmeal Bars C) The appliances had the following findings: ?? Seals on the freezer and refrigerator were covered with dirt and grime ?? The freezer had old fallen labels dating back to 2019 ?? The freezer bottom had substance on the bottom of the freezer. ?? The interior of the oven had unknown substances on the glass doorway ?? The microwave oven was covered with an unknown substance within the appliance House #16 A) Eight (8) items did not have labels describing what they were or what they contained: ?? Frozen hamburgers located within a freezer ?? Frozen scones located within a freezer ?? Frozen cookies located within a freezer ?? Frozen sausage links located within a freezer ?? Frozen fish fillets located within a freezer ?? Frozen corn located within a freezer ?? Frozen dinner rolls located within a freezer ?? Frozen broccoli located within a freezer B) Two (2) items lacked a label or writing of when they were opened: ?? Two (2) packages of wheat bread ?? Package of cookies C) The appliances had the following findings: ?? Seals on the freezer and refrigerator were covered with dirt and grime ?? The freezer had old fallen labels dating back to 2019 ?? The freezer bottom had substance on the bottom of the freezer ?? The interior of the oven had unknown substances on the glass doorway ?? The microwave oven was covered with an unknown substance within the appliance Interviews: During an interview on [DATE] at 10:44 AM, Shahbaz (Certified Nurse Aide) #4 stated that staff should have properly labeled and discarded the expired item. They stated that the labels did not always stick in the freezer and fell off. During an interview on [DATE] at 10:54 AM, Shahbaz #5 stated all staff needed to be more diligent in labeling and tracking item dates and labeled when identified. During an interview on [DATE] at 11:49 AM, Shahbaz #1 stated that all Certified Nurse Aides were responsible for looking at items and determining if they needed to be discarded by the date. During an interview on [DATE] at 11:08 AM, Registered Nurse #1 stated that food and kitchen activities were ultimately the staff's responsibility. All staff in the kitchen area should have checked the items regularly for resident safety. Registered Nurse #1 stated that it was the daily routine of the Shahbaz (Certified Nurse Aides) to maintain the cleanliness of the kitchen areas. They stated that there was a daily cleanliness checklist for them to follow. They further stated that they would periodically meet with the food service division to review the items found. During an interview on [DATE] at 2:15 PM, Director of Nursing #1 stated that the Food Service Director oversaw the food at the facility. However, it was a joint staff effort to check the food and food items daily for potential expiration dates. They further stated that the facility's distribution manager and Shahbaz (Certified Nurse Aides) were to check the items regularly, with them opened and labeled per policy. 10 New York Codes of Rules and Regulations 415.14(h) | Plan of Correction: ApprovedMay 8, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F812 Element 1 No individual was affected by this deficient practice. In house #5 the uncooled chicken was disposed of immediately, and a replacement was provided. In house #10 the following items were disposed of immediately. ?? Frozen French fries located within a freezer ?? Frozen scones located within a freezer ?? Frozen cookies located within a freezer ?? Frozen sausage patties located within a freezer ?? Frozen fish fillets located within a freezer ?? Frozen peas located within a freezer ?? Frozen dinner rolls located within a freezer ?? Frozen broccoli located within a freezer . A bag of Ruffles chips ?? Package of cookies House #10 The following appliances were cleaned immediately Seals on freezer were cleaned Old labels were cleaned from the bottom of the freezer Freezer bottom was cleaned the oven doors were cleaned the microwave oven was cleaned House #12 The following items were disposed of in House 12 immediately ?? Frozen waffle fries located within a freezer ?? Frozen hot dogs located within a freezer ?? Frozen hamburgers located within a freezer ?? Two (2) packages of frozen sausage patties located within a freezer ?? Four (4) packages of frozen sausage patties located within a freezer ?? Frozen fish fillets labeled as sausage located within a freezer ?? Frozen corn located within a freezer ?? Frozen cinnamon rolls labeled as dinner rolls located within a freezer ?? Frozen broccoli located within a freezer ?? Frozen berry mix located within a freezer ?? Two (2) packages of wheat bread ?? Package of cookies The appliances in house #12 were cleaned immediately to include: ?? Seals on the freezer and refrigerator ?? The freezer had labels cleaned off bottom of freezer ?? The freezer bottom was cleaned ?? The interior oven door was cleaned ?? The microwave oven was cleaned House #14 The following items were disposed of immediately : ?? Frozen French fries located within a freezer ?? Frozen scones located within a freezer ?? Frozen cookies located within a freezer ?? Frozen sausage patties located within a freezer ?? Frozen fish fillets located within a freezer ?? Frozen peas located within a freezer ?? Frozen dinner rolls located within a freezer ?? Frozen broccoli located within a freezer ?? A bag of Ruffles chips ?? Package of cookies ?? Package of Cinnamon Toast Crunch bars ?? Package of Oatmeal Bars The following appliances were cleaned immediately: ?? Seals on the freezer and refrigerator were covered with dirt and grime ?? The freezer had old fallen labels dating back to 2019 ?? The freezer bottom had substance on the bottom of the freezer. ?? The interior of the oven had unknown substances on the glass doorway ?? The microwave oven was covered with an unknown substance within the appliance House #16 The following items were disposed of immediately: ?? Frozen hamburgers located within a freezer ?? Frozen scones located within a freezer ?? Frozen cookies located within a freezer ?? Frozen sausage links located within a freezer ?? Frozen fish fillets located within a freezer ?? Frozen corn located within a freezer ?? Frozen dinner rolls located within a freezer ?? Frozen broccoli located within a freeze ?? Two (2) packages of wheat bread ?? Package of cookies The following items were cleaned immediately: ?? Seals on the freezer and refrigerator ?? The freezer was cleaned of fallen labels ?? The freezer bottom was cleaned ?? The interior of the oven glass doorway was cleaned ?? The microwave oven was cleaned Element 2 All individuals that partake in the dining services have the potential to be affected by this deficient practice. An Inspection of all houses was conducted to identify the deficient practice in other houses, items that were not labeled, dated, those that did not have discard date, or items that were expired were disposed of at the time of the inspection by the Dietary Services management group. Element 3 Important Foodservice and Sanitation Guidelines policy was reviewed with no changes. Inservice?ÇÖs were conducted by [DATE] to all staff in the houses regarding the Food Safety Labeling Procedure, specifically, the requirements to all food or beverage items, stored, opened, prepared, or leftover in kitchen / storage areas or delivered areas such as nursing stations or pantries. Items require to be clearly identified by: ?Çó The item name/product ?Çó The production or opened date ?Çó The use by date Inservice?ÇÖs were conducted by [DATE] to all staff in the houses regarding the ?Ç£Important Food service and Sanitation Guidelines?Ç¥, specifically the requirements that: ?Çó Prepared food opened or stored must be labeled and discarded within three days ?Çó Any beverage pr dairy product, must be labeled with the opening date ?Çó Items must be discarded within seven days of being opened or the manufacturers use-by date, whichever comes first ?Çó Condiments that must be refrigerated after opening must be labeled with the open date, and item discarded within 30 days of opening. Element 4 Audits will be conducted once weekly in each house for the next 4 weeks and then once every 2 weeks for the next month, and monthly until 100% compliance is met. Results of audits will be reported monthly at the Quality Assurance Committee meeting. The Committee will make recommendations based on results of audits for change in plan, policy, education audit frequency. The facility utilizes a Plan-Do-Check-Act model for Quality improvement. This cyclical model of improvement includes regular reviews of processes and outcomes to ensure the effectiveness and sustainability of corrections made. The committee will be responsible for monitoring to ensure on-going compliance and to determine frequency of periodic audits to determine if changes are maintaining the desired corrections or if the plan needs to be altered. Monitored by the Administrator, or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the recertification and abbreviated (Case #NY 717) survey, the facility did not ensure that residents were free from neglect for four (4) (Resident #s 16, 25, 99, and 115) of five (5) residents reviewed for neglect. Specifically, Residents #s 16, 25, 99, and 115 were not provided toileting care by staff on evening and night shift of 10/27/2024. Some of these residents were left overnight in the same clothes they had been dressed in the day before, and some with their incontinence garment, clothes, and bedding saturated with urine. This is evidenced by: The Policy and Procedure titled Abuse Prevention and Investigation Policy effective 3/25/2025, neglect is defined as the failure to provide timely, consistent, safe, adequate and appropriate services treatment, and care necessary to avoid physical harm, mental anguish or mental illness. The Resident Kardex (Resident care card followed by Certified Nurse Aide) dated 10/29/2024, documented Resident #16 required substantial/maximum assistance to get dressed. Resident #16 required substantial/maximum assistance using a gait belt and walker for transfers and was dependent on staff for toilet transfers. Resident #16 was on a toileting schedule: upon waking, before and after meals, before bed and on first and last rounds during the night. The Resident Kardex dated 10/29/2024, documented Resident #25 required substantial/maximum assistance to get dressed. Resident #25 required touching assistance with wheeled walker for transfers and toilet transfers. Resident #25 was on a toileting schedule: upon waking, before and after meals, before bed, and on first and last rounds. The Resident Kardex dated 10/29/2024, documented Resident #99 required substantial/maximum assistance for toilet clothing management. Resident #99 required partial/moderate assist with a gait belt to get on and off the toilet. Resident #99 was on a toilet schedule: upon waking, before meals and before bed, check on last rounds. The Resident Kardex dated 10/29/2024, documented Resident #115 was non ambulatory and required a ceiling lift for transfers. Resident #115 required a total lift into a chair over the toilet. Resident #115 was on a toileting schedule: upon waking, before and after meals, before bed, and on first and last rounds. The Investigation Summary Form dated 10/28/2024, documented Shahbaz (Certified Nurse Aide) #1 reported that Resident #25 was still in the same clothes they had been dressed in the day before and their incontinence garment, clothes, and bedding were saturated with urine. It further documented Shahbaz #1 reported that Resident #115 was found saturated with urine on morning rounds at approximately 8:30 AM on 10/28/2024. In a written statement obtained on 10/29/2024, Shahbaz #11 stated there were residents that were not changed that should have been, specifically Residents #'s 16 and 99. Shahbaz #11 stated they also did not change Resident #25 and did not read their care card. The Investigation Summary Form dated 10/28/2024 stated surveillance footage was reviewed for the 10/27/2024 evening and overnight shift. The footage documented that (a) Resident #16 was put to bed at 7:17 PM on 10/27/2024 and their room was not entered until the arrival of the day shift on 10/28/2024, (b) Resident #25 was in their room at 7:44 PM on 10/27/2024 and no staff entered their room until the arrival of the day shift on 10/28/2024, (c) Resident #99 was put to bed at 10:30 PM on 10/27/2024 and no staff entered their room to provide care until the arrival of the day shift on 10/28/2024, and (d) Resident #115 was put to bed at 9:13 PM on 10/27/2024 and no staff entered their room to provide care until the arrival of the day shift on 10/28/2024. The Weekly Wound tracking documented Resident #16 had a deep tissue injury on the left heel with an onset date of 10/29/2024. Former Director of Nursing #1 documented an in-person interview with Shahbaz #11 that took place on 10/29/2024 at 2:00 PM. During this interview, Shahbaz #11 admitted they had not changed Resident #16 during the overnight shift and had not toileted Resident #25 and Resident #99 during the overnight shift. Former Director of Nursing #1 documented an in-person interview with Shahbaz #12 that took place on 10/29/2024 at 2:30 PM. During this interview, Shahbaz #12 admitted they had put extra incontinence pads and briefs on Resident #25 despite knowing they were not supposed to, per the resident ' s care card. During an interview on 3/31/2025 at 3:00 PM, Director of Nursing #1 stated they were not involved with the investigation but confirmed that it was required that a Shahbaz read the resident's care card and provide care as laid out in the care card. They stated that Shahbaz #11 and Shahbaz #12 were terminated for neglect after this incident. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i) | Plan of Correction: ApprovedMay 7, 2025 Element 1 Resident's 16,25,99, and 115 were provided with the necessary care at time of discovering the incident. Skin assessments were done. Residents were monitored for any psychosocial stressors related to this event. The residents did not have any psychosocial stressors related to the event. The residents will continue to be monitored by social work to ensure no ongoing psychosocial impact from this event such as withdrawal, decreased appetite sleep disturbance. All staff involved in the cited case are no longer employed at the facility. Staff involved in the cited case are no longer employed at the facility. Element 2 All residents have the potential to be affected by stated deficiency. Any concerns will be investigated and reported as required under New York State Department of Health reporting requirements. All staff were educated on abuse prevention and reporting as part of New York State Department of Health Complaint Survey. Staff are educated on hire, annually and if an event occurs at the facility of the resident's rights to be free from abuse neglect or mistreatment. All staff will re-inserviced on the abuse prevention and reporting policy by 5/13/2025. Element 3 The facility will take the following measures to ensure that the problem does not reoccur: The Abuse Prevention and Investigation Policy reviewed with no changes made Inservice's will be conducted to all nursing and Shahbaz staff on the toileting needs as outlined on the Kardex. Nursing staff will be in-serviced on the facility Abuse Prevention and Investigation Policy. Element 4 The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: The Administrator will be responsible for ongoing compliance Nurses will conduct random audits, during the night shifts to check that the residents Kardex is being followed according to the Kardex at the rate of 10 per week for three months. Audit results will be brought to the monthly Quality Assurance Committee. Committee will be responsible to determine need and frequency of ongoing audits. Committee will make recommendations as needed based on results of audits for changes in plan, policy, or education. Audits will continue until 100% compliance is achieved. Monitored by Director of Nursing, or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for five (5) (Resident #s 53, 89, 145, 161, and 166) of nine (9) residents reviewed for unnecessary medications. Specifically, for Resident #s 53, 89, 145, 161, and 166, as needed [MEDICAL CONDITION] medication orders did not include end dates. This is evidenced by: The Policy and Procedure titled, [MEDICAL CONDITION] Medication Management, effective 3/06/2024, documented as needed orders for anti-psychotic and anti-anxiety medications were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. If the attending physician or prescribing practitioner believed that it was appropriate for the as-needed order to be extended beyond 14 days, they would document their rationale and indicate the duration for the as needed order. Resident #53 Resident #53 was admitted to the facility with [DIAGNOSES REDACTED]. primarily affects the nervous system, causing impaired muscle coordination). The Minimum Data Set (an assessment tool) dated 2/11/2025, documented that the resident could be understood, understand others, and was cognitively intact. A Clinical Physician order [REDACTED]. The end date was documented as indefinite. Resident #89 Resident #89 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was sometimes understood, usually understand others, and was cognitively intact. A Clinical Physician order [REDACTED]. The end date was documented as indefinite. Resident #145 Resident #145 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented that the resident was sometimes understood, sometimes understand others, and was severely cognitively impaired. The Clinical Physician order [REDACTED]. The as-needed order end date was documented as indefinite. Resident #161 Resident #161 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. The Clinical Physician order [REDACTED]. The end date was documented as indefinite. Resident #166 Resident #166 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was usually understood by others, could usually understand others, and was severely cognitively impaired. The Clinical Physician order [REDACTED]. The end date was documented as indefinite. During an interview on 3/31/2025 at 10:00 AM, Medical Director #1 stated they were aware of the regulation regarding as needed [MEDICAL CONDITION] medication and end dates. They felt medical providers should have discretion when ordering medications including applying end dates to as-needed medications. During an interview on 3/31/2025 at 2:43 PM, Director of Nursing #1 stated [MEDICAL CONDITION] medications ordered on an as needed basis should have an end date. 10 New York Codes, Rules, and Regulations 415.18 (c)(2) | Plan of Correction: ApprovedMay 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 758 Element 1 Residents 53, 89, 145, 161 and 166 physician medication orders were reviewed, and appropriate updates were made to reflect the 14-day end date. Element 2 All residents receiving [MEDICAL CONDITION] medications have the potential to be affected by this deficient practice. All residents with a as needed order for [MEDICAL CONDITION] medication were reviewed to ensure a stop date. !3 residents reviewed no changes needed. Element 3 The [MEDICAL CONDITION] Medication Management Policy was reviewed, and no changes were made. Inservice?ÇÖs were conducted by The Medical Director to the attending physicians and nurse practitioners regarding the [MEDICAL CONDITION] Medication Management Policy, specifically, the need to indicate a stop date within 14 days for as needed (PRN) [MEDICAL CONDITION] medications. Element 4 Audits will be conducted for 100% of residents with orders for as needed (PRN) [MEDICAL CONDITION] medication for the presence of a 14 day stop date/reevaluation rate on a weekly basis for the next four weeks and then monthly until substantial compliance is met. Results of the weekly audits will be presented monthly to the Quality Assurance Committee. The audits will continue to be completed until the committee determines 100% compliance. The committee will make recommendations for ongoing frequency and any need for change in plan, education or policy based on results of audits. Monitored by Director or Nurses, or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification and abbreviated (Case #NY 510) survey, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents, and did not ensure that the resident environment remained as free of accident hazards as is possible. This was evident for one (1) (Residents #146) of the 36 residents reviewed, and for House #s 10, 16, and 21. Specifically, (a.) Resident #146, who had a prior incident of being found outside of the home unsupervised, was found to have an electronic monitoring device alarm on their walker that was not functioning as it should. There was no documented evidence that the electronic monitoring device was checked daily for placement and function to prevent further accidents. Additionally, (b.) alcoholic beverages within spaces and rooms of House #s 10, 16, and 21 were observed to be open and unattended. The facility did not identify the risk and the provision of supervision to prevent accidental consumption of alcohol that was accessible to residents, staff and visitors. This is evidenced by: (a) Resident #146 Resident #146 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 2/21/2025 documented that the resident was severely cognitively impaired, could be understood and understand others. Policy titled Elopement and Disruptive Wandering (Exit-Seeking), effective 2/24/2023, documented that it was the policy of the facility to identify those residents at risk for elopement and disruptive wandering behavior and to take the necessary steps to ensure their safety. If a resident was determined to be at risk for elopement, the following steps would be followed: wandering device would be placed on the resident. If the resident is wearing the device, it would trigger the alarm. Battery life would be monitored and addressed within the manufacturer's recommended timeframes. Each wander device would be checked weekly for proper functioning. The placement of the wander device for each resident would be checked at every shift. The comprehensive Care Plan with a focus on safety awareness deficit related to confusion/decreased memory, dementia, history of falls, and impulsive behavior documented on 7/06/2024. Resident #146 exited the house and was found at the end of the carport by a staff member. Resident #146 was directed back into the home. The sole of the shoe was searched, and the electronic monitoring device was not present. A new electronic monitoring device was placed on Resident #146 ' s walker. Intervention initiated 7/08/24, documented Wander alert bracelet: (check function each week) on walker. A physician's orders [REDACTED]. Directions documented that the battery should be checked every day of the shift on Wednesday. The Medication Administration Record/Treatment Administration Record, which started on 12/20/2023, documented checking the battery for the electronic monitoring device electronic monitoring device weekly and changing it if needed each day shift, every Wednesday for safety. During (MONTH) 2025, the battery was checked on 3/05/2025, 3/12/2025, 3/19/2025, and 3/26/2025. Task sheet with intervention listed, check the electronic monitoring device bracelet for placement every 12-hour shift while awake. If the alarm does not sound, or the watch is missing, notify the supervisor, Nurse Manager, or House Nurse to replace the watch (place on the walker in the red box). Walk the elder past the patio door to check the function by sound. The following dates and times were listed as times this task was documented, and it was completed: 3/18/2025- 8:13PM 3/19/2025 6:59 AM 3/25/2025 8:33 PM 3/26/2025 6:54 AM 4/01/2025 10:30 AM and 9:29 PM There was no documentation that this task was completed on 3/20/2025, 3/21/2025, 3/22/2025, 3/23/2025, 3/24/2025, 3/27/2025, 3/28/2025, 3/29/2025, 3/30/2025, and 3/31/2025. During an interview and an observation on 3/31/2025 at 2:39 PM, Shahbaz (Certified Nurse Aide) #9 stated Resident # 146 had an electronic monitoring device on their walker which was in a red plastic box attached to their walker by screws. If Resident #146 approached the doors that led outside the home, an alarm would sound. When they heard the alarm, they would check to see if the resident was attempting to exit the house. Shahbaz (Certified Nurse Aide) #9 walked with Resident #146 to the home's front door to demonstrate how the alarm was activated. Resident #146 was using their walker with the electronic monitoring device attached. When they approached the front door, an alarm did not go off, indicating Resident #146 had approached the front door. Licensed Practical Nurse #6 approached Shahbaz #9 and Resident #146 at the front door, and they all walked with Resident #146 and their walker to the side door of the home to test the alarm on the side door. When Licensed Practical Nurse #6 approached the side door with Resident #146, the alarm was not triggered and did not make a sound alerting them. During an interview on 3/31/2025 at 2:52 PM, Licensed Practical Nurse #6 stated the electronic monitoring device for Resident #146 was kept in the red box screwed on to their walker because they would remove the electronic monitoring device if it were on their body or in their shoe. Resident #146 could not remove the red box from their walker. They stated that if the alarm worked properly, it would sound when Resident #146 approached the front or side door with the walker. An alert was sent to the pagers the Shahbaz (Certified Nurse Aide) ' s used and to the cell phones the Licensed Practical Nurse and Registered Nurse used that indicated the electronic monitoring device alarm was set off. They stated that during this observation on 3/31/2025, the electronic monitoring device alarm did not go off, and the Shahbaz pager and nurse's cell phone did not receive an alert that the electronic monitoring device alarm was set off. They stated the electronic monitoring device and alarm/alert system did not work as they should have, and they would call the person responsible for maintenance to fix the electronic monitoring device. During an interview on 3/31/2025 at 4:02 PM, Director of Maintenance #1 stated they checked the battery in Resident #146 ' s electronic monitoring device after the above-described observation. They stated the battery was dead, and the electronic monitoring device was not working. They programmed a new electronic monitoring device and checked it to make sure it was working, and they said it was working as it was supposed to at this time. During an interview and observation on 4/01/2025 at 12:36 PM, Shahbaz (Certified Nurse Aide) #10 stated that if they heard an alarm sound, they would check the pager they wore and each door in the home to see what could have caused the alarm to go off. They said they check Resident #146 ' s electronic monitoring device daily to ensure it works. Shahbaz (Certified Nurse Aide) #10 took Resident #146 ' s walker to the front door. The door alarm went off, and Shahbaz (Certified Nurse Aide) #10 received a notification on their pager that the electronic monitoring device had set off the alarm. Shahbaz (Certified Nurse Aide) #10 approached the side door with Resident #146 ' s walker, and the alarm went off. Shahbaz (Certified Nurse Aide) #10 received a notification on their pager that the electronic monitoring device had set the alarm off. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated Resident #146 was able to wander out of the house one time, so they now have an electronic monitoring device in a locked box on their walker to alert staff if the resident was attempting to leave the house. Registered Nurse #4 said the electronic monitoring device was checked weekly to ensure it was functioning as it should be, and the placement of the electronic monitoring device was checked daily. Registered Nurse #4 stated they did not think checking the function of the electronic monitoring device once a week was enough and that it should be checked each 12-hour shift. They stated that if the alarm were to be set off, they would hear the alarm, and the doors would automatically lock. The Shahbaz (Certified Nurse Aide) received a notification on their pager, and the nurses received a notification on their phone that the alarm was set off. Registered Nurse #4 stated they heard the alarm did not go off for Resident #146 on 3/31/2025, and on 4/01/2025, staff checked every alarm for residents that had them to ensure they were working. During an Interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated that if a resident wearing an electronic monitoring device were to approach an exit, the system would alarm with a beeping noise, and Shahbaz (Certified Nurse Aide) received a notification on their pager. The Shahbaz (Certified Nurse Aide) should respond to the noise and check on the residents, check the exits, and redirect the residents if necessary. They stated the nurses check the batteries in the electronic monitoring device once a week, but the batteries could stop working. The batteries could be working one minute and not the next. Director of Nursing #1 stated it was not difficult to check if Resident #146 ' s electronic monitoring device was working because a Shahbaz (Certified Nurse Aide) could take the walker and bring it to the door to see if it sets the alarm off. The resident did not need to be with them as they did this. When Director of Nursing #1 saw the gaps on the task sheet to check the electronic monitoring device placement every 12-hour shift while awake, they stated that the Shahbaz (Certified Nurse Aide) were not documenting that they completed this task consistently. Director of Nursing #1 could not say the electronic monitoring device was checked to ensure it was functioning correctly on the days that were not documented. (b) Resident environment During an observation in House #16 on 3/26/2025 at 10:46 AM, the kitchen pantry contained a box of Sam(NAME)Oktoberfest beer with three (3) bottles, labeled with the Resident #54's name. In the pantry refrigerator, two (2) bottles of the same beer were on the door shelf with no label of the resident's name. The pantry was accessible to residents, staff and visitors. During an observation in House #10 on 3/26/2025 at 11:05 AM, the unlocked medication room contained one (1) bottle of wine and two (2) bottles of hard liquor on a shelf approximately 5 feet from the ground. During an observation on 3/28/2025 at 12:34 PM, House 21 Medication Room Door was wide open. Signage was posted on door that read, Please Keep Med Room Door Closed At All Times. Four (4) wine bottles were observed within the room. Licensed Practical Nurse #1 was observed walking from medication room to kitchen area while leaving medication room door open. They returned approximately 10 minutes later. In the interim, Certified Nurse Aide #2 went into medication room and retrieved supplies leaving door open. During an interview on 3/28/2025 at 12:44 PM, Licensed Practical Nurse #1 stated the Certified Nurse Aides and dietary staff had the access code to medication room. Record review revealed some residents had a physician order [REDACTED]. Record review of Resident #54's care plan documented Resident #54 enjoyed a beer occasionally; staff were to offer a beer to them when having Happy Hour. Record review of physician orders [REDACTED]. During an interview on 4/02/2025 at 2:38 PM, Registered Nurse #1 stated that nurses would give Resident #54 the alcoholic beverage when requested. They indicated that they were unsure where they would document when the nurse would give the resident their beer. Registered Nurse #1 stated there was no way of documenting when Resident #54 was given a beer due to how it was entered into the system. During an interview on 3/31/2025 at 2:43 PM, Director of Nursing #1 stated Certified Nurse Aides, dietary staff, and central supply staff had access to the medication room. They further stated the Nurse Manager would keep an eye on alcoholic beverages, and there was no tracking for how much alcohol was used/distributed. There was no documented evidence that the facility identified the accessible alcoholic beverages as an environmental hazard, assessed individual resident risk of an accident, tracked consumption of alcoholic beverages ordered by a physician when administered to a resident, or identified and implemented measures to mitigate the risk of unintended alcoholic consumption. During an interview on 3/31/2025 at 3:18 PM, Administrator #1 stated staff who were not certified to pass medication should not access the medication room. They stated that as of 3/31/2025, Shahbaz (Certified Nurse Aide) supplies were relocated to another area, and the access code to the mediation rooms were changed and given only to licensed staff who administer medication. During an observation on 4/01/2025 at 10:17 AM, House #19 Medication Room door was wide open and unattended. At the time of observation, Shahbaz (Certified Nurse Aide) #3 stated it was their mistake, but the door was usually open anyway. 10 New York Codes, Rules and Regulations 415.12(h)(1) | Plan of Correction: ApprovedMay 12, 2025 F689 Element 1 Resident #146 The wander guard for resident 146 was replaced on 3/31/2025. Care plan was updated to indicate wander guard should be checked for placement and to be sure it is working effectively every shift. The codes to the medication room doors (where alcohol is stored) were changed on 3/31/2025. Resident 54 order was changed to allow alcoholic beverages per resident request. Residents' alcohol is locked in medication room to minimize access to only licensed staff. Element 2 All residents who utilize wander guards have the potential to be affected by this practice. All elders who have a wander guard were checked on 5/7/24 to ensure the wander guard was working as per policy. No issues identified. Storage of resident alcohol in all houses has been moved to the medication room where access is limited to licensed staff only. Element 3 Residents who utilize wander guards will have their care plans updated to include checks for placement of the wanderguard band on the resident's arm/leg and that the band is functioning properly every shift. The policy for Elopement/Disruptive monitoring was reviewed and updated to include checks for placement and function every shift. Inservice?ÇÖs will be conducted for all nurses (registered nurses, licensed practical nurses and Shahbaz) regarding the Elopement policy including but not limited to checking of placement and functioning of the wander guard devices. Inservice?ÇÖs will be conducted for all Facilities Maintenance staff regarding the need to check doors with egress on a routine schedule to ensure alarms are functioning. In-servicing will be provided to all nurses (registered nurses and licensed practical nurses) on the Storage of Medication Policy with specifically on the importance of keeping the medication rooms locked, and specifically the requirement applies when they are present. Resident Rights policy revised to reflect the residents right to alcohol. Per resident rights residents have the right to consume alcohol. Resident Rights policy has been revised to state residents have the right to consume alcohol per his/her request. Residents have the right to consume alcohol with no restrictions unless indicated by physician. If resident is identified as over consuming, ie. intoxication, falling, slurred speech resident will be educated to the dangers of over consuming. If the order for alcohol stipulates a certain amount per day the alcohol will be added to the treatment administration record for tracking purposes. Nursing staff will administer and oversee the provision of alcohol. Nursing staff will monitor for adverse effects from alcohol consumption, and document findings in progress notes and notify the provider. Provider will review to determine if alcohol restrictions are needed. Nursing staff (Registered nurse, Licensed practical nurse, Certified Nursing assistant) will be educated to the changes to the resident rights policy to include provision of alcohol, storage, tracking, documentation and physician follow up). Education to be completed by (MONTH) 13, 2025. Element 4 Random Audits will be conducted and will note if wander guard is in place and functioning and if the routine checks every shift are documented. Three audits per week, for all three shifts, at three different houses for the next three months. Random Observations of all medication room doors will be done on daily basis, on varying shifts, at varying houses, to ensure the doors are closed and locked. Three audits per week, for all three shifts, at three different houses for the next three months. Audits will be completed for residents with an order limiting alcohol consumption to ensure order is being followed. All residents with these orders will be audited monthly for three months. Audit/observation results will be brought to the Quality Assurance Performance Improvement Committee monthly. The committee will make recommendations for the ongoing audits and frequency based on achieving 100% compliance. Committee will make recommendations for change in policy, plan or education based on results of the audits. Monitored by the Director of Nursing or designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 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 the recertification survey, the facility did not ensure that it made prompt efforts to resolve a grievance and to keep the resident appropriately apprised of progress towards resolution for one (1) (Resident #28) of 36 residents reviewed. Specifically, Resident #28 and their representative did not receive prompt resolution when a grievance was filed regarding missing hearing aids on 2/19/2025. The facility did not follow up with this grievance until 4/01/2025. This is evidenced by: Resident #28 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 1/03/2025 documented that the resident could be understood, could understand others, and had moderately impaired cognition. Facility policy titled, Complaints and Grievances, effective 1/2016, documented the facility provided a method to promptly deal with complaints and recommendations made by residents, their next of kin and/or their designated representative. The Social Worker was the grievance official or the person responsible for addressing complaints. Residents who wished to make a complaint were scheduled to be seen by the Social Worker or designee or would have the responsibility of presenting the complaint in writing to the Social Worker. Social Services would advise the Administrator of all complaints within 2 days of receipt. A response would be made to the resident, next of kin, or designated representative within 21 days of the day the complaint was made. Grievance Complaint/Follow Up Form, documented a grievance was received on 2/19/2025 and filed by Family Member #1. The form documented Resident #28 was missing two of their hearing aids. Staff were able to locate one of them, but the other hearing aid was still missing. The grievance form documented Social Worker #2 completed the form and an email was sent to the Administrator on 2/19/2025. Follow up notes on this form documented the Administrator spoke with Family Member #1 on 4/01/2025 and stated Family Member #1 said the prior administrator had agreed to reimburse the lost hearing aid prior to their departure from the facility, but to date they have not received reimbursement. Follow up notes were signed by Administrator #1. During an interview on 3/25/2025 at 10:46 AM, Family Member #1 stated Resident #28's hearing aids were missing and they looked everywhere but were not able to find them. Family Member #1 stated they told a nurse about the missing hearing aids and filed a grievance with the Social Worker. They stated this happened a few weeks ago but was unsure of the date and had not received a resolution for the filed grievance. During an interview on 3/31/2025 at 1:47 PM, Shahbaz #8 (Certified Nurse Aide) stated Resident #28 had a hearing aid for each ear. If a hearing aid was missing, they would notify the nurse. Shahbaz #8 stated they could not recall if they notified the nurse that Resident #28's hearing aids were missing. They stated by the time they realized the hearing aids were missing, they thought the nurse already knew about it. During an interview on 3/31/2025 at 2:08 PM, Licensed Practical Nurse #5 stated they were not aware of Resident #28's missing hearing aids or what was done to attempt to find them. They stated they may have been off for a few days when the hearing aids went missing. If they knew they were missing, they would write a note and tell the nurse manager or the nursing supervisor. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated they had no knowledge of Resident #28's missing hearing aids. They stated they spoke with Family Member #1 on the afternoon of 4/01/2025 and this was when Registered Nurse #4 learned the hearing aids were missing. They stated Family Member #1 told them about the missing aids and that there was no follow up on the grievance. Registered Nurse #4 stated there have been a lot of changes with nurse managers and it could have gotten lost in the shuffle, but they would communicate and make sure there was follow through on this grievance. During an interview on 4/01/2025 at 11:13 AM, Social Worker #2 stated when they got a complaint from a family member, they filled out a grievance form and they notified the Administrator or the Director of Nursing. The Administrator was the grievance officer. They worked together to figure out how to move forward on the complaint and come to a conclusion. They stated Family Member #1 filled out a grievance form regarding Resident #28's missing hearing aid on 2/19/2025. Social Worker #2 gave this form to the former administrator. Social Worker #2 stated there was a disconnect with follow up on this grievance. During an interview on 4/03/2025 at 12:15 PM, Administrator #1 stated a family member, or a resident could report a grievance, and an investigation would be completed. If the incident was reportable, they would report it, but if it was not reportable, they would come up with a solution to resolve the grievance for the family member/resident. They would expect the grievance to be resolved within 21 days but if the grievance was regarding missing items, it could take longer. 10 New York Code Rules and Regulations 415.3(d)(1)(ii) | Plan of Correction: ApprovedMay 7, 2025 F585 Element 1 Resident #28 was reimbursed for the missing hearing aid on . Both Family Member and resident report that they were satisfied with the resolution regarding to reimbursement of the hearing aid. Element 2 Every resident that files a grievance has the potential to be affected by this deficient practice. Any resident with a Brief Interview for Mental Status of 8 or higher will be interviewed by social work to ensure that any prior grievances have been resolved. Any with less than an 8 on the Brief Interview of Mental Status, the point of contact will be interviewed to ensure that all grievances have been resolved. Element 3 Grievance Policy was reviewed with no changes. Grievance officer, and the social worker designees, were given a 1:1 in-service on the Grievance process and specifically of the prompt efforts to resolve the grievance and keeping the family member and/or resident apprised of the progress on the grievance with final resolution to occur within 21 days. A Grievance Log will be maintained as each grievance occurs. The grievance Log will contain the original/copy of the grievance, the date submitted, date that the Administrator became aware, date family member and/or resident was notified, and the date the grievance was resolved. Element 4 Grievance Officer, or designee, will complete an audit of all Grievances/missing items weekly, using the Grievance log, to ensure the grievance process has been followed. Results of the audits will be reviewed with the Quality Assurance Performance Improvement Committee monthly. The committee will make recommendations for the ongoing audits and frequency based on achieving 100% compliance. Committee will make recommendations for change in policy, plan or education based on results of the audits. Monitored by Grievance Officer, or designee. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (House 21 and House 24) of 8 medication carts reviewed, and 8 (Houses 1, 2, 3, 4, 19, 21, 22, 24) of 8 medication rooms reviewed. Specifically, (a.) opened medications had no open and or expiration dates; (b.) one active medication had expired; (c.) medication rooms were left open and unattended; (d.) unlicensed staff had key/access code to medication rooms. This is evidenced by: The facility's Policy and Procedure Titled, Medication Administration effective [DATE] documented, each patient/resident/elder would receive medications according to provider orders and accepted professional standards. Under General Considerations, Responsibility and Procedure: The nurse is responsible for: #3: NOTE carefully the name, dose, amount of administration and expiration date. Be sure the frequency and time schedules correspond. Multidose medications: [REDACTED]. 2. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. 3. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. a. Facility staff may record the calculated expiration date based on date opened on the medication container. The facility's Policy and Procedure 5.3 titled Storage and Expiration Dating of Medications and Biologicals, revised dated [DATE], documented General Storage Procedures: 1. Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. 5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. During an observation on [DATE] at 12:34 PM, House 21 Medication Room Door was wide open. Signage was posted on door that read, Please Keep Med Room Door Closed At All Times. Licensed Practical Nurse #1 was observed walking from medication room to kitchen area while leaving medication room door open. They returned approximately 10 minutes later. In the interim, Shahbaz (Certified Nurse Aide) #2 went into medication room and retrieved supplies leaving door open. During an interview on [DATE] at 12:44 PM, Licensed Practical Nurse #1 stated the Shahbaz (Certified Nurse Aides) had the access code to medication room because some of their patient care supplies, such as soap, toothpaste, deodorant, combs, etcetera are kept in the medication room. Dietary staff also had access code to enter medication room to deliver tube feeding supplies. During an observation on [DATE] at 12:55 PM, House 21 medication cabinet contained 1 Basaglar Kwik insulin pen with no open and or expiration date. It was placed in a bag dated [DATE]; 1 bottle of [MEDICATION NAME] Peroxide ear drops with no open and or expiration dates. 1 expired [MEDICATION NAME] sulfate hydrofluoroalkane (HFA) inhaler dated [DATE]. During an observation on [DATE] at 1:20 PM, House #24 medication cabinet contained the following with no open and or expiration dates: 1 [MEDICATION NAME] alcohol ophthalmic 1.4 percent eye drops; 1 [MEDICATION NAME]pen, and 1 [MEDICATION NAME] inhaler with no open and or expiration dates. During an observation on [DATE] at 3:15 PM, House #21 Medication Room contained the following stock medications: [REDACTED]. [MEDICATION NAME] powder; Artificial Tears Eye Drops; [MEDICATION NAME] Ear Drops; Deep Sea Nasal Spray; 4% [MEDICATION NAME] Patches. The unlocked medication room refrigerator contained a six-back beer for resident use as prescribed. On top of the medication room filing cabinet there were 3 bottles of wine. During an observation on [DATE] at 3:30 PM, Medication Rooms in House 1, 2, 3, 4, 19, 21, 22, and 24 contained stock mediations as above and supplies that Shahbaz (Certified Nurse Aide) use for resident care. During an interview on [DATE] at 2:43 PM, Director of Nursing #1 stated nurse should date medication upon opening with open and expiration dates. Shahbaz (Certified Nurse Aides) had access to the medication room so that they could obtain necessary supplies for patient care. Dietary staff deliver tube feeds, central supply delivers stock medication and other stocks. Both had access to medication room. Families provided alcohol beverages unless there was a special event. In that case the facility will order alcoholic beverages to serve. The Nurse Manager kept an eye on alcoholic beverages. There was no tracking for how much alcohol was used. During an interview on [DATE] at 03:18 PM, Administrator #1 stated staff who were not certified to pass medication should not access the medication room. As of today, the Certified Nurse Aide supplies were relocated to another area, and the access code to the mediation rooms were changed and given only to licensed staff who administer medication. During an observation on [DATE] at 10:17 AM, House #19 Medication Room was wide open and unattended. At the time of observation, Certified Nurse Aide #3 stated it was their mistake, but the door was usually open anyway. 10 New York Codes, Rules, and Regulations 415.18(d) | Plan of Correction: ApprovedMay 7, 2025 F761 Element 1 Staff identified educated to importance of keeping medication room door closed and locked. All outdated or unlabeled medication were removed and discarded by nurse managers on 4/1/25. Thise that required replacement were replaced and dated and labelled per policy . All patient care items needed by shahbaz were removed on 3/30/25. All door combinations were changed on the same day and only licensed staff have access to the medication rooms. Element 2 All residents have the potential to be impacted by this deficient practice. All medication carts, medication rooms, medication refrigerators and cabinets were inspected by the nurse managers on 4/1/25 for any undated or expired medications. No additional medications were identified. As ststed in element 1 all combination locks were changed, and supplies moved to ensure only licensed have access to the medication rooms. Element 3 Inspection of all Medication carts, Medication rooms, and Medication Refrigerators in the 16 houses was conducted to check for any undated or expired medications. The codes to the medication room doors, where alcohol is stored, changed to prevent unauthorized access to those room and the supplies/medications/ alcohol they contain. Supplies utilized by the Shahbazim were moved to another location. 1:1 Inservice was conducted for nurse 19 specifically on the requirement to keep the medication room door secured. Medication storage policy reviewed with no changes made. Inservice?ÇÖs were conducted to all licensed nurses, (Registered Nurse, Licensed Practical Nurse) regarding the Medication Administration Policy and Medication Storage Policy as it pertains to the following Requirements: - Required to write the date and expiration date in newly opened medications according to professional standards. - Required to discard expired medications according to professional standards. - Review of the Omnicare Pharmacy Grid, a reference tool to indicate expiration of a multi dose medications after being opened. - Requirement to constantly maintain proper medication carts, medication rooms, and medication refrigerators on all units. - Requirement to keep all medication room doors locked when not present. Element 4 Random audits of four houses per week, every shift nurse manager or designee. audits to include: The proper use medication carts, medication rooms, medication refrigerators and the locking of medication room doors. The review of opened medications not labeled with dates and expiration dates. Any deficient practice will be corrected at time of identification. Any deviation from policy will be corrected at time of identification and education provided. Results of audits will be reported monthly at the Quality Assurance Committee meeting. Audits will continue until 100% compliance achieved, The Committee will make recommendations based on results of audits for change in plan, policy, education and audit frequency to monitor frequency for continued compliance. Monitored by the Director of Nursing, or designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that one (1) (Resident # 130) of four (4) residents reviewed for hospitalization received notice of the bed-hold policy and return prior to or within 24 hours of an emergency transfer. Specifically, Resident #130 was not given written notice of the bed hold policy prior to or within 24 hours of transfer to the hospital on [DATE]. This is evidenced by: The Facility's Policy and Procedure titled Bed Hold Policy, effective 6/27/2023 documented facility support the resident's right to retain their bed when they are hospitalized or take a therapeutic leave. The policy promotes continuity of care and ongoing psychosocial support for residents. Procedure, The Bed Hold Policy Summary form must be provided to the resident, or resident's representative, at the time of transfer, or in cases of emergency transfer within 24 hours. a. Facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to contact the representative. When a resident residing in a skilled nursing facility (SNF) under their Medicare benefit is hospitalized or takes therapeutic leave, Medicare would not pay to hold the bed. The Facility policy allows for the resident to pay privately to hold the bed if so desired. Facilities must make all residents, regardless of payor source, aware in writing of their policies related to holding beds during absences from the facility. Resident #130 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/22/2024, documented resident had mild cognitive impairment, could be understood and understand others. Nursing progress note dated 1/18/2025 documented Resident #130 was found on the floor. A subsequent x-ray revealed a right [MEDICAL CONDITION]. An order was obtained to transfer Resident #130 to the hospital via ambulance at 10:30 AM. Family aware. There was no documented evidence of Bed Hold Transfer Notice. During an interview on 4/02/2025 at 10:41 AM, Social Worker #2 stated when a resident was transferred to a hospital and was admitted for greater than 24 hours, social work mailed a notice of transfer to family along with bed hold. Social work then would notify the Ombudsman via email of the transfer with copy of the envelope with stamp sent to family. Afterwards, documents were uploaded to the electronic medical record. During an interview on 4/02/2025 at 4:05 PM, Social Worker #1 stated they were aware of facility Bed Hold Policy, but did not follow the policy and did not send Bed Hold/Transfer Notice for this admission. They stated they believed this was a weekend admission that was overlooked. During an interview on 4/03/2025 at 10:10 AM, Admission's Coordinator #1 stated Bed Hold policy was reviewed upon admission with residents. Transfers thereafter were handled by Social Work. 10 New York Codes, Rules, and Regulations 415.3(h)(4(i)(a) | Plan of Correction: ApprovedMay 7, 2025 F625 Element 1 Resident #130 returned to the community on 1/21/2024 and returned to her original bed. Element 2 All residents who discharged to the hospital have the potential to be impacted by this deficient practice. A Discharge summary report from Point Click Care was run from 4/23/2025 through 05/07/2025 to ensure that any hospital discharges received the appropriate Bed Hold Policy. Element 3 Bed Hold Policy was reviewed with no changes. A bed hold policy log was created to ensure that those residents that were sent to the hospital was sent the Notice Bed Hold. Social Worker staff were in-serviced regarding The Bed Hold Policy specifically the procedure to review all weekend transfers to ensure the notice of transfer was sent. Element 4 All hospital transfers will be audited weekly at the Decline Meeting held on Thursdays to ensure the Bed Hold policy was followed. Any noncompliance will be corrected immediately, and the colleague involved will be reeducated to the policy. Audit results will be brought to the Quality Assurance Performance Improvement Committee monthly. The committee will make recommendations for the ongoing audits and frequency based on compliance. Committee will make recommendations for change in policy, plan or education based on results of the audits. Audits to continue until 100% compliance is met. Monitored by Director of Social Services, or designee. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details Based on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift was displayed on one (1) resident unit, and not accessible to residents and visitors on the other resident units of the facility. This is evidenced by: During an observation from 3/25/2025 through 4/03/2025, the doorway to the administration suite was labeled with a sign documenting that no one was allowed in the building except staff. During an observation on 4/03/2025, at 11:10 AM, the daily nurse staffing postings were located on the wall by the reception desk in the administration building, which was not readily visible or accessible to all residents and visitors. There was no nurse staffing levels posted at any of the 16 residential units where residents and visitors from other units would walk through. During an interview on 4/03/2025 at 11:15 AM, Director of Nursing #1 stated that the nurse staffing postings were not posted in the residential houses, and they would expect residents and visitors to go to the administration building to see the staff posting it if they wanted to. 10 New York Codes, Rules, and Regulations 415.13 | Plan of Correction: ApprovedMay 7, 2025 F732 Element 1 No individual resident was affected by this deficient practice. The staffing was posted immediately in the 200 Administration Building. The location was changed to have the staff posting to each individual home to ensure that family members and elders have access to view the staff posting. Element 2 No individual resident will be affected by this deficient practice. Element 3 Inservice?ÇÖs will be conducted to ensure that each house knows the requirement for posting the daily staffing in the individual houses. The staffing Coordinator, Nurse Managers and the Nursing Supervisors were in-serviced regarding the requirement to post the daily staffing at the entrance of each individual home. The daily Staff Posting in the entrance of the home makes the daily staff posting available and accessible to all who would like to review it. Element 4 Random Audits will be conducted five time a week at five different houses for the next 90 days until substantial compliance is met. Results of the weekly audits will be presented monthly to the Quality Assurance Committee. The audits will continue to be completed until the committee determines 100% compliance. The committee will make recommendations for ongoing frequency and any need for change in plan, education or policy based on results of audits. Monitored by Director of Nurses, or designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #54) of the 36 residents reviewed. Specifically, for Resident #54, the physician's orders [REDACTED]. This is evidenced by: Resident #54 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 2/14/2025 documented that the resident could be understood and usually understand others and had intact cognition for daily living decisions. During an observation in House #16 on 3/26/2025 at 10:46 AM, the kitchen pantry contained a box of Sam(NAME)Oktoberfest beer with three (3) bottles, labeled with the Resident #54's name. In the pantry refrigerator, there were two (2) bottles of the same beer on the door shelf with no label of the resident's name on them. During a record review of Resident #54's care plan on 3/28/2025, it was documented that Resident #54 enjoyed a beer on occasion, and staff were to offer this to them during Happy Hour. During a record review of physician orders [REDACTED].#54 may have a beer nightly at dinner and may have a beer daily. Record review of the (MONTH) 2025 Medication Administration Record [REDACTED]. Record review revealed no documented evidence on a process for staff to document in the medical record when a resident was given an alcoholic beverage. Record review revealed no documented evidence of policies regarding resident consumption of alcoholic beverages. During an interview on 4/02/2025 at 2:38 PM, Registered Nurse #1 stated that nurses were to give the resident the alcoholic beverage when they requested it. They indicated that they were unsure where they would document when the nurse gave the resident their beer. Registered Nurse #1 looked at the physician's orders [REDACTED].#1 stated that there should be something in the electronic records to track and record when the resident was given the beverage. 10 New York Code of Rules and Regulations 483.70 (h)(2)(ii) | Plan of Correction: ApprovedMay 8, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F842 Element 1 Resident #54 ?Çô The alcohol brought in for resident #54 was relocated to the medication room. Physician order [REDACTED]. Element 2 All residents who have physician orders [REDACTED]. All residents who have orders that they may have alcohol are at risk for this same practice. Orders were reviewed for those residents that may have alcohol and updated related to the new resident rights policy revision that states that Residents' have the right to consume alcohol at his or her request with no restrictions unless indicated by the provider. Element 3 Resident Rights policy revised to reflect the residents right to alcohol. Per resident rights residents have the right to consume alcohol. Resident Rights policy has been revised to state residents have the right to consume alcohol per his/her request. Residents have the right to consume alcohol with no restrictions unless indicated by physician. If resident is identified as over consuming, i.e. intoxication, falling, slurred speech resident will be educated to the dangers of over consuming. If the order for alcohol stipulates a certain amount per day the alcohol will be added to the treatment administration record for tracking purposes. Nursing staff will administer and oversee the provision of alcohol. Nursing staff (Registered nurse, Licensed practical nurse, Certified Nursing assistant) will be educated to the changes to the resident rights policy to include provision of alcohol, storage, tracking). Education to be completed by (MONTH) 13, 2025. Inservice?ÇÖs were conducted to registered nurses and licensed practical nurses regarding: ?Çó Handle alcoholic beverages like any other medication, specifically, the requirement to store alcoholic beverages in the medication room, and to enter orders for the consumption of alcoholic beverages in the Medication Administration Record. Element 4 Audits conducted weekly to ensure that all new admissions, as well as residents with changes in orders, and those with existing orders related to alcohol administration, are entered into the Medication Administration Record. Audit will include observation of the medication room/house to ensure that alcohol is stored in the locked medication room. Results of the weekly audits will be presented monthly to the Quality Assurance Committee. The audits will continue to be completed until the committee determines 100% compliance. The committee will make recommendations for ongoing frequency and any need for change in plan, education or policy based on results of audits. The facility utilizes a Plan-Do-Check-Act model for Quality improvement. This cyclical model of improvement includes regular reviews of processes and outcomes to ensure the effectiveness and sustainability of corrections made. The committee will be responsible for monitoring to ensure on-going compliance and to determine frequency of periodic audits to determine if changes are maintaining the desired corrections or if the plan needs to be altered. Monitored by the Director of Nursing or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect, cared for in a manner, and in an environment that promotes maintenance or enhancement of their quality of life for three (3) (Resident #s 110, 136 and 145) of 36 residents reviewed for dignity. Specifically, (a.) Resident #110 was administered medications in a common area with other residents and individuals present without resident's permission; (b.) Certified Nurse Aide stood over the dining room table instead of sitting with resident, while assisting Resident #136 with their meal; (c.) Resident #145 was served meals at dining room table with the use of plastic utensils. This is evidenced by: The facility's Policy and Procedure titled Resident Rights, effective 5/28/2024, documented it is the policy to ensure residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Social Work staff, in accordance with facility, New York State Department of Health, and CMS regulations, will act as the designated advocates for resident rights. New York State Manual or Nursing Home Resident Rights, 2022, documented, right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of your self-worth. o Be cared for in a manner that enhances your quality of life, free from humiliation. Privacy: Personal privacy during care and treatment. o Confidentiality concerning your personal and medical information. https://www.health.ny.gov/facilities/nursing/rights/docs/rights_booklet.pdf Resident #110 Resident #110 was admitted to the facility with a [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 10/13/2024 documented that the resident could be understood, was understand by others, and was mildly cognitively impaired. During an observation on 3/28/2025 at 10:59 AM, Licensed Practical Nurse #4 administered a cup of prescribed medication to resident while resident was sitting in living room. In addition, Licensed Practical Nurse held conversation with Resident regarding the medications received. Two other residents were present. During an interview on 3/28/2025 at 11:05 AM, Licensed Practical Nurse #4 stated Resident #110 always took their medication in the living room, and it was okay. Therefore, they did not ask resident's permission to administer the medication in the common area. Licensed Practical Nurse #4 stated they should have asked permission since the Department of Health was observing the medication pass. Resident #136 Resident #136 was admitted to the facility with [DIAGNOSES REDACTED]. resulting from insufficient intake of protein and/or energy (calories) leading to weight loss or failure to gain weight). The Minimum (MDS) data set [DATE] documented Resident had severe cognitive impairment, and usually could make themselves understood and usually understand others. During an observation on 3/26/2025 at 12:26 PM, Shahbaz (Certified Nursing Aide) #9 was standing up next to Resident #136 while the resident was seated in their wheelchair at the dining table. Shahbaz #9 was feeding the resident their lunch meal. Shahbaz #9 remained standing up until they were done assisting the resident with finishing their lunch. During an interview on 3/26/2025 at 12:26 PM, Shahbaz # 9 stated they normally sat next to residents while feeding them but because there were no chairs around for them to sit in, they stood up while feeding Resident #136. They stated they were taught to sit next to the residents when feeding them so they could observe how they were eating, but they were standing as there were no chairs available for them to sit in when feeding the resident. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated when Shahbaz is feeding a resident, they should be sitting down next to them and conversing with the resident. They should not be standing up while feeding the resident because it was a dignity concern. They stated sometimes they had to remind Shahbaz they should be sitting down while feeding residents. They stated this was the resident's home and they should be treated like they were in their home and Shahbaz should not be standing up while feeding residents. During an interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated Shahbaz should sit down next to a resident when they are feeding the resident. There were little stools in the houses that the Shahbaz could sit on when they aided with meals. The Shahbaz should sit next to the resident when feeding them because it was a dignity concern. They did not want the resident to feel rushed or pressured through the meal and this may occur if the Shahbaz were standing over them when eating. They stated meals should be enjoyable. Resident #145 Resident #145 was admitted with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that the resident sometimes could be understood and sometimes understand others and was severely cognitively impaired. During an observation on 3/26/2025 at 12:25 PM, seven residents, including Resident #145, were given plastic utensils for their meals. During a record review on 3/26/2025 at 1:45 PM, Resident #145's Comprehensive Care Plan did not include the usage of plastic utensils at meals. During an interview on 4/01/2025 at 12:45 PM, Shahbaz #4 stated that plastic utensils may be used for safety reasons and should be in the comprehensive care plan. During an interview on 4/02/2024 at 11:35 AM, Registered Nurse #1 stated that the use of plastic utensils should be included in the comprehensive care plan for each resident who used them 10 New York Codes, Rules, and Regulations 415.3(c)(1)(i) | Plan of Correction: ApprovedMay 8, 2025 F550 ELEMENT 1 Resident 110 ?Çô Resident was interviewed regarding Medication Administration preferences with preferences entered into the Care Plan. Licensed Practical Nurse #4 will be given a 1:1 in-service by 5/13/2025 policy as it relates to providing privacy for residents when administering medications for Resident # 110 Resident #136 ?Çô In-service education will be conducted by 5/13/2025 specifically regarding appropriate assisted dining protocols that state that staff are to be seated while performing assisted dining duties. Shahbaz #9 will be given a 1:1 in-service by 5/13/2025 stating the expectations of sitting while performing the assisted dining functions for Resident #136 Resident #145 - Shahbaz #4 will be given a 1:1 in-service by 5/13/2025 stating the expectations of supplying the appropriate utensils for dining functions for Resident # 145 Element #2 All residents that take medications, are assisted in the dining process, and use plastic utensils for anything other than a special event or specified in the care plan have the potential to be affected by this deficient practice. Social Worker interviewed all residents who are able to be interviewed with a Brief Interview for Mental Status with an 8 or above to identify any concerns with medication administration location, resident rights, dignity, respect with dining assistance, and the use of appropriate utensils while dining, other than a special event or specified in the care plan. Residents with Brief Interview for Mental Status assessment lower than 8, had letters mailed to their respective responsible party inquiring about any concerns or issues with medication administration location, resident rights, dignity, respect with dining assistance, and the use of appropriate utensils while dining, other than a special event or specified in the care plan dining. Letter stated that if there are issues to bring them to the attention of Social Services. Issues will be corrected as they are brought forward. Element #3 Resident Rights Policy reviewed with no changes. In-service education will be conducted by 5/13/2025 to all nursing staff, to include registered nurses, licensed practical nurses and Shahbaz regarding the following policy and procedures: Resident Rights Policy, with specific in-services will be conducted on 5/13/2025 on: ?Çó Inappropriateness of standing while assisting the resident while dining ?Çó Use of inappropriate utensils for dining, specifically the use of plastic utensils without appropriate documentation in the care plan, or special event ?Çó Location and privacy requirements during Medication Administration. Education on Resident Rights will also provide with onboarding and annually Element #4 Medication Administration Audits will be conducted for 16 residents per week, for 4 weeks to ensure appropriate location of Medication Administration is conducted and that privacy is maintained while administering the Medication. Audits to continue quarterly until substantial compliance is met as determined by the Quality Assurance Performance Improvement Committee. Meal Observation Audits will be conducted for 16 residents per week, for 4 weeks to ensure that policy and procedure is being adhered to specifically not standing while assisting the resident with dining. Audits will be conducted quarterly, until substantial compliance is met as determined by the Quality Assurance Performance Improvement Committee. Audits of the Care Plans will be conducted for the use of plastic utensils with documentation supporting the use of plastic utensils. The Quality Assurance Performance Improvement Committee will make recommendations on the need to alter the plan, policy, education, or remediation based on results of the weekly audits. Monitored by Director of Nursing, or Designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure residents could safely self-administer medication when clinically appropriate for one (1) (Resident #84) of one (1) resident reviewed for medication administration. Specifically, Resident #84 was observed with a medicine cup of pills while eating breakfast in the dining area on 3/26/2025 and independently taking the pills. There was no documented evidence that Resident #84 was assessed to determine their ability to safely self-administer medications, or physician orders [REDACTED]. This is evidenced by: Resident #84 was admitted to the facility with [DIAGNOSES REDACTED]. condition in which bones become weak and brittle). The Minimum Data Set (an assessment tool) dated 2/15/2025, documented the resident usually made themselves understood, usually understand others, and had moderate cognitive impairment The facility policy, Self-Administration of Medications, dated 6/19/2023, documented it was the facility's policy to honor a resident's request to self-administer medication unless the interdisciplinary team determined the practice was unsafe. As part of the admission process, the nurse would determine if a resident wished to self-administer medications. If they did, the resident would be evaluated for self-administration of medications and the assessment would be completed and reviewed by the interdisciplinary team. If the assessment concluded the resident was able to self-administer medications, a written order would be obtained from the attending physician. The residents ability to self-administer medications would be reviewed on any readmissions, quarterly, and with significant changes. During an observation on 3/26/2025 at 10:23 AM, Resident #84 was sitting in the dining area by themselves at the table eating their breakfast. There was a plastic medicine cup with their morning medications to the side of their plate. Resident #84 poured the pills onto their plate and took them with yogurt. There was no nurse supervising Resident #84 while they independently took their medications. There was no documented evidence in Resident #84's medical record that they could self-administer their medications. There was no documented evidence of physician order [REDACTED]. During an interview on 3/28/2025 at 3:17 PM, Licensed Practical Nurse #5 stated they put Resident #84's medications in a plastic cup and left them for Resident #84 to take with their yogurt. They stated they would leave Resident #84 alone while they took their medication, and they would come back to check on Resident #84 to make sure they took all their medication. They further stated they were not aware that Resident #84 was not formally assessed to take their medication independently. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated if a resident self-administered medication, an assessment for self-administration should have been completed. Registered Nurse #4 stated they did not think Resident #84 had an assessment for self-administration of medications and this resident should not have medications left for them to take independently. During an interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated if a resident wanted to self-administer medications, an assessment would be completed, and the interdisciplinary team would need to agree that the resident was able to self-administer their medications. They stated Resident #84 did not have an evaluation for self-administration of medication and their medication should not have been left in a medicine cup for them to take independently. 10 New York Codes, Rules, and Regulations 415.3(e)(1)(vi) | Plan of Correction: ApprovedMay 7, 2025 F554 Element 1 Resident #84 - An Assessment for Self-Administration of Medications was completed for resident #84 on 4/24/2025. Resident #84, after Self-Administration of Medications expressed that she wanted to Self-administer her Medications and the Nursing team agreed that Resident #84 was able to self-administer her medications. Resident #84 wants her medications at mealtime, at the dining table, in a cup placed near her plate. Care plan was updated to reflect the results of assessment. Licensed Practical Nurse #5 was in serviced regarding Self -Administration of Medication Policy All staff administering medications to resident #84 will be in-serviced on the Self Administration of Medication specifically for this resident. Element 2 All residents the self-administer medications have the potential to be impacted by this deficient practice. All resident with a Brief Interview of Mental Status of 8 or higher will be interviewed to determine if any medications administration practices where followed, specifically if any medications are placed in medication cups and left at the table. This review will be completed by 5/13/2025. Any findings where medications were not administered per policy, staff responsible will be re-educated to the medication administration practice. Element 3 Self-Administration of Medications Policy was reviewed with no changes. Audit of all resident records will be reviewed to ensure that if a resident indicated that he/she was interested in self-administering medications that an Assessment for Self-Administration of Medication has been completed and reflected in the Care Plan. Audits of the Care plans and Medication Administration Records will be reviewed to ensure that it was indicated that the resident would self-administer medications. Review of New admissions will be done weekly for four (4) weeks to ensure the Self-Administration of Medication Assessment has been completed for all residents expressing an interest to Self-Administer. All new admissions will be reviewed as a part of morning meeting Monday through Friday to ensure self-administration was completed and care plans updated as appropriate. Any Residents that indicated that they would like to administer their medications, which is indicated by the Yes box checked on the assessment, will be assessed for the self-administration of medications if the assessment is not already completed with the Care Plan to indicate the change in the administration of medications. Education on the policy is provided with onboarding for all licensed nursing staff (registered nurses and licensed practical nurses). Medication Administration Audits will be conducted for 16 residents per week, for 4 weeks to ensure appropriate location of Medication Administration is conducted and that privacy is maintained while administering the Medication. Audits to continue quarterly until substantial compliance is met. Substantial compliance will be met when the audits are 100% accurate Monthly Quality Assurance Performance Improvement Meeting for three months. Any non-compliance will be corrected immediately. Element 4 In-services will be conducted for all registered nurses and licensed practical nurses on the following topics: - Accurate and timely completion of the assessment for Self-Administration of Medications - Care planning for Self-Administration of Medications - The policy and Procedure when providing medications to residents who self-administer medications. An Audit will be done of New admissions weekly for four (4) to ensure the Self-Administration of Medication Assessment has been completed for all residents expressing an interest to Self-Administer. An audit of Care Plans will be reviewed for those newly admitted residents to ensure that the results of the assessment are indicated in the Care Plan. Medication Administration Audits will be conducted for 16 residents per week, for 4 weeks to ensure appropriate location of Medication Administration is conducted and that privacy is maintained while administering the Medication. Audits to continue quarterly until substantial compliance is met. Substantial compliance will be met when the audits are 100% accurate Monthly Quality Assurance Performance Improvement Meeting for three months. Audits to ensure appropriate location of Medication Administration and that privacy is maintained while administering the Medication will be conducted quarterly, until substantial compliance is met at 100% as determined by the Quality Assurance Performance Improvement Committee. The Quality Assurance Performance Improvement Committee will make recommendations on the need to alter the plan, policy, education or remediation based on results of the weekly audits. Monitored by Director of Nursing, or designee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (2) (Resident #s 28 and 89) of three (3) residents reviewed. Specifically, (a.) Resident #28 order for continuous oxygen was not administered. The oxygen nasal cannula was placed on the resident, but the oxygen concentrator was off, therefore not delivering oxygen to the resident; (b.) Resident #89's order for 2 liters of oxygen were not followed consistently. This is evidenced by: The facility Policy and Procedure titled, Oxygen Management, effective 5/13/2024 documented, it was policy to administer oxygen per provider order in a safe manner. Responsibility of Licensed Nursing Staff: Procedure: (1) Review orders; (2) Identify resident and explain procedure; (3) Plug in power cord; (4) Keep concentrator at least 12 inches from walls, draperies and avoid confined spaces; (5) Connect humidifier (if needed); (6) Attach oxygen tubing from the humidifier bottle to oxygen outlet connector on the concentrator. If humidification is not being utilized place adaptor on the outlet connector and attach oxygen tubing directly to the adaptor; (7) Press power switch on; (8) Turn the flow meter to the prescribed flow rate setting. (9) Follow manufacturer's recommendations on filter changes or additional required maintenance. Resident #28 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 1/03/2025, documented the resident had moderate cognitive impairments, could be understood, and understand others. The Comprehensive Care Plan with focus, Potential/Actual Impaired Breathing related to [MEDICAL CONDITION], effective 1/17/2023, last revised 1/01/2025, documented Resident #28 was to receive 2 liters of oxygen via nasal cannula continuously. (MONTH) increase as needed. Physician order [REDACTED]. During an observation and interview on 3/26/2025 at 10:46 AM, Resident #28 was in their room, seated in a recliner. They were wearing a nasal cannula that was attached to an oxygen concentrator (a device that draws air from the surrounding environment and delivers a concentrated, purified stream of oxygen). The oxygen concentrator was turned off. Resident #28 was not receiving continuous oxygen. Family Member #1 stated Resident #28 was brought back to their room after eating breakfast. When they ate breakfast in the dining area, Resident #28 used a portable oxygen tank attached to their wheelchair to supply oxygen, and when Resident #28 was in their room the concentrator was used to supply oxygen. Family Member #1 stated the concentrator was not turned on when Resident #28 was returned to their room. Family member #1 turned on Resident #28's oxygen concentrator. They stated Resident #28 was supposed to receive supplemental oxygen continuously. During an interview on 3/31/2025 at 1:47 PM. Shahbaz (Certified Nurse Aide) #8 stated Resident #28 always used supplemental oxygen. When they were in their room, Resident #28 used the concentrator to supply oxygen and during meals or activities they used a portable tank to supply the oxygen. During an interview on 3/31/2025 at 2:08 PM, Licensed Practical Nurse #5 stated Resident #28 should have received supplemental oxygen continuously. Residents may need to be checked on to make sure they were receiving supplemental oxygen. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated they were not sure if Resident #28 was to receive continuous oxygen, but if a resident had orders for continuous oxygen, they should have received oxygen at all times. Resident #89 Resident #89 was admitted to the facility with [DIAGNOSES REDACTED].), and [MEDICAL CONDITION]. The Minimum (MDS) data set [DATE], documented the resident was cognitively intact, could be understood, and understand others. The Comprehensive Care Plan for Cardiac Function initiated 10/24/2024, revised 1/18/2025, documented actual alteration in cardiac function, as manifested by cardiac arrhythmia, [MEDICAL CONDITION], unstable vital signs. Interventions include: (a) assess lung sounds as needed and report changes to Medical Doctor; (b.) oxygen as ordered. During an observation on 3/26/2025 at 12:14 PM, Resident #89 was at the dining room table, oxygen concentrator in place, set at 5 liter per minute via nasal cannula. During an observation on 4/01/2025 at 10:57 AM, Resident #89 was sitting in the recliner in their room, oxygen concentrator in place, set at 3 liters per minute via nasal cannula. The physician order [REDACTED]. Notify medical doctor if increased flow rate and/or continued use as needed for shortness of breath. During an interview on 4/03/2025 at 11:30 AM, Director of Nursing #1 stated nursing staff were to check and follow oxygen orders as prescribed. The concentrator may be used in or out of the room. If the resident is on a lower flow, they may use a tank or a portable oxygen delivery system if away from the concentrator. Certified Nurse Aides could make sure the cannula is in and turn the machine on or off but could not adjust flow of oxygen. During an interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated if a resident had orders to receive continuous oxygen, they should have oxygen on all the time. Director of Nursing #1 stated if a resident was wearing a nasal cannula attached to an oxygen concentrator, but the concentrator was turned off, the resident was not receiving supplemental oxygen. 10 New York Codes, Rules, and Regulations 415.12(k)(6) | Plan of Correction: ApprovedMay 7, 2025 F695 Element 1 Resident 28 - Oxygen concentrator turned on immediately upon discovery. Resident 89 - Oxygen orders and care plan were reviewed and updated. Resident 28 and 89 will be assessed by respiratory therapist to ensure no ill effects from deviation from oxygen order. Staff that work in resident 28 and 89 house will be educated to the elder's oxygen order and use of concentrator. Education will be provided by the nurse educator by (MONTH) 13, 2025. Element 2 All residents that receive oxygen may be impacted by this practice. For all residents with oxygen orders were reviewed for accuracy to ensure the treatment administration matched the physician order. No changes needed. All residents with an oxygen concentrator were reviewed to ensure in working order and in use per manufacturer guidelines. No changes needed. Element 3 Oxygen management policy reviewed no changes made. Inservice?ÇÖs will be conducted for nursing staff (registered nurses, licensed practical nurses and Shahbaz) regarding the oxygen administration policy including the following areas: ?Çó Oxygen orders ?Çó The need to notify the provider if the resident is utilizing PRN oxygen or oxygen at a higher flow rate than previously noted. ?Çó Checking oxygen concentrator with provision of care. Element 4 Audits will be conducted for all residents receiving Oxygen to ensure that the Oxygen is in On, and that the Oxygen received is administered according to Physician Order. Audits will be conducted 3 times, per week varying shifts and varying houses. Results of the weekly audits will be presented monthly to the Quality Assurance Committee. The audits will continue to be completed until the committee determines 100% compliance. The committee will make recommendations for ongoing frequency and any need for change in plan, education or policy based on results of audits. Monitored by the Director of Nurses, or designee. |
Scope: N/A
Severity: N/A
Citation date: April 3, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the recertification survey, the facility did not take appropriate actions after the termination of one employee reviewed. Specifically, the facility did not notify the New York State Criminal History Record Checks Legal Review Unit within 30 calendar days when an offer of employment was rescinded, as required by 10 New York Codes, Rules and Regulations section 402.9(b)(2). This is evidenced by: There was no documented evidence that the New York State Criminal History Record Checks Legal Review Unit was notified within 30 days from when the offer of employment for Certified Nursing Aide Trainee #1 was rescinded. During an interview on 3/28/2025 at 9:42 AM, Colleague Relations Partner #1 stated that the Department of Health should have been notified within 30-days of when the offer of employment to Certified Nursing Aide Trainee #1 was rescinded. 10 New York Codes, Rules and Regulations 402.9(b)(2) | Plan of Correction: ApprovedApril 25, 2025 Element 1 Certified Nursing Aide was terminated from Employment. Element 2 Human Resources will review staff whose job offers are rescinded as a result of a background check. Element 3 Policy for Criminal History Record Check has been updated to reflect the need for any staff that has had a job rescinded needs to notify the New York State Criminal History Record Checks Review Unit within 30 days from when the offer of employment is rescinded. Human Resources will be in-serviced on the requirement to notify the New York State Criminal History Record Checks Legal Review Unit within 30 days from when the offer of employment is rescinded due to the results of the Criminal History Background Check. Element 4 Audits will be conducted monthly to ensure that any employee that had an offer of employment rescinded that the New York State Criminal History Record Checks Legal Review Unit is notified within 30 days. The Quality Assurance Performance Improvement Committee will be responsible for recommending ongoing need and frequency of audits and if plan needs to be amended based on findings of audits and compliance with plan. Human Resources Authorized Person is responsible for on-going compliance. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 3, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case #NY 845), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, (1) an analysis of the actual staffing schedule showed that on multiple occasions from 3/25/2025 through 4/02/2025, the facility was below the minimum levels required; (2) staff reported a lack of sufficient staffing; and (3) residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and long wait times for care to be provided. This is evidenced by: Upon entrance to the facility on [DATE], there were 170 residents residing in 16 housing units. The Facility Assessment, last reviewed on 7/31/2024, documented that the facility's bed capacity was 190. The section titled Staffing Plan documented the following: ?? The day shift required 1 Registered Nurse for four houses, 2 Licensed Practical Nurses for two houses, and 3 Shahbaz (Certified Nurse Aide) per house. ?? The evening shift required 1 Registered Nurse for the facility, 2 Licensed Practical Nurses for two houses, and 2 Shahbaz per house. ?? The night shift requires one Registered Nurse for the facility, two Licensed Practical Nurses for two houses, and one Shahbaz per house. A review of staffing sheets provided by the facility from 1/19/2025 through 3/22/2025 documented that they did not meet their assessed minimum staffing on most day shifts, for the following: ?? On 1/20/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 7, 10, and 16, which had 1.5 Shahbaz each; houses 12 and 19, which had two Shahbaz each. ?? On 1/28/2025, during the day shift, all houses had 2.5 Shahbaz except for house 1, which had 1.5 Shahbaz; houses 3, 10, and 12, which had two Shahbaz each. ?? On 2/05/2025, during the day shift, all houses had 2.5 Shahbaz providers except for house 6, which had 1.5 Shahbaz. ?? On 2/13/2025, during the day shift, all houses had 2.5 Shahbaz providers except houses 1, 2, 4, 10, and 12, which had two Shahbaz each. ?? On 2/21/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 1 and 4, which each had 1 Shahbaz; house 7, which had 2 Shahbaz. ?? On 2/24/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 5 and 22, which each had 1.5 Shahbaz; houses 1, 2, 3, 4, and 7, which had 2 Shahbaz. ?? On 3/05/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 1 and 12, which each had 1.5 Shahbaz; house 2, which had 2 Shahbaz; and houses 7, 21, and 24, which each had 3 Shahbaz. ?? On 3/14/2025, during the day shift, all houses had 2.5 Shahbaz providers except for house 24, which had 2 Shahbaz; and houses 2, 7, 10, and 21, which each had 3 Shahbaz. ?? On 3/19/2025, during the day shift, all houses had 2.5 Shahbaz providers except for house 5, which had 1 Shahbaz; houses 2, 8, and 12, which each had 2 Shahbaz. During an interview on 3/25/2025 at 10:35 AM, Resident #70 stated that the staff were sometimes late in providing care. They stated that it could take up to an hour for staff to assist in the bathroom. They also stated that the staff stated that they were always busy and unable to do certain tasks because they were busy taking care of 12 residents. During an interview on 3/25/2025 at 3:01 PM, Resident #91 stated that they were consistently short-staffed in the morning, and breakfast was usually delayed. During an interview on 3/27/2025 at 12:04 PM, Resident #19 stated that they had waited a long time to get assistance. They also stated that the call bell system did not work well, and staff sometimes ignored it. During a surveyor-led group resident meeting on 3/27/2025 at 11:35 AM, the nine (9) residents in attendance all reported insufficient staffing to meet their needs. They often had to wait after they activated their call light. They stated that the call light system was unreliable, and staff do not hear it. They stated that staff would turn off their call light and told them they would return to provide requested care, and sometimes never returned. They stated that mealtimes were when they did not get the assistance needed, as everyone was busy trying to get the residents' meals, moved, and cleaned up afterwards. During an interview on 4/01/2025 at 12:35 PM, Shahbaz (Certified Nurse Aide) #7 stated that they were often short-staffed, residents would have to wait for care, and they had no time for anything extra. During an interview on 4/02/2025 at 2:09 PM, Registered Nurse #1 stated that staffing was not great. During an interview on 4/03/2025 at 10:54 PM, Scheduler #1 stated that they had been the scheduler since (MONTH) of 2024, and the schedule calls for 2.5 Shahbaz (Certified Nurse Aides) per day per house. They stated that there were two (2) Shahbaz scheduled for the 7:00 AM to 3:00 PM shift and one (1) Shahbaz from the 8:00 AM to 1:00 PM shift. They stated that the 8:00 AM shift was tough to fill and would drop that shift if needed, and work at their minimum staffing level of two (2) Shahbaz for the house. They stated that if able, they would move individuals around the campus to achieve the minimum staffing if there were call-outs. They stated that they have had to use more agency personnel lately due to staffing issues. During an interview on 4/03/2025 at 10:54 PM, Nurse Educator #1, stated they also completed scheduling and agreed with Scheduler #1 regarding the facility staffing level and minimum staffing. Nurse Educator #1 was shown the facility assessment and staffing plan, which stated that the staffing calls for a minimum of three (3) Shahbaz per resident house. They stated that they were unsure when the facility assessment was updated but indicated that it should not have been three (3) Shahbaz. Nurse Educator #1 was shown that the facility assessment was updated on 7/31/2024 by Administrator #2. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedMay 12, 2025 F725 Element 1 Eddy Village Green will focus staffing efforts on maintaining staffing that meets the New York State staffing standards. The facility will achieve this by utilizing agency when needed and continuing to offer critical and crisis pay incentives to reach desired staffing. Resident 70, 91, and 19 were interviewed regarding staffing concerns and all residents stated satisfaction with care provided at facility Element 2 To ensure no other residents are impacted by this practice social services will interview all residents regarding call light responses. If during interview issues arise regarding call light response social work will follow the grievance policy to work with the team to resolve the issues. Interviews will be completed by (MONTH) 15 2025 Review of staffing will be conducted at Resident Council and during the Care Plan Meetings with residents and families. The Facility Assessment that was used to determine this deficiency was reviewed, found to be in error and updated to reflect the accurate staffing levels for this facility. Record review found that the Facility Assessment furnished to the Survey Team was copied from another facility with different staffing needs. Utilizing the guidelines outlined in the Centers for Medicare & Medicaid Services Reference: QSO-24-13-NH Revised Guidance for Long-Term Care Facility Assessment Requirements Dated (MONTH) 18, 2024, and Centers for Medicare & Medicaid Services Form (10/2023) Sufficient and Competent Nurse Staffing Review the Facility Assessment was updated, reviewed, and submitted to Quality Assurance Performance Improvement for formal acceptance. The staffing will be reviewed to ensure that the staffing meet the New York State required hours per patient day. Any variation will be reviewed, and the appropriate staffing levels will be adjusted to meet the required hours. Facility Assessment was changed to: Per house of 12 Elders RegisteredNurse Licensed Practical Nurse Certified Nursing Aide 7-3 .25 .5 1.5 3-11 .25 .3 1.5 11-7 .25 .3 1.0 The review of the Quality Indicators that do not meet acceptable levels in any cluster will trigger a New Sufficient and Competent Nurse Staffing Review will be conducted to identify the changing acuities/ needs of the clustered residents. Element 3 Staffing policy reviewed no changes made. Continue to focus on A3 (Assess, Analyze and Act) related to recruitment and retention best practices to increase staffing levels in the facility. Facility will continue to schedule certified nursing assistant trainees to local approved training programs. Education will be provided to all staff (Nursing, social services, therapy, housekeeping, maintenance, administration) regarding call bell policy. Education will include but not be limited to the following: * Responding to call bells are the responsibility of all departments * Most call bell care for non-clinical needs and can be responded to by non-clinical colleagues *What to do to communicate unmet need after call bell response. *Facility assessment Education will be completed by (MONTH) 15, 2025 Element 4 Weekly random call bell audits (10 per week) encompassing all shifts will be pulled and reviewed to determine any resident who was waiting for care longer than 10 minutes. Resident will interview and caregiver on assignment will be interviewed to determine factors causing wait outside parameter. Audits will be brought to the monthly Quality Assurance Committee. The audits will continue to be completed until the committee determines 100% compliance for three consecutive months. The Quality Assurance Committee will make recommendations on the need to alter plan, policy, education, or remediation based on results of the weekly audits Element 4 The Facility Assessment will be reviewed quarterly in Quality Assurance Performance and Improvement to determine if any changes should be made to the Facility Assessment as it relates to staffing. Monitored by Administrator, or designee. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment in accordance with adopted regulations relative to Building #10. Specifically, nebulizers were not maintained as prescribed in the owner's manuals as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 10.3. This is evidenced by: During observations on 03/27/2025 at 12:15 PM, Nebulizer ASP 59, located in room [ROOM NUMBER] was plugged in and not in use. The undated document titled (manufacturer) Nebulizer User Manual documented that to reduce the risk of electrocution, to unplug the nebulizer after use. During an interview on 03/27/2025 at 12:20 PM, Registered Nurse #1 stated that the nebulizer should have been unplugged. During an interview on 03/27/2025 at 1:09 PM, Director of Nursing #1 stated that they would re-train the nurses to unplug the nebulizers after treatments. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 10.3 10 New York Codes, Rules, and Regulations 713-1.1, 711.2 (19) | Plan of Correction: ApprovedMay 5, 2025 ELEMENT1 Nebulizer was unplugged at time of identification by surveyor during the facility New York State Department of Health annual recertification survey. Nursing staff assigned to that house was re-educated to need to unplug the nebulizer after use at the time the nebulizer was identified as being plugged in. ELEMENT 2 All nebulizers have been checked to ensure that they have been unplugged and comply with manufacturer requirements. No issues identified. ELEMENT 3 Education will be provided to staff regarding PCREE including but not limited to the following: -Testing and inspection prior to use -Availability of owner's manual for all Patient Care Electrical Equipment to determine appropriate use and safety measures specific to the equipment -Risks associated with the use of Patient Care Electrical Equipment During weekly environmental rounds checking of Patient care electrical equipment will be added to items reviewed to ensure compliance with safe use of this equipment. ELEMENT 4 Audits on 25% of Patient Care Electrical Equipment will be completed monthly to ensure that the Patient Care Equipment is being used per owner's manual. Results will be recorded on the Equipment audit tool. These audits with results and trends will be reported to the monthly Quality Assurance Committee. Any equipment noted to be out of compliance will be corrected at time of audit with education in real time to clinical staff. Audits will continue until the facility achieves 100% compliance. Quality Assurance Committee will make recommendations as to ongoing need for frequency and duration of audits. Maintenance Director responsible for ongoing compliance. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #2. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #2. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #2. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #3. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #3. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #3. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #4. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #4. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #4. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #5. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #5. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #5. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #6. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #6. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #6. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #7. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #7. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #7. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #8. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #8. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #8. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #10. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #10. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #10. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #12. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #12. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #12. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #14. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #14. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #14. Specifically, the emergency generator monthly and 4-hour load test record did not document the amperages incrementally as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #16. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #16. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #16. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #19. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #19. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #19. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #21. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #21. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #21. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #22. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #22. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #22. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #24. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #24. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #24. Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #31 (House #1). Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #31 (House #1). Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on interview and record review during the Standard Life Safety Code Survey, the facility did not maintain emergency generator testing records according to adopted regulations relative to Building #31 (House #1). Specifically, the emergency generator monthly test record did not document the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times, and the 4-hour load test record did not document the engine performance during each hour of the test as required by the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 edition section 6.4.4.2 and NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.4.1. This is evidenced by: The document titled Emergency Generator Test Log did not record the load (percentage of the nameplate) under which the monthly test was conducted and the generator transfer times. There was no documented evidence that the record of the 36-month 4-hour load test included the engine performance during each hour of the test, including but limited to the transfer time, percent of load, amperage, oil pressure, and water pressure. During an interview on 03/26/2025 at 12:07 PM, Facilities Manager #1 stated that they would update the generator testing records to include the load (percentage of the nameplate) and the generator transfer times, and they would schedule 4-hour load tests with their vendor and ensure the record of the test included the correct documentation. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 99 6.4.4.1 2010 NFPA 110 8.3.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedApril 25, 2025 Element 1 Generator vendor was contacted to complete the 4-hour load test by (MONTH) 13, 2025. including engine performance during each hour of the test including transfer time, percent of load, amperage, oil pressure and water pressure. Generator testing records were amended to the load and generator testing times. Element 2 All residents have potential to be impacted Element 3 Maintenance staff will be educated by facilities manager on the updated generator test log to ensure staff are aware of the required elements of generator testing. Education will be completed by (MONTH) 13, 2025. Element 4 Generator Test logs will be reviewed by facility manager or designee after all any generator testing to ensure all required elements were documented. Completed log will be brought to the monthly Quality Assurance committee to ensure compliance. Audits will be an ongoing part of the monthly Quality Assurance Committee. Committee will make recommendations for changes in plan as appropriate based on audit results. Facility Manager responsible for ongoing compliance. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the Standard Life Safety Code Survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include instruction and a demonstration of knowledge (quiz) on the most likely hazards as identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the Emergency Preparedness Plan, Training Program to include training and a demonstration of knowledge (quiz) in the following most likely hazards: ?? Tropical Storm. ?? Blizzard. ?? Flood. ?? Thunderstorm. ?? Snow. ?? Communication Failure. During an interview on 03/28/2025 at 2:49 PM, Nurse Senior Educator #1 stated that they would update the Emergency Preparedness Plan, Training Program to include training and a demonstration of knowledge (quiz) in the most likely hazards missing in the program. 42 Code of Federal Regulations 483.73(d)(1)(ii) | Plan of Correction: ApprovedMay 3, 2025 Element 1 The Emergency Plan was updated to include training on the hazards rated most likely. The plan was updated to more correctly reflect the hazards the facility is most at risk to experience. The updated plan includes training for the following: Blizzard Thunderstorm Snow Communication Failure Element 2 All residents have potential to be impacted Element 3 The Emergency preparedness education plan was updated to include training on the hazard's most likely based on the facility hazard vulnerability assessment. The nurse educator will provide education to staff regarding the high-risk areas. Annually as part of the facility assessment review the All hazards assessment will be reviewed. Any changes in identified risks will be added to the education plan. Element 4 Results of the education will be presented to the Facility Quality Assurance Committee at monthly meeting. The committee will make recommendations for ongoing frequency and any need for change in plan, education, or policy based on results of review. Executive Director responsible for ongoing complaince |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #10. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #10. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #14. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #14. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #21. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #21. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #22. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation, record review, and interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations relative to Building #22. Specifically, the placement smoke detectors relative to ventilation system supply and return ductwork was not installed as required by the National Fire Protection Association (NFPA) 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1. This is evidenced by: During observations on 03/27/2025 at 11:00 AM through 1:30 PM, a smoke detector was installed within 3-feet of a ventilation duct in the nurse office. During an interview on 03/27/2025 at 1:30 PM, Facilities Manager #1 stated that they would have the smoke detectors relocated. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.6.1.3 1999 NFPA 72: 17.7.4.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 Element 1 The smoke detector will be removed and relocated to be in compliance with the National Fire Protection Association 72 National Fire Alarm and Signaling Code 2010 Edition section 17.7.4.1 by (MONTH) 13, 2025 Element 2 All residents have the potential to be impacted by this practice. All smoke detectors will be checked to ensure compliance with National Fire Protection Association as it relates to location of detector and distance from ventilation ducts. Any alarms as identified as needing to be moved to meet these requirements will be moved by (MONTH) 13, 2025. Element 3 Smoke detectors will be added to the monthly facility preventive maintenance rounds to ensure that all smoke detectors are in a location that meets National Fire Protection Association regulations. Any new installation of smoke detectors will be checked by the facility Fire Alarm Protection vendor to ensure they meet National Fire Protection Association guidelines. Element 4 Installation of new or replacement of existing smoke detectors will be added to the monthly Facility Quality Assurance Committee meeting to ensure that the new equipment was approved by the Fire Alarm Detection system vendor. This will be a standing item for this meeting. Facility Manager responsible for ongoing compliance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #2. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #3. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #4. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #5. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #6. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #7. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #8. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #10. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #12. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #14. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #16. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #19. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #21. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #22. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #24. Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, the facility did not provide emergency illumination in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the facility did not provide emergency lighting or emergency lighting that would operate automatically without manual intervention along the means of egress to the public way as required by the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. This is evidenced by: During observations on 03/28/2025 at 12:00 PM, emergency lighting or emergency lighting that would operate automatically without manual intervention in the den. During an interview on 03/28/2025 at 3:24 PM, Facilities Manager #1 stated that they would install emergency lighting in the dens. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 19.2.8, 7.8 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2025 Element 1 Vendor has been contacted to install required emergency lighting in the den in accordance with National Fire Protection Association 101 safety code to illuminate means of egress. Work to be completed by (MONTH) 13, 2025 Element 2 All residents have potential to be impacted by this practice Element 3 Facilities manager will educate maintenance staff on the emergency lighting installed and addition of lights to the Preventative maintenance schedule. Element 4 Emergency lighting audits will be completed monthly. Audits will be checking the functionality of the emergency lights to ensure they are in good working order. Results of audits will be provided monthly to the Quality Assurance Committee. Results will be reported for three months with the Quality Committee making recommendations as to ongoing frequency. Facilities Manager responsible for compliance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #2. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #2. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #2. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #2. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #5. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #5. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #5. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #5. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #6. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #6. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #6. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #6. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #16. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #16. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #16. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #16. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #19. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #19. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #19. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #19. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #21. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #21. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #21. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #21. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #24. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #24. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #24. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on record review and interviews during the recertification, fire-rated doors were not maintained in accordance with adopted regulations relative to Building #24. Specifically, the facility did not ensure defects that could interfere with operation of fire-rated doors were corrected without delay as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition, sections 5.1 and 5.2. This is evidenced by: The document titled (vendor) Coiling Steel Door Inspection and Drop Test Report and dated 01/08/2025 documented that the application of lubricant to the steel door was required. There is no documented evidence that the lubrication was applied. During an interview on 03/26/2025 at 11:48 AM, Facilities Manager #1 stated that they did not have documentation that the lubrication was applied to the door. 2012 NFPA 101 19.2.1, 7.2.1.15 2010 NFPA 80 Chapter 5 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 Element 1 Lubricant was applied to the steel door per Inspection report. Element 2 All doors in the facility were reviewed for compliance with NFPA. No issues identified. Re: Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Element 3 Facilities manager will provide education to the facility staff on following through on all inspection recommendations and documentation of work completed Element 4 All inspection reports will be reviewed by Facility Manager to ensure any identified work needed is scheduled and completed. The report will be rolled up to the monthly quality assurance committee to review work recommended and date completed. This will be a standing agenda item for the month quality meeting Facility manager responsible for ongoing compliance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #4. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #4. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #4. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #4. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #12. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #12. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #12. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #12. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #16. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #16. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #16. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #16. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #24. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #24. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #24. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1)Based on observation and interview during the recertification survey, exits were not maintained in accordance with adopted regulations relative to Building #24. Specifically, exit doors were not maintained free of all obstructions or impediments for full instant use (e.g., stop signs were placed on smoke barrier doors) as required by the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. This is evidenced by: During observations on 03/27/2025 at 12:51 PM, stop signs were posted on the on the smoke barrier doors. During an interview on 03/27/2025 at 1:33 PM, Facilities Manager #1 stated that they would have the signs removed. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101 7.1.10.1 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedMay 3, 2025 Element 1 The STOP sign has been removed from all smoke barrier doors Element 2 All residents can be impacted by this practice. All exit doors were checked to ensure they were free of obstructions. No issues identified. Element 3 The facility manager or designee will provide education to the facility management staff regarding the requirement for exit doors to be free of obstructions or impediments per National Fire Protection Association (NFPA). Environmental rounds will be made daily by nursing supervisor or designee to ensure exit doors remain accessible and unencumbered. Any issues identified will be corrected immediately and education provided. Element 4 Facilities staff will complete weekly audits of all exit doors to ensure they meet the National Fire Protection Association (NFPA) requirements. Results of the audits will be presented to the Facility Quality Assurance Committee at monthly meeting. The committee will make recommendations for ongoing frequency and any need for change in plan, education, or policy based on results of review. Audits will continue until facility achieves 100 percent compliance. Facility Manager responsible for ongoing compliance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on record review and interview during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include contact information of the other health care facilities with which they have agreements and resident physicians. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the facility Emergency Management Plan, Communications Plan included the contact information for the following: ?? Physicians. ?? Other facilities. During an interview on 03/27/2025 at 12:57 PM, Facilities Manager #1 stated that they would update the Emergency Plan to include the missing contact information. 42 Code of Federal Regulations 483.73(c) | Plan of Correction: ApprovedApril 25, 2025 Element 1 The Emergency plan, communications was updated to include the contact information for the attending physicians, medical director, facilities included in our emergency preparedness plan Element 2 The Emergency Plan, communications were reviewed to ensure all required elements included in the plan. No changes required. Element 3 Nursing educator will provide education to Leadership Team ( ie Director of Nursing, social work, Rehabilitaion manager, facilities manager, Assistant Director of Nursing, Dietary manager, Nurse managers) on the addition of the contact information in the plan. Education will include but not be limited to the following: The information in the communications plan How to use information in the communications plan Element 4 The Safety Committee will review the Emergency Preparedness plan monthly to ensure that the plan is up to date and includes all required elements per regulation. Review will be reported monthly at the facility quality assurance committee for review and recommendations. This review will continue as a standard agenda item for the monthly quality assurance meeting. Facility manager responsible for ongoing compliance |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the facility did not include strategies for addressing each emergency event identified by the risk assessment. This could affect all residents at the facility. This is evidenced by: There was no documented evidence that the facility had an emergency policies and procedures for: ?? Loss of sprinkler system. ?? Cyber-attack. ?? Use of portable generators. During an interview on 03/27/2025 at 12:57 PM, Facilities Manager #1 stated that they would update the Emergency Plan to include the missing policies and procedures. 42 Code of Federal Regulations 483.73(a)(1) | Plan of Correction: ApprovedApril 25, 2025 Element 1 The Emergency Plan was updated to include policy and procedures for: Loss of sprinkler Cyber-attack Use of portable generators Element 2 All required elements for Emergency Preparedness reviewed to ensure facility plan includes all required elements. No additional changes required. Element 3 Nursing Education will provide education to all staff regarding the above named areas. The education includes but not limited to the following: Interruption of the fire system/sprinkler system Cyber-attack Portable generators This education will be included in the annual education and new hire education programs Element 4 Emergency Preparedness Plan will be reviewed monthly as part of the safety meeting agenda. Results of the Review will be reported to Quality Committee monthly. This will continue to be a standing item of the Quality Committee and Safety committee. Executive Director responsible for ongoing compliance |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 1, 2025
Corrected date: N/A
Citation Details Based on observation and interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations relative to Building #31 (House #1). Specifically, the top of storage was not less than 18 inches of sprinkler deflectors as required by the National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition sections 4.1.6.1 and 5.3.1.1.1.6. This is evidenced by: During observations on 03/28/2025 at 2:24 PM, storage was within 18-inches of the sprinkler deflectors in the storeroom and walk-in freezer. During an interview on 03/28/2025 at 2:26 PM, Facilities Manager #1 stated that they would have the storage moved and would speak with the dietary department about the storage requirements. 42 Code of Federal Regulations 483.70(a)(1) 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8 NFPA 25 4.1.6.1, 5.3.1.1.1.6 2010 NFPA 13: 8.5.6, Chapter 26 10 New York Codes, Rules, and Regulations 415.29, 711.2(a)(1) | Plan of Correction: ApprovedMay 5, 2025 Element 1 Storeroom and walk-in freezer was moved to ensure storage is not with-in 18 inches of the sprinkler Element 2 All kitchen storage areas will be checked to ensure storage meets requirements with sprinkler clearance. Any inconsistency in storage will be corrected at time of identification and education provided. Element 3 The nurse educator or designee will provide education to food service staff regarding storage clearance requirements. This education will be part of onboarding of new staff and annual education. Element 4 Weekly audits of the storage room and walking freezer will be completed to ensure that storage is not within 18 inches of sprinkler. Audits will continue for 3 months. Results of audits will be reviewed at the monthly Quality Assurance Committee meeting. Audits will continue for 3 months a that time the Quality assurance committee will make recommendations regarding ongoing audits, frequency or change in plan Facility manager responsible for ongoing compliance |