NY State Tag

Deficiency in Facility Maintenance and Safety

Briarcliff Manor Center For Rehab And Nursing CareBriarcliff Manor, New York Survey Completed on 03-20-2025

Summary

The facility failed to maintain a safe and healthy environment as required by regulations. During a life safety recertification survey, a black mold-like substance was observed on one of the walls in the women's locker room located in the basement. This was attributed to a leak from the floor above, as confirmed by the Director of Maintenance. Additionally, in the men's locker room, several wall tiles were missing, resulting in a large opening in one of the walls. These conditions indicate that the facility did not adequately maintain the building to prevent fire and other hazards to personal safety.

Plan Of Correction

Plan of Correction: Approved April 10, 2025

I. Immediate Corrective Action:

1. Black Mold in Women's Locker Room:
- On 3/19/25, the Director of Maintenance immediately initiated remediation of the black mold-like substance in the women's locker room. The affected wall was cleaned.
- The wall was dried, and mold remediation procedures were followed as per environmental safety standards.

2. Opening in Men's Locker Room Wall:
- On 3/19/25, the Director of Maintenance immediately secured the area with a safety barrier around the large opening in the men's locker room wall to prevent any safety hazards.
- The hole in the men’s locker room was repaired.

II. Identification of Others:
- All residents have the potential to be affected.
- A thorough inspection of all locker rooms, bathrooms, and other areas within the facility was conducted to identify potential mold growth or structural integrity issues.
- No additional issues were identified. However, the facility will continue to monitor for any future concerns.

III. Systemic Changes:

1. The Director of Maintenance reviewed and updated the Facility Maintenance Policy to include regular checks for signs of moisture, mold, and structural integrity, particularly in high-risk areas such as bathrooms, locker rooms, and ceilings.
- A bi-monthly inspection schedule was established to identify and address any potential issues before they become major hazards.

2. The Director of Maintenance scheduled monthly inspections for six months to monitor moisture damage, mold growth, and structural issues throughout the facility, including in areas previously identified as high-risk, such as locker rooms and bathrooms.

IV. Quality Assurance:

1. An audit tool was developed to monitor and track the facility's compliance with moisture control, mold prevention, and structural integrity standards.
- Quarterly audits of locker rooms, bathrooms, and other high-risk areas will be conducted for six months. The findings will be reported to QAPI.

V. Person Responsible:
- Director of Maintenance

Penalty

No penalty information released