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Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility failed to ensure each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [REDACTED]. This was identified for one (Resident #220) of three residents reviewed for Behavioral health. Specifically, Resident #220 was admitted to the facility with a known history of illicit drug abuse. The admission psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The facility failed to develop and implement an effective comprehensive person-centered plan of care to address the substance abuse disorder. On 12/13/2021, Resident #220 was found unresponsive, was transferred to the hospital, and was diagnosed with [REDACTED]. No assessments or changes to the resident's plan of care were made upon their return from the hospital on [DATE]. Subsequently, Resident #220 was again found unresponsive on 3/2/2022, was transferred to the hospital for an overdose of Heroin and was diagnosed with [REDACTED]. This resulted in actual harm to Resident #220 with potential for serious harm for 64 residents with a history of drug abuse that is Immediate Jeopardy. The finding is: The facility policy on assessment process dated 12/2021 documented that all residents receive timely, accurate, and appropriate interdisciplinary assessment and care planning. The assessment and review should be completed upon return from the hospital, when there is a significant change that appears to be permanent, based on a comparison of the resident's pre and post hospital status. The facility Behavior Documentation Policy and Procedure dated 4/4/2008 and last revised in 3/2022 documented to monitor residents' behavior and document on a daily basis. Behavior documentation is done on a daily basis on the Certified Nursing Assistant (CNA) Accountability Record by the CNA. It is the responsibility of the caregiver to document the resident's behavior, the intervention utilized for that behavior, and the efficacy of the intervention used every shift. The facility Contraband policy and procedure dated 11/2021 documented in order to ensure a safe environment, all residents presenting to the facility will be subject to a search directed towards identifying contraband and preventing its entrance into the facility. The policy defined contraband as items of danger including illegal substances. The procedure documented that all residents who enter the facility will be subjected to search if any suspected, or any evidence of having contraband. If a resident is found to have controlled substances during their stay, the staff member who finds the controlled substances will bring this to the attention of the attending in charge and the nurse in charge. Visitors who bring contraband into the facility may be asked to leave and may be denied visiting privileges in the future. The resident involved may become subject to a repeat search with confiscation or checking of objects as described above. The facility did not have a documented Policy and Procedure for management of residents with [DIAGNOSES REDACTED]. Resident #220 was admitted with [DIAGNOSES REDACTED]. The MDS documented Resident #220 required limited assistance of one-person with locomotion in the resident's room. The locomotion off the unit did not occur in seven days of the MDS look back period. The MDS documented the resident was feeling depressed, or hopeless, and had disturbed sleep. The Quarterly MDS assessment dated [DATE] documented Resident #220 had a BIMS score of 15, indicating intact cognition. The MDS further documented Resident #220 required supervision without physical help from staff for locomotion on and off the unit. The resident was feeling depressed, or hopeless, and had disturbed sleep. The resident exhibited behavioral symptoms that were not directed towards others in four to six days in the last 7 day look back period of the MDS. Resident #220 was observed on 3/1/2022 at 10:29 AM seated in their wheelchair in the hallway and conversing with another resident. Resident #220 stated that there are no activities that meet their interests. Resident #220 stated that it was very boring at the facility, and they (Resident #220) had complained to the recreation staff. Resident #220 stated that nothing was done and they did not find the current activities appropriate for them (Resident #220). The psychosocial assessment dated [DATE] documented Resident #220 was at another skilled nursing facility for 2 years for back issues. Resident was discharged in (MONTH) 2021 from the other facility. Resident #220 was admitted to the current facility on 8/24/2021 for subacute rehabilitation and was discharged on [DATE]. Resident #220 decided they (Resident #220) could not stay where they were discharged to and had several hospitalization s until admitted as a second admission to the facility on [DATE]. The psychosocial assessment documented Resident #220 was kicked out of previous facility for using and selling heroin, [MEDICATION NAME], and cocaine. The psychosocial assessment documented that Resident #220's judgement was poor. Resident #220 was noted to be anxious, impulsive, easily agitated, and disregarded rules. The history of polysubstance abuse care plan dated 9/28/2021 documented that Resident #220 was kicked out of a previous skilled nursing facility for using and selling heroin, [MEDICATION NAME] and cocaine. Resident #220 knew what was done was wrong and will not do that in the current facility. The goal included that Resident #220 will not use or sell illegal substances. The interventions included to encourage participation in activities of interest, social work one to one visits for emotional support and counselling as needed, psychiatric consultation, and psychological services follow up as needed. There were no care plan updates from 9/21/2021 to 3/2/2022. The psychology consultation dated 10/14/2021 documented that Resident #220 had [DIAGNOSES REDACTED]. Resident #220 reported briefly receiving psychotherapy at a previous Skilled Nursing Facility. Resident #220 reported that they (Resident #220) were living with a friend but were unhappy with the arrangement because their friend was using drugs. The Psychologist documented the Resident #220 presents with a history of drug abuse and was homeless with limited social supports and significant health issues. Resident #220 agreed to speak with the Psychologist today but declined psychotherapy and was coping adequately. No psychotherapy was recommended at this time. The Physician's Order dated 12/2/2021 documented to obtain a psychological evaluation for Anger Management due to Resident #220 having a peer-to-peer altercation. There was no documented evidence that a psychological evaluation was completed after the 12/2/2021 referral. The Situation Background Assessment Recommendation (SBAR) Communication Form dated 12/13/2021 documented Resident #220 had a change in condition with symptoms of altered mental status. The SBAR documented Resident #220 presented with altered level of consciousness, weakness, and shortness of breath. Around 9:00 PM, Resident #220 was observed sitting in the chair very lethargic with alteration in consciousness and was transferred to the hospital. The hospital record dated 12/13/2021 documented that Resident #220 was admitted to the hospital for altered mental status with Acute Hypoxic [MEDICAL CONDITION] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION NAME] 2 milligram (mg) injection. As per Emergency Medical Service (EMS) the oxygen saturation rate for Resident #220 was 82% (normal 95% or above) on room air at the Skilled Nursing Facility and was Hypotensive (low blood pressure). The hospital discharge summary dated 12/15/2021 documented a note to the Skilled Nursing Facility: supervised visiting only. Resident #220 has been receiving drugs from outside visitors and subsequently overdosed. There was no documented evidence of an investigation to determine the root cause of Resident #220's opiate overdose nor where and how the resident received the drugs. The Nursing Admission/Readmission note dated 12/16/21 documented that Resident #220 was admitted from the hospital at 7:40PM. Resident to only have supervised visitation. The Social Work note dated 12/16/2021 documented Resident #220 stated that a visitor brought the drugs to the building. Resident #220 stated that they took the visitor's phone number out of their phone and will not do it again. The Social Worker re-educated Resident #220 about not to smoke or vape in the facility. A document titled Resident Delivery Searches dated 12/2021 documented that when a delivery comes to the facility for any of the following residents, the deliveries are to be searched for contraband. The list of names included Resident #220. The Physician readmission note dated 12/17/2021 documented Resident #220 had a past medical history of [REDACTED].#220 was admitted on [DATE] (to the hospital) for altered mental status with Acute Hypoxic [MEDICAL CONDITION] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION NAME] 2mg injection. The assessment and plan included to continue current medications, provide safe environment, adequate nutrition, and supportive care. Monitor fingerstick, GI follow up for hepatic mass and psychiatry follow up. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The Physician's Order dated 12/28/2021, 11 days after the Physician's readmission note, documented to obtain a Psychiatric consultation for adjustment disorder. The Social Work note dated 1/4/2022 documented Resident #220 was moving from Unit 22 to Unit 46. Resident #220 was educated about not smoking or vaping in the facility. The Physician's note dated 1/12/2022 documented that Resident #220 has not had any acute events. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The Psychiatric Evaluation dated 1/28/2022, one month after requested by the Physician, documented Resident #220 had the [DIAGNOSES REDACTED]. The social history included a history of polysubstance abuse. The recommendation included to decrease [MEDICATION NAME] to 0.5 mg from 1mg and individual therapy 2-5 times monthly. There was no documented evidence that the individual therapy 2-5 times monthly was offered or provided to Resident #220. The physician's note dated 2/9/2022 documented that Resident #220 has not had any acute events and Resident #220 was able to transfer out of bed to ambulate by pushing the wheelchair independently. The physician documented that Resident #220 has a history of anxiety that is controlled with [MEDICATION NAME]. Psychiatry recommended to decrease [MEDICATION NAME] and Resident #220 gets very agitated and violent when you try to discuss tapering the [MEDICATION NAME]. Resident #220 is on [MEDICATION NAME] and [MEDICATION NAME] for chronic back pain. Will decrease [MEDICATION NAME] and discontinue [MEDICATION NAME] and follow up Psychiatry regularly. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. The facility did not provide evidence of a Psychiatric follow up after 1/28/2022. Nursing progress notes from 2/1/2022 to 3/2/2022 were reviewed. There was no documented evidence that the resident was being monitored or supervised for drug seeking behavior, attempts to sell illicit drugs, or consumption of illicit drugs prior to 3/2/2022. The (MONTH) 2021 to (MONTH) 2022 Certified Nursing Assistant (CNA) Accountability Records documented Resident #220 had a [DIAGNOSES REDACTED].#220 could push the wheelchair independently. There was no documented evidence that the resident was to have supervision or monitoring related to Polysubstance abuse. The SBAR Communication Form dated 3/2/2022 documented Resident #220 had a change in condition. At 6:00 PM, Resident #220 was unresponsive to verbal and tactile stimuli. The SBAR documented oxygen saturation level of 66% when on oxygen at 3 liters per minute. Resident #220 was transferred to the hospital. The hospital record dated 3/2/2022 documented Resident #220 was transferred from the Skilled Nursing Facility for altered mental status. Resident #220 was brought in by EMS from the Skilled Nursing Facility for possible overdose. [MEDICATION NAME] 2mg was administered intramuscularly by EMS. Resident #220 stated that they (Resident #220) snorted some Heroin and passed out. Resident #220 had an admission three months ago in (MONTH) (2021) for a similar overdose. Resident #220 was admitted to the hospital for altered mental status secondary to opioid intoxication. The urine toxicology report was positive for opiates and benzodiazepines. The attending physician at the hospital diagnosed Resident #220 with toxic [MEDICAL CONDITION] secondary to opioid intoxication and Substance abuse. Certified Nursing Assistant (CNA) #8 was interviewed on 3/03/2022 at 2:17 PM and stated they (CNA #8) were the regularly assigned CNA for the 7AM to 3PM shift for Resident #220 for the past 2 months. Resident #220 did not have any specific instructions to be monitored. CNA #8 stated that Resident #220 was independent in mobility and did not require any oversight. CNA #8 stated that they have not received any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #8 was not aware if Resident #220 had any visitors on 3/2/2022 or even in the past month. CNA #8 further stated that there were no special instructions to monitor Resident #220 for substance abuse behaviors and there was no direction provided to supervise the resident throughout the facility. Registered Nurse (RN #7) was interviewed on 3/3/2022 at 2:20 PM. RN #7 stated that they (RN #7) were the regular 7AM to 3PM shift Unit Nurse for Resident #220's unit and has known Resident #220 since the resident was transferred to the unit two months ago. RN #7 stated that the staff did not have any specific instructions for monitoring Resident #220's whereabouts in the facility or for supervised visits. RN #7 was not aware if Resident #220 had any visits on 3/2/2022. RN #7 stated that they were aware of Resident #220's history of substance abuse but thought it was a long time ago. RN #7 was not aware of Resident #220's overdose in the facility in (MONTH) 2021. RN #7 did not receive any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #9 was interviewed on 3/3/2022 at 3:15 PM and stated that they (CNA #9) were the assigned CNA for Resident #220 on the 3PM -11PM nursing shift on 3/2/2022. CNA #9 stated that they did not have any instructions for monitoring the resident for substance abuse behaviors and were not aware of Resident #220's history of drug overdose at the facility. CNA #10 was interviewed on 3/3/22 at 3:20 PM and stated that they (CNA #10) were the regularly assigned CNA on the 11:00 PM to 7:00 AM nursing shift for the past 2 months for Resident #220. CNA #10 stated they rarely went into Resident #220's room because Resident #220 was able to care for themself. CNA #10 stated that there was nothing on the CNA accountability record that instructed the CNAs to monitor the resident for drug abuse behavior. CNA #10 further stated they (CNA #10) were not aware of Resident #220's overdose and illicit drug use in the facility. RN #10 was interviewed on 3/3/2022 at 3:26 PM and stated that they (RN #10) were the RN Supervisor on 3/2/2022 on the 11 PM-7AM nursing shift and was covering the 3 PM-11 PM nursing shift on Resident #220's unit. RN #10 stated that they were called by RN #8 to Resident #220's room because Resident #220 presented with an altered mental status and was not waking up. Resident #220's oxygen saturation level was 66%. RN #10 was aware of Resident #220's overdose in (MONTH) 2021 but did not suspect that the resident had a drug overdose in this case. RN #10 did not tell the EMS anything about Resident #220's drug abuse behavior. RN #8 was interviewed on 3/3/2022 at 3:52 PM and stated that they (RN #8) were covering the 3PM-11PM nursing shift on 3/2/2022. RN #8 stated they were not the regularly assigned nurse for the resident's unit. At 5:00PM, RN #8 went to Resident #220's room and Resident #220 seemed out of it. Resident #220 was transferred to the hospital due to the unresponsiveness. RN #8 stated they (RN #8) were not aware that Resident #220 had substance abuse behaviors and had overdosed in (MONTH) 2021 in the facility. RN #8 further stated that there were no Physician's orders or instructions related to substance abuse monitoring for Resident #220. Social Worker (SW) #2 was interviewed on 3/3/2022 at 5:11 PM and stated Resident #220 had a short stay at the facility from 8/24/2021 to 9/3/2021 and was readmitted on [DATE] which was considered a new stay. SW#2 stated that Resident #220 informed them (SW #2) that Resident #220 was kicked out of another skilled nursing facility two years ago because of selling and using illicit drugs. Resident #220 informed SW #2 that they (Resident #220) were clean and were not using illicit drugs when they were admitted on [DATE]. Resident #220 was referred to psychology for therapy and only had one psychotherapy session in (MONTH) 2021. SW #2 stated that the plan of care for history of substance abuse was to refer Resident #220 to psychology and to check any incoming packages for illicit drugs. SW #2 stated that searching packages is a standard protocol in the facility and did not have to be in a care plan. The nursing staff are expected to look through food items brought in from outside as per the facility-wide protocol. SW #2 stated that Resident #220 was not actively having substance abuse disorder so a care plan to prevent and monitor substance abuse behavior was not developed. SW #2 stated that Resident #220 had a history of [REDACTED]. SW #2 stated that the facility cannot always search Resident #220's belongings and there is only so much we can do. On 12/13/21, Resident #220 was found in their room unresponsive and was hospitalized . SW #2 stated that they (SW #2) followed up with Resident #220 on 12/16/21 and educated Resident #220 on the facility rules. SW #2 stated that Resident #220 was placed on SW #1's caseload when readmitted on [DATE]. SW #2 stated that it was SW #1's responsibility to develop and update the care plan to address Resident #220's substance abuse behavior when Resident #220 was readmitted on [DATE]. SW #1 was interviewed on 3/3/22 at 5:51 PM. SW #1 stated that they were assigned to Resident #220 upon their readmission in (MONTH) 2021 after the resident returned from the hospital from the opiate overdose. SW #1 stated that they did not complete a psychosocial assessment and did not develop a revised plan of care to address Resident #220's substance abuse behavior. SW #1 stated that they could not recall reviewing the hospital discharge paperwork with the instruction for supervised visitation to reduce substance abuse behavior. SW #1 stated that an interdisciplinary team approach was not used to address Resident #220's substance abuse behavior. SW #1 stated that they did not initiate any additional interventions for Resident #220 after the resident's return from the hospital on [DATE]. Resident #220 was reassigned to SW #2 on 1/4/2022. The Medical Director and Director of Nursing was interviewed concurrently on 3/3/22 at 6:30 PM. The Medical Director stated that Resident #220's [DIAGNOSES REDACTED].#220's history. The Director of Nursing stated that everyone on the team is aware of Resident #220's substance abuse history is noted in the medical record. The Director of Nursing stated that the facility did not initiate an Incident Report to investigate how Resident #220 obtained drugs in the facility on 12/13/2021 because SW #2 had written a note that Resident #220 received the drugs from a visitor. The Director of Nursing stated that the facility was in COVID-19 quarantine and Resident #220 did not require increased supervision. The Director of Nursing stated that the visitation protocols were facility wide and did not need to be documented in a care plan. The Director of Nursing stated that Resident #220 refused psychotherapy in the past. The Medical Director stated that they were not aware if the psychotherapist had seen Resident #220 after 12/16/2021. The Medical Director was not aware if the substance abuse behaviors were addressed in psychotherapy or psychiatry and if substance abuse treatment was offered. The Director of Nursing stated that it was the hospital's responsibility to refer Resident #220 to a drug rehabilitation programs and that the facility can only offer psychiatric and psychological care. The Director of Recreation was interviewed on 3/4/22 at 2:40 PM. The Director of Recreation stated that Resident #220 preferred extra newspapers and enjoyed watching television. The Director of Recreation stated that during the outbreak in (MONTH) 2021 and (MONTH) 2022, activities were provided one to one or in the room. When Resident #220's unit was cleared in (MONTH) 2022, Resident #220 would go out to the courtyard when weather permitted and self-propelled throughout the facility, to other units to talk to other residents and to go to the vending machines. Attending Physician #2 was interviewed on 3/4/22 at 3:42 PM and stated that they (Attending Physician #2) provided care for Resident #220 since Resident #220 was moved to Unit 46 on 1/4/2022. Resident #220 has a history of high blood pressure, chronic lower back pain, and anxiety disorder. Attending Physician #2 stated that Resident #220 was known to have agitated and aggressive behaviors and was followed by a psychiatrist. Resident #220 refused psychotherapy on several occasions. Attending Physician #2 stated that they (Attending Physician #2) believed that Resident #220 was very agitated when the suggestion to decrease the [MEDICATION NAME] was recommended by the psychiatrist and Attending Physician #2 reduced [MEDICATION NAME] instead. Attending Physician #2 stated that Resident #220 required monitoring and supervision and they (Attending Physician #2) had verbally informed CNA #10 and RN #7 to monitor Resident #220 for Substance abuse behavior. Attending Physician #2 stated that they did not recall documenting the need for increased monitoring for substance abuse behaviors or placing an order instructing nurses to do so. SW #2 was re-interviewed on 3/4/2022 at 5:15 PM. SW #2 stated that the facility staff located Resident #220's care plan entitled history of substance abuse which was dated 9/28/2021. The interventions did not include to monitor and supervise Resident #220's whereabouts in the facility for substance abuse behavior. SW #2 stated that they had developed the care plan but did not revise the care plan after the resident returned from the hospital on [DATE] since that was the responsibility of SW #1. Resident #220 should have had a revised care plan after the 12/13/2021 hospitalization . The care plan did not include any updates in (MONTH) 2021. Resident #220 was not on the radar for active use of drugs at the time of the 9/28/2021 care plan. The search of packages is a standard practice for any resident in the facility so that intervention would not be in the care plan. The facility was notified of the Immediate Jeopardy on 3/3/2022. The Immediate Jeopardy was removed on 3/7/2022 prior to the completion of the survey. -The facility created policies and procedures to address needs of the residents with Alcohol and Drug problems and Management of Residents with History of Substance abuse. -The facility Educated 95% of the facility staff on the newly developed policies and procedures and on identification of care for resident history of using Polysubstance/Polydrug abuse and identifying signs and symptoms of drug abuse. The facility also educated staff on narcotic overdose and use of [MEDICATION NAME]. Those not in-serviced are either on vacation, on medical leave, or have not been scheduled for duty and will be in-serviced as they report to work. - The facility assessed and formulated care plans for all residents identified as having history of Polysubstance abuse. -The facility created Resident contracts/agreements to educate residents on facility's zero tolerance drug policy along with consequences. -The facility developed audit tools to monitor residents with history of Substance abuse history for signs and symptoms of drug abuse and updated the room search audit tool to include legal and illegal substances. | Plan of Correction: ApprovedApril 15, 2022 Plan of correction not approved or not required |
Scope: Pattern
Severity: Immediate jeopardy to resident health or safety
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022 the facility failed to ensure that the resident's environment was free of accident hazards for one (Resident #220) of 4 residents reviewed for accidents. Specifically, Resident #220 with a known history of Polysubstance abuse, was not supervised to prevent the availability of non-prescribed illicit drug usage within the facility. Resident #220 was readmitted to the facility on [DATE]. A Psychosocial assessment dated [DATE] documented the resident was utilizing and selling illicit drugs in the previous nursing facility. The current facility did not develop care plan interventions to monitor and supervise the resident for substance abuse. On 12/13/2021 Resident #220 was found unresponsive and transferred to hospital for opioid drug overdose. The facility did not initiate an investigation after the 12/13/2021 incident. The hospital discharge recommendations were to provide supervised visits. The facility did not address and re-assess the interventions to monitor and prevent the resident from obtaining illicit drugs. Subsequently, on 3/2/2022 the resident was found unresponsive and sent to hospital with [DIAGNOSES REDACTED].#220) snorted heroin and passed out. Additionally, the facility did not have a system in place to identify and monitor residents with history of drug abuse. This resulted in actual harm to Resident #220 with potential for serious harm for 64 residents with history of drug abuse that is Immediate Jeopardy and Substandard Quality of Care. The finding is: The facility Contraband policy and procedure dated 11/2021 documented in order to ensure a safe environment, all residents presenting to the facility will be subject to a search directed towards identifying contraband and preventing its entrance into the facility. The policy defined contraband as items of danger including illegal substances. The procedure documented that all residents who enter the facility will be subjected to search if any suspected, or any evidence of having contraband. If a resident is found to have controlled substances during their stay, the staff member who finds the controlled substances will bring this to the attention of the attending in charge and the nurse in charge. Visitors who bring contraband into the facility may be asked to leave and may be denied visiting privileges in the future. The resident involved may become subject to a repeat search with confiscation or checking of objects as described above. The facility did not have a documented Policy and Procedure for management of residents with [DIAGNOSES REDACTED]. Resident #220 was admitted with [DIAGNOSES REDACTED]. The MDS documented Resident #220 required limited assistance of one-person with locomotion in the resident's room. The locomotion off the unit did not occur in seven days of the MDS look back period. The MDS documented the resident was feeling depressed, or hopeless, and had disturbed sleep. The Quarterly MDS assessment dated [DATE] documented Resident #220 had a BIMS score of 15, indicating intact cognition. The MDS further documented Resident #220 required supervision without physical help from staff for locomotion on and off the unit. The resident was feeling depressed, or hopeless, and had disturbed sleep. The resident exhibited behavioral symptoms that were not directed towards others in four to six days in the last 7 day look back period of the MDS. The psychosocial assessment dated [DATE] documented Resident #220 was at another skilled nursing facility for 2 years for their back issues and was kicked out of previous facility for using and selling heroin, [MEDICATION NAME] and cocaine. The psychosocial assessment documented that Resident #220's judgement was poor. Resident #220 was noted to be anxious, impulsive, easily agitated, and disregarded rules. The history of polysubstance abuse care plan dated 9/28/2021 documented that Resident #220 was kicked out of a previous skilled nursing facility for using and selling heroin, [MEDICATION NAME] and cocaine. Resident #220 knew what was done was wrong and will not do that in the current facility. The goal included that Resident #220 will not use or sell illegal substances. The interventions included to encourage participation in activities of interest, social work one to one visits for emotional support and counselling as needed, psychiatric consultation, and psychological services follow up as needed. The Nursing Progress Note from 9/23/2021 through 12/12/2021 were reviewed and indicated no documented behaviors related to consuming or selling illicit drugs. The Situation Background Assessment Recommendation (SBAR) Communication Form dated 12/13/2021 documented Resident #220 had a change in condition with symptoms of altered mental status. The SBAR documented Resident #220 presented with altered level of consciousness, weakness, and shortness of breath. Around 9:00 PM, Resident #220 was observed sitting in the chair very lethargic with alteration in consciousness and was transferred to the hospital. The hospital record dated 12/13/2021 documented that Resident #220 was admitted to the hospital for altered mental status with Acute Hypoxic [MEDICAL CONDITION] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION NAME] 2 milligram (mg) injection. As per Emergency Medical Service (EMS) the oxygen saturation rate for Resident #220 was 82% (normal 95% or above) on room air at the Skilled Nursing Facility and was Hypotensive (low blood pressure). The hospital discharge summary dated 12/15/2021 documented a note to the Skilled Nursing Facility: supervised visiting only. Resident #220 has been receiving drugs from outside visitors and subsequently overdosed. There was no documented evidence of an investigation to determine the root cause of Resident #220's opiate overdose nor where and how the resident received the drugs. The Nursing Admission/Readmission note dated 12/16/2021 documented that Resident #220 was admitted from the hospital at 7:40 PM. The resident was to only have supervised visitation. The Social Work note dated 12/16/2021 documented Resident #220 stated that a visitor brought the drugs to the building. Resident #220 stated that they took the visitor's phone number out of their phone and will not do it again. The Social Worker re-educated Resident #220 about not to smoke or vape in the facility. The history of polysubstance abuse care plan dated 9/28/2021 was not updated after the resident had returned from the hospital on [DATE] with a [DIAGNOSES REDACTED]. A document titled Resident Delivery Searches dated 12/2021 documented that when a delivery comes to the facility for any of the following residents, the deliveries are to be searched for contraband. The list of names included Resident #220. The Physician readmission note dated 12/17/2021 documented Resident #220 had a past medical history of [REDACTED].#220 was admitted on [DATE] (to the hospital) for altered mental status with Acute Hypoxic [MEDICAL CONDITION] secondary to drug overdose (cocaine, opiate and benzodiazepine) with moderate improvement after [MEDICATION NAME] 2mg injection. The assessment and plan included to continue current medications, provide safe environment, adequate nutrition, and supportive care. Monitor fingerstick, GI follow up for hepatic mass and psychiatry follow up. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The Social Work note dated 1/4/2022 documented Resident #220 was moving from Unit 22 to Unit 46. Resident #220 was educated about not smoking or vaping in the facility. The Physician's note dated 1/12/2022 documented that Resident #220 has not had any acute events. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. The Physician did not acknowledge the recommendation from the hospital related to supervised visitation for Resident #220. The physician's note dated 2/9/22 documented that Resident #220 has not had any acute events and Resident #220 was able to transfer out of bed to ambulate by pushing the wheelchair independently. The physician documented that Resident #220 has a history of Anxiety that is controlled with [MEDICATION NAME]. Psychiatry recommended to decrease [MEDICATION NAME] and Resident #220 gets very agitated and violent when you try to discuss tapering of the [MEDICATION NAME]. Resident #220 is on [MEDICATION NAME] and [MEDICATION NAME] for chronic back pain. Will decrease [MEDICATION NAME] and discontinue [MEDICATION NAME] and follow up with Psychiatry regularly. The assessment and plan included to provide current medications, provide safe environment, adequate nutrition, and supportive care. Continue 2 liters of oxygen via nasal cannula. Nursing progress notes from 2/1/2022 to 3/2/2022 were reviewed. There was no documented evidence that the resident was being monitored or supervised for drug seeking behavior, attempts to sell illicit drugs, or consumption of illicit drugs prior to 3/2/2022. The (MONTH) 2021 to (MONTH) 2022 Certified Nursing Assistant (CNA) Accountability Records documented Resident #220 had a [DIAGNOSES REDACTED].#220 could push the wheelchair independently. There was no documented evidence that the resident was to have supervision or monitoring related to Polysubstance abuse. The SBAR Communication Form dated 3/2/2022 documented Resident #220 had a change in condition. At 6:00 PM, Resident #220 was unresponsive to verbal and tactile stimuli. The SBAR documented oxygen saturation level of 66% when on oxygen at 3 liters per minute. Resident #220 was transferred to the hospital. The hospital record dated 3/2/2022 documented Resident #220 was transferred from the Skilled Nursing Facility for altered mental status. Resident #220 was brought in by EMS from the Skilled Nursing Facility for possible overdose. [MEDICATION NAME] 2mg was administered intramuscularly by EMS. Resident #220 stated that they (Resident #220) snorted some Heroin and passed out. Resident #220 had an admission three months ago in (MONTH) (2021) for a similar overdose. Resident #220 was admitted to the hospital for altered mental status secondary to opioid intoxication. The urine toxicology report was positive for opiates and benzodiazepines. The attending physician at the hospital diagnosed Resident #220 with toxic [MEDICAL CONDITION] secondary to opioid intoxication and Substance abuse. Certified Nursing Assistant (CNA) #8 was interviewed on 3/03/2022 at 2:17 PM and stated they (CNA #8) were the regularly assigned CNA for the 7AM to 3PM shift for Resident #220 for the past two months. CNA #8 stated Resident #220 propelled their wheelchair throughout the facility and sometimes went downstairs to the vending machine. Resident #220 did not have any specific instructions to be monitored. CNA #8 stated that Resident #220 was independent in self-care and mobility and did not require any oversight. CNA #8 stated that they have not received any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #8 was not aware if Resident #220 had any visitors on 3/2/2022 or even in the past month. CNA #8 further stated that there were no special instructions to monitor Resident #220 for substance abuse behaviors and there was no direction provided to supervise the resident throughout the facility. Registered Nurse (RN #7) was interviewed on 3/3/2022 at 2:20 PM. RN #7 stated that they (RN #7) were the regular 7AM to 3PM shift Unit Nurse for Resident #220's unit and has known Resident #220 since the resident was transferred to the unit two months ago. RN #7 stated that the staff did not have any specific instructions for monitoring Resident #220's whereabouts in the facility or for supervised visits. RN #7 was not aware if Resident #220 had any visits on 3/2/2022. RN #7 stated that they were aware of Resident #220's history of Substance abuse but thought it was a long time ago. RN #7 was not aware of Resident #220's overdose in the facility in (MONTH) 2021. RN #7 further stated they (RN #7) did not receive any instructions to look through Resident #220's belongings to check for substance abuse related materials. CNA #9 was interviewed on 3/3/2022 at 3:15 PM and stated that they (CNA #9) were the assigned CNA for Resident #220 on the 3 PM -11 PM nursing shift on 3/2/2022. CNA #9 stated that the regularly assigned CNA was on vacation as of 3/2/2022. Resident #220 was able to independently propel their wheelchair throughout the facility without supervision. CNA #9 stated that they last saw Resident #220 at 4:30 PM in their room on 3/2/2022. Resident #220 was in the room and was talking. CNA #9 was called over by RN #8 who discovered Resident #220 unresponsive in their room at 5:00 PM. CNA #9 stated that they did not have any instructions for monitoring the resident for substance abuse behaviors and was not aware of Resident #220's history of drug overdose at the facility. CNA #10 was interviewed on 3/3/2022 at 3:20 PM and stated that they (CNA #10) were the regularly assigned CNA on the 11:00 PM to 7:00 AM nursing shift for the past two months for Resident #220. CNA #10 stated that Resident #220 was usually in bed sleeping or watching television when they (CNA #10) started the 11:00 PM to 7:00 AM shift. CNA #10 stated they rarely went into Resident #220's room because Resident #220 was able to care for themself. CNA #10 stated that there was nothing on the CNA accountability record that instructed the CNAs to monitor the resident for drug abuse behavior. CNA #10 further stated they (CNA #10) were not aware of Resident #220's overdose and illicit drug use in the facility. RN #10 was interviewed on 3/3/2022 at 3:26 PM and stated that they (RN #10) were the RN Supervisor on 3/2/2022 on the 11 PM-7AM nursing shift and was covering the 3 PM-11 PM nursing shift on Resident #220's unit. RN #10 stated that they were called by RN #8 to Resident #220's room because Resident #220 presented with an altered mental status and was not waking up. Resident #220's oxygen saturation level was 66% and oxygen was being administered. The oxygen saturation level went up to 90-92%. RN #10 was aware of Resident #220's overdose in (MONTH) 2021 but did not suspect that the resident had a drug overdose in this case. RN #10 did not tell the EMS anything about Resident #220's drug abuse behavior. RN #8 was interviewed on 3/3/2022 at 3:52 PM and stated that they (RN #8) were covering the 3PM-11PM nursing shift on 3/2/2022. RN #8 stated they were not the regularly assigned nurse for the resident's unit. RN #8 stated they (RN #8) were not aware that Resident #220 had substance abuse behaviors and had overdosed in (MONTH) 2021 in the facility. RN #8 stated that there were no Physician's orders or instructions related to substance abuse monitoring for Resident #220. At the beginning of the shift Resident #220 was talking and seemed to be their usual self. RN #8 stated that they (RN #8) were not sure if Resident #220 left their bedroom at all during the shift. RN #8 stated that they (RN #8) did not see any visitors for Resident #220 during that shift nor did the Resident Care Associate (RCA) come to escort Resident #220 for a visit. At 5:00 PM, RN #8 went to Resident #220's room and Resident #220 seemed out of it. RN #8 stated they knew Resident #220 had a [DIAGNOSES REDACTED].#220 was in Diabetic shock. RN #8 did a fingerstick to check the blood sugar level which was 258 which did not indicate Diabetic shock. RN #8 stated they called RN #10 and continued to try to get Resident #220 to respond. When RN #10 arrived on the unit, RN #8 reported the resident's condition to RN #10. Resident #220 was transferred to hospital due to the unresponsiveness. Social Worker (SW) #2 was interviewed on 3/3/2022 at 5:11 PM and stated that they (SW #2) were the assigned SW for Resident #220 when the resident was admitted in (MONTH) 2021. SW #2 stated they were aware that Resident #220 had a history of [REDACTED].#2 stated that residents with a known history of Substance abuse problems are referred to psychology and their incoming packages are to be checked for illicit drugs. SW #2 stated that searching packages is a standard protocol in the facility and did not have to be in a care plan. The nursing staff are expected to look through food items brought in from outside as per facility wide protocol. SW #2 stated that they (SW #2) believed that Resident #220 was not actively having Substance abuse disorder so a care plan to prevent and monitor substance abuse behavior was not developed. SW #2 stated that the facility cannot always search Resident #220's belongings and there's only so much they can do. SW #2 stated that Resident #220 was placed on SW #1's caseload when the resident was readmitted from the hospital on [DATE] and that it was SW #1's responsibility to develop a care plan to address Resident #220's substance abuse behavior. SW #1 was interviewed on 3/3/2022 at 5:51 PM. SW #1 stated that they were assigned to Resident #220 upon their readmission in (MONTH) 2021 after the resident returned from the hospital from the opiate overdose. SW #1 stated that they did not complete a psychosocial assessment and did not develop a revised plan of care to address Resident #220's Substance abuse behavior. SW #1 could not recall reviewing the hospital discharge paperwork with the instruction for supervised visitation to reduce Substance abuse behavior. SW #1 stated that an interdisciplinary team approach was not used to address Resident #220's Substance abuse behavior. Resident #220 was reassigned to SW #2 on 1/4/2022. The Medical Director and Director of Nursing were interviewed concurrently on 3/3/2022 at 6:30 PM. The Medical Director stated that Resident #220's [DIAGNOSES REDACTED].#220's history. The Director of Nursing stated that there is a system in place to monitor Resident #220 and it is the facility wide protocol to check packages and to supervise visits for all residents in the auditorium. The Director of Nursing stated that everyone on the interdisciplinary team is aware of Resident #220's smoking behavior and the substance abuse history is noted in the medical record. The Medical Director stated that Resident #220's name is on the list at the entrance way for security to search any packages that came from the outside. The facility wide protocol is that the Social Worker, Recreation Aide, and Security are to look through incoming food and packages for any hazardous materials. The Director of Nursing stated that room searches are only done if a staff member suspected that a resident was smoking and that the facility cannot do more than that. The Medical Director and the Director of Nursing stated that Resident #220 has not had any visitors. The Director of Nursing stated that the facility did not initiate an Incident Report to investigate how Resident #220 obtained drugs in the facility on 12/13/2021 because SW #2 had written a note that Resident #220 received the drugs from a visitor. The Director of Nursing stated that Resident #220 did not require increased supervision. The Director of Nursing further stated that the protocols were facility wide and did not need to be documented in a care plan. Attending Physician #2 was interviewed on 3/4/2022 at 3:42 PM and stated that they (Attending Physician #2) provided care for Resident #220 since Resident #220 was moved to Unit 46 on 1/4/2022. Attending Physician #2 stated that Resident #220 required monitoring and supervision and they (Attending Physician #2) had verbally informed CNA #10 and RN #7 to monitor Resident #220 for Substance abuse behavior. Attending Physician #2 stated that they did not recall documenting the need for increased monitoring for Substance abuse behaviors or placing an order instructing nurses to do so. SW #2 was re-interviewed on 3/4/2022 at 5:15 PM. SW #2 stated that the facility staff located Resident #220's care plan entitled history of substance abuse which was dated 9/28/2021. The interventions did not include to monitor and supervise Resident #220's whereabouts in the facility for substance abuse behavior. SW #2 stated that they had developed the care plan but did not revise the care plan after the resident returned from the hospital on [DATE] since that was the responsibility of SW #1. Resident #220 should have had a revised care plan after the 12/13/2021 hospitalization . The care plan did not include any updates in (MONTH) 2021. Resident #220 was not on the radar for active use of drugs at the time of the 9/28/2021 care plan. The search of packages is a standard practice for any resident in the facility so that intervention would not be in the care plan. 415.12(h)(1) The facility was notified of the Immediate Jeopardy on 3/3/2022. The Immediate Jeopardy was removed on 3/7/2022 prior to the completion of the survey. -The facility created policies and procedures to address needs of the residents with Alcohol and Drug abuse problems and Management of Residents with a History of Substance abuse. -The facility Educated 95% of the facility staff on the newly developed policies and procedures and on identification of care for residents' with a history of using Polysubstance/Polydrug abuse and identifying signs and symptoms of drug abuse. The facility also educated staff on narcotic overdose and use of [MEDICATION NAME]. The staff that did not receive in-service education were either on vacation, on medical leave, or not were been scheduled for duty and will be in-serviced as they report to work. - The facility assessed and formulated care plans for all residents identified as having a history of Polysubstance abuse. -The facility created Resident contracts/agreements to educate residents on the facility's zero tolerance drug policy along with consequences. -The facility developed audit tools to monitor residents with a history of Substance abuse for signs and symptoms of drug abuse and updated the room search audit tool to include legal and illegal substances. | Plan of Correction: ApprovedApril 15, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** To address the issue of F689-483.25, the Quality of Care: Free of Accident Hazards/Supervision/Devices for resident #220 with a history of Polysubstance abuse non-prescribed illicit and/or any non-administered legal drugs. The following actions were accomplished after Immediacy was placed on 3/3/22 during the Department of Health (DOH) recertification survey. A. Holly Patterson Extended Care Facility (AHPECF) promptly placed measures to address the immediacy. Interim Plan of Correction completed 3/3/22 lists explicit procedures initiated, developed, and implemented by AHPECF to address the issue of immediacy. On 3/7/22 AHPECF wrote a letter for removal of immediacy, this letter was accepted by the DOH on 3/7/22 and, the immediacy was removed on the same date of 3/7/22. On 3/21/22 the Official SOD was issued. Along with taking measures listed below to assure the safety of other residents in the care of the facility, AHPECF obtained consultant services to address the Statement of Deficiency (SOD). The consultant?s information was sent via secure file to the Department of Health, Division of Nursing Homes, on the evening of 3/21/22. ELEMENT NUMBER ONE (#1) RESIDENT# 220: For Resident #220 the measures listed below were implemented to immediately address F689-483.25, the Quality of Care: Free of Accident Hazards/Supervision/Device. No further resident was harmed by this issue 1. CCP updated by multidisciplinary team resident as a Polysubstance Abuser/High Alert Resident 2. Resident #220 was notified of the drug rehabilitation program attendance requirement prior to re-entering/re-admission to the facility 3. Upon readmission all visitation will also be supervised and packages searched for an illegal substance. 3A. Resident #220 returned and was immediately sent out again for attempting to hit another resident. 4. Upon readmission to the facility resident will be given a Contract/Agreement for a resident with a substance abuse history 5. Refusal to sign the contract or violation of this agreement will be witnessed by two social workers and documented in the resident?s chart, along with documentation in the care plan A) Ramifications/Violation of contract are as follows: B) First violation will result in counseling and random urine toxicology no less than once a week C) Second violation of the agreement will result in revocation of visitation and placed in the secure unit D) Third violation will result in discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility ELEMENT NUMBER TWO (#2) IDENTIFYING OTHER RESIDENTS: These measures/corrective actions are accomplished by AHPECF for those residents found to have been affected by the practice. No other resident was harmed, below is a list of measures taken to identify any other possible residents: 1. Immediately the multidiscipline team checked all charts, records, and created a High Alert List of residents who have a history of Polysubstance Abuse 2. The education/in-service department began and completed educating facility-wide staff on the list. This education notified staff that a resident with a history of polysubstance abuse is kept on a High Alert List. This High Alert List will be kept, maintained, and updated by Admission Department. An orange reference Binder title with up-to-date HIGH ALERT LIST will be kept on all units and at the Security/Ambulance Entrance and at the Security/Visitor Entrance of all residents with a history of Polysubstance Abuse - Completed by the Admission Department. ELEMENT NUMBER THREE (#3) EDUCATION: Additional measures/actions and systemic changes taken by AHPECF to identify other residents having the potential to be affected by this same issue: 1. A High Alert List of residents with a history of polysubstance abuse is kept in an orange reference binder on all units and at the Security/Ambulance Entrance and at the Security/Visitor Entrance of all residents with a history of Polysubstance Abuse. The admission Department will update this list as needed. Once the resident has been placed on the High Alert list, nursing staff documentation daily after observation of any change in the resident alter mental status, behavior, or change in resident's status. Nurses will notify the MD of any alert changes. [MEDICATION NAME] will then be used on residents if needed. Nursing monitoring documentation on audit tool of resident on High Alert list any change related to s/s of drug abuse will be completed daily. 2. All staff, every discipline, which includes nursing, SW, dietary, housekeeping, medical, environmental, rehab, recreation, security, HR, business office, Asian, and central supply, every employee in AHP educated on identifying signs and symptoms of drug abuse on 3/3/22 3. Medical and Nursing department's re-education on the use of [MEDICATION NAME] Incident report began on 3/3/22. Other actions/measures and systemic changes taken by AHPECF to ensure this is addressed and does not recur are: 1. [MEDICATION NAME] kept in the Nursing Supervisors' Office is now placed in all unit's emergency carts as well as the Nursing Supervisors' Office. Nursing and Medical Staff were re-educated on how to use [MEDICATION NAME] Nasal. [MEDICATION NAME] was to be given and 911 called for a change in Loss of Consciousness for any High Alert Resident 2. Room Search documentation ? resident on High Alert list ? completed randomly by two staff from Nursing, Security, and/or Social Work. 3. New Care Plans were developed and placed in High Alert residents' charts. 4. AHPECF developed Resident Substance Abuse Agreement/Contract -- created and given to all residents on the High Alert List. The Contracts that are 100% completed notifies residents of AHPECF stands on using Polysubstance altering alcohol and/or drug is not allowed. A resident who refuses to sign a contract or violator is notified of consequences - completed by SW. A resident who fails to comply will be given discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility. A) First violation will result in counseling and random urine toxicology no less than once a week. B) Second violation will result in revocation of visitation and placed in a secure unit. C) Third violation will result in discharge planning in accordance with facility policy and government regulations, based upon the danger to self and others in the facility. 1. Additional EDUCATION implemented by AHPECF are: A) Identifying Signs and Symptoms of Drug abuse B) Medical and Nursing department re-educated on the use of [MEDICATION NAME] C) High Alert List (History of Polysubstance Abuse) ? Orange Binder D) Recognizing Drug Seeking Behaviors E) Education for Security Department consists of Resident?s Delivery Log and Resident?s Incident Report. 2. Additionally POLICIES created and/or revised implemented by AHPECF to are: A) Management of resident with a history of substance abuse B) Resident with Alcohol and other drug problems C) Contraband ELEMENT NUMBER FOUR (#4) FACILITY'S PLAN TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: To ensure the corrective actions are monitored and to ensure deficient practices will not recur, AHPECF has created several tools to check and monitor residents on the High Alert List. These tools/ audit measuring devices are completed by Nursing, Social Work, Security, and other disciplines as needed. Documentation is kept daily, monthly, and quarterly as needed. Below is a list of tools used to ensure deficient practices will not recur: 1. Nursing daily observation tool (Identify any change in resident's L(NAME)) 2. Room Search Tool - (Identify any suspicious objects found in the resident's room) 3. Security - Returning resident tool (Identify any change in resident's status after Out of Facility) 4. Contracts - (Identify any resident who refuses to sign a contract, will then initiate policy) Another corrective action to ensure deficient practices will not recur is, AHPECF Quality Assurance Performance Improvement (QAPI) department will randomly check each department to make sure procedures developed/tools/audits are being used correctly. QAPI will monitor this monthly, document findings, and bring them to monthly QAPI meetings. Non-compliance will be addressed by re-education and further disciplinary action to staff as needed. CONSULTING GROUP The date Consulting began with the Group Nash Healthcare, Instructors: GN, HP, and LG are 3/21/22. The exact dates and times of the Direct In-services and continued facility in-services will be documented in a letter on facility letterhead as discussed with DOH on 4/6/22. DATE OF CORRECTION Date for Correction - 4/29/22 and the responsible party for the P(NAME) is: ELEMENT NUMBER FIVE (#5) RESPONSIBLE PARTIES FOR CORRECTIVE ACTION IMPLEMENTED: The Administrative team, specifically Administrator, DON, and Medical Director |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details Based on record review and interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, there was no documented evidence that the Legionella Water Management Plan and Environmental Assessment were reviewed and/or revised annually. The finding is: The facility's policy/procedure titled Legionnaires Disease, last reviewed 11/12/2021, documented an Environmental Assessment will be performed using the New York State Department of Health (NYSDOH) form. The assessment will be reviewed/updated annually and as needed. Records pertaining to the environmental assessments, sampling and management plan, including sampling results, will be retained by the Director of Maintenance. The last facility's Legionella Water Management Program document was dated (no month) (YEAR). The Director of Engineering On 3/3/2022 at 9:05 AM was interviewed. The Director of Engineering stated a new contractor took over the Legionella water management contract in (MONTH) 2021. Prior to (MONTH) 2021 the water management contract was with another contractor. The Director of Engineering stated the water management plan document in the facility for the potable water system was dated (YEAR) from the former contractor. The Director of Engineering stated when the new contractor took over in (MONTH) 2021, they did not provide a new water management plan. The Director of Engineering stated they (Director of Engineering) were not aware that the water management plan had to be reviewed and/or revised on an annual basis and was not clear if the environmental assessment was done by the water management company or by building staff. The Director of Engineering stated that they (Director of Engineering) were unfamiliar with the NYSDOH Environmental Assessment form. The Director of Engineering was re-interviewed on 3/4/2022 at 10:39 AM and stated they (Director of Engineering) spoke to the new water management contractor on 3/3/2022. The Director of Engineering stated that the water management plan was not part of the new company's contract and will now be done by the new water management company along with the environmental assessment. The Administrator was interviewed on 3/8/2022 at 2:21 PM. The Administrator stated there is a new Legionella water management contractor and the water management plan and environmental assessment will be reviewed and /or revised on an annual basis going forward. | Plan of Correction: ApprovedApril 7, 2022 I 210 Infection Control There was no documented evidence that the Legionella Water Management Plan and Environmental Assessment were reviewed and/or revised annually. This issue did not relate to any individual/resident. No resident was harmed from this issue. The following corrective action was implemented: 1. The facility?s Water Management Plan, (WMP) was amended effective 10/14/2019 by our vendor at that time, with addendum entitled ?Cooling Tower Maintenance Program and Plan.? 2. On 3/4/22, the complete WMP was provided to current vendor for review and updating for 2022. Their proposal was received/approved and purchase order issued to vendor for this work. Completion date: 4/14/22 3. The facility?s Environmental Assessment was reviewed and updated for 2022 by the Director of Engineering and the Administrator. Completion date: 3/31/2022 The following procedural changes were implemented to ensure continued compliance: 1. The Administrator and the Director of Engineering reviewed the facility's Infection Prevention and Control Policy/Procedure - Legionnaires Disease for Engineering/Maintenance Department's role in the facility's water management program. 2. The WMP and EA have been added to the preventative maintenance schedule for annual review/update in March, and as needed to reflect any changes in potable water or cooling tower systems. Completion date: 3/31/2022 To Monitor compliance and performance AHPECF WMP and EA will be submitted to QA Committee - for 2022, on receipt from vendor, and annually thereafter, or as updated to reflect any changes in potable water or cooling tower systems. Completion date: 3/31/2022 The Director of Engineering is responsible for implementing these corrective actions and ensuring continued compliance. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey initiated on 3/1/2022 and completed on 3/9/2022, the facility did not ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was identified on one of thirteen units reviewed for the Medication Storage task. Specifically, Resident #364 was administered [MEDICATION NAME] ([MEDICAL CONDITION]) 0.5 milligrams (mg) without accurate reconciliation on the Control Substance Administration Record (Narcotic Sheet). The finding is: The facility's undated Medication Administration Policy and Procedure documented upon removal of the controlled substance from the container the nurse must record the date, hour, amount used, signiture and the amount of the controlled substance remaining on the Controlled Substances Administration Record form. The nurse. The Policy further documented the nurse administer the medication per the policy then documents the date and time on the Medication Administration Record. Resident #364 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. The MDS documented the resident received Antianxiety medication for the seven days during the assessment look back period. During a Medication Storage observation on 3/7/2022 at 12:05 PM on nursing unit 31, the unit medication cart was observed, including the Narcotic medications in the cart. Resident #364's Controlled Substance Administration Record for [MEDICATION NAME] was reviewed. The Controlled Substance Administration Record documented that the last [MEDICATION NAME] tablet was administered on 3/6/2022 at 8:00 PM. The amount of the [MEDICATION NAME] medication remaining on the Controlled Substance Administration Record was documented to be 22 tablets. However, the [MEDICATION NAME] medication tablets remaining in the blister pack were 21 tablets. The Medication Administration Record [REDACTED]. The Licensed Practical Nurse (LPN) #3 was interviewed on 3/7/22 at 12:15 PM and stated they (LPN #3) had administered the medication to Resident #364 at 8:00 AM on 3/7/22 but did not sign the Controlled Substance Administration Record. LPN #3 stated when they (LPN #3) removed the tablet from the blister pack, they (LPN #3) should have signed the Control Substance Administration Record and after administering the medication they should have signed the MAR. The Registered Nurse (RN) #6, who was the Nurse Manager, was interviewed on 3/7/22 at 12:20 PM and stated that all the nurses are instructed to sign the Narcotic Sheet after removing the narcotic medication from the blister pack. RN #6 stated that LPN #3 should have signed the Controlled Substance Administration Record at the time the tablet was removed from the blister pack and should have signed the MAR indicated [REDACTED] The Director of Nursing Services (DNS) was interviewed on 3/9/2022 at 1:23 PM and stated when LPN#3 removed the medication from the blister pack LPN #3 should have signed the Control Substance Administration Record right away. After administering the medication to the resident, LPN #3 should have signed the MAR. 415.18(b)(1)(2)(3) | Plan of Correction: ApprovedApril 7, 2022 F755- 493.47(a)(b)(1)-(3) Pharmacy/Srcvs/Procedures/Pharmacist/ Records AHPECF provides pharmaceutical services, including following procedures that assure the accurate acquiring, receiving, dispensing, and administering of all resident's drugs and biologicals) needs are met. To correct the deficiency related to resident #364, staff LPN#3 gave control substance medication and did not sign the medication record after administering the medication. AHPECF immediately re-educated LPN#3 on signing directly after medication is given. Staff was also written up for a medication error. This was an isolated issue with one nurse and no resident was harmed from this error. AHPECF further undated Medication Administration Policy and Procedure documented upon removal of the controlled substance from the container the nurse must record the date, hour, amount used, signature and the amount of the controlled substance remaining on the Controlled Substances Administration Record form. The Policy further documented the nurse administers the medication per the policy then documents the date and time on the Medication Administration Record. The resident was not harmed nor was any other resident harmed by this issue. The Corrective action taken by AHPECF to insure other residents that could be affected by the practice are as follows: 1) The facility immediately intervened and assuring staff LPN #3 was instantly re-educated on the importance of signing for medication after dispensing/giving any resident his/her medication. 2) The facility then re-educated all LPNs and RNs on the need of signing directly after medication is given. 3) The facility additionally instituted disciplinary action to LPN #3 for this error. Below is a list of measures/actions and systemic changes taken by AHPECF to identify other residents having the potential to be affected by this same issue are safe: 1) The facility re-education of all nurses on all shifts. 2) The facility will ensure along with re-education, all nurses complete an annual medication pass which includes reviewing of the nurse signing immediately after medication is given to the resident 3) Facility updated the medication control drug policy indicated staff signing/documenting immediately after medication and narcotic administration. 4) Nurses are re-educated on checking MAR for missing signatures at the end of each shift. To ensure the corrective actions are monitored and to ensure these practices will not recur, AHPECF has taken the following steps: 1) Monthly random audits will be conducted by the Nursing Supervisor to insure all MARs and narcotic sheets are signed on every shift. 2) QAPI will conduct their own random documented survey. 3) QAPI will also keep this issue on the QAPI monthly agenda as needed. Date for Correction - 4/29/22 and responsible party for the P(NAME) is: The Director of Nursing (DON) |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details 2012 NFPA 101:19.3.6.2 Construction of Corridor Walls. 19.3.6.2.1 Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8. 19.3.6.2.2* Corridor walls shall have a minimum 1/2-hour fire resistance rating. 19.3.6.2.3* Corridor walls shall form a barrier to limit the transfer of smoke Based on observation and staff interview, the facility failed to ensure that corridors were constructed to limit the transfer of smoke. This occurred on the 3rd floor, 1st floor and the basement of the facility. On 3/1/2022 to 3/4/2022 between the hours of 8:45am and 4:30pm during the life safety recertification survey, the following was noted. On Unit 11, the IT closet adjacent to the Nursing Station contained 2 unsealed pipe penetrations. On Unit 31, the IT closet adjacent to the Nursing Station contained unsealed wire penetrations. In the basement in the C Way, unsealed pipe penetrations were observed in the corridor walls near the ceiling, adjacent to the old pharmacy and across from the elevator bank. In an interview with the Director of Environmental Services on 3/1/2022 at 2:00pm, they stated they can seal the holes. In an interview with the Director of Environmental Services on 3/3/2022 at 11:15am, they stated they will let the Supervisor of Plant Operations know of the issue. 2012 NFPA 101 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedApril 5, 2022 K362 NFPA 101 Corridors- Construction of Walls 1. No residents were affected by this deficient practice. 2. Perpetrations were identified in Unit 11 IT closet adjacent to the nurses station, Unit 31 IT closet adjacent to the nurses station, and in basement C Way, were corrected and immediately sealed, and exposed wires were insulated. The insulation that was used to fill these penetrations was Handi Foam Fire Block #P 3G fire blocking compound. 3. The director of engineering or designee will be responsible to make random rounds to different areas in the building to check locations for exposed penetrate and immediately repair them. 4. Director of engineering is responsible for ensuring the corrective action is implemented 5. The Director of engineering will report findings to the Administrator. The Administrator will report findings to the monthly QAPI meeting. Correction date: 4/29/2022 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details 2012 NFPA 101: 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. 2012 NFPA101: 7.2.1.6.1 Delayed-Egress Locking Systems. 2012 NFPA101: 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTILALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS This requirement is not met as evidenced by: Based on observation, and staff interview during the recertification survey it was noted that unapproved hasps and locks were used to lock accessible egress doors on 6 un-occupied units/wings inspected for compliance. The findings are: During the Life Safety Code survey on 3/1/2022 to 3/4/2022 between 8:45am and 4:30pm, it was noted that the egress doors to unoccupied units/wings were kept locked with hasps and locks. Examples included Units/Wings 26, 25, 23, 36, 35 and 45. All of the identified unit/wings are accessible from resident use areas via emergency exit stairwells located within them. The locked egress doors could prevent egress if resident, staff or visitors accessed the locked units/wings via the emergency exit stairwell within. During the Life Safety Code exit conference on 03/04/2022 at 3:30pm, the facility attending personnel were made aware of the issue. 2012 NFPA 101 NYCRR 711.2(a) 10 NYCRR 415.29 | Plan of Correction: ApprovedApril 5, 2022 K222 - Egress Doors No residents were affected by this deficient practice. 1. AHP took measures that were implemented by the director of engineering were to contact the locksmith to replace all hasps and locks. 2. The locksmith will install new hardware/locks according to the rules and regulations noted, on units 26,25,23,36,35,and 45. 3. The director of engineering or designee will ensure work is completed and up to codes and regulations. 3a. The measures that the facility will take to ensure that the problem does not occur again, the director of engineering will do weekly rounds to ensure all items are completed and up to standards and regulations as per the deficiency, also coordinate the trades schedule to do the work and there time frame. 4. The director of engineering will report completion of the work to the Administrator. The Administrator will report findings at our monthly QAPI meetings. Correction date:4/29/2022 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 25, 2022
Corrected date: June 3, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and documentation review during the recertification survey, the facility was not provided with a conforming 2012 NFPA 99 - Health Care Facilities and 2011 NFPA 70 - National Electrical Code Conforming Type 1 Essential Electrical System (EES) in that Life Safety Branch wiring was not separated from Critical System Branch wiring. This was noted for Unit 22 of the A building that has a certified ventilator unit that utilizes life support equipment. The findings are: During the Life Safety Code inspection on [DATE] to [DATE] between of 8:45am and 4:30pm, it was noted that resident rooms on Unit 22, that has residents requiring life support equipment, was not provided with a 2012 NFPA 99 - Health Care Facilities and 2011NFPA 70 - National Electrical Code conforming Type 1 Essential Electrical System. The Essential Electrical System contained loads from both the Life Safety Branch and the Critical System branch (CS). Examples include the following: 1) Emergency power panel EL-201 located in the ventilator unit, Unit 22, contained loads from both the Life Safety Branch (Emergency Lighting) and the Critical Branch (Nurse Call). 2) Emergency power panel EL-201A located in the ventilator unit, Unit 22, contained loads from both the Life Safety Branch (Oxygen Control Panel) and the Critical Branch (Room Receptacles). At the time of the survey, it was noted that the facility has 21 certified ventilator beds with a current census of 10 residents requiring life support equipment (electrically connected ventilators). In an interview on [DATE], at 10:45am, the Administrator stated that the facility had a time limited waiver for the installation of a Type 1 Essential Electrical System that expired and that an extension for the waiver was filed with the Bureau of Architectural and Engineering Review (BAER). The Administrator further stated that the work to complete the separation of the wiring and for a new generator hasn't commenced. A review of BAER records on [DATE] revealed that a time limited waiver for this issue expired on [DATE]. 2012 NFPA 101 2012 NFPA 99 NYCRR 711.2(a) 10 NYCRR 415.29**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and documentation review during the recertification survey, the facility was not provided with a conforming 2012 NFPA 99 - Health Care Facilities and 2011 NFPA 70 - National Electrical Code Conforming Type 1 Essential Electrical System (EES) in that Life Safety Branch wiring was not separated from Critical System Branch wiring. This was noted for Unit 22 of the A building that has a certified ventilator unit that utilizes life support equipment. The findings are: Based on record review during an offsite post survey revisit on [DATE], the facility was not provided with a 2012 NFPA 99 - Health Care Facilities and 2011NFPA 70 - National Electrical Code conforming Type 1 Essential Electrical System for resident on life support equiment. The facility could not provide an approved Time Limited Waiver from CMS to address this issue as indicated on their Electronic Plan Of Corrections. The facility was cited for the following during the [DATE] recertification survey: The findings are: During the Life Safety Code inspection on [DATE] to [DATE] between of 8:45am and 4:30pm, it was noted that resident rooms on Unit 22, that has residents requiring life support equipment, was not provided with a 2012 NFPA 99 - Health Care Facilities and 2011NFPA 70 - National Electrical Code conforming Type 1 Essential Electrical System. The Essential Electrical System contained loads from both the Life Safety Branch and the Critical System branch (CS). Examples include the following: 1) Emergency power panel EL-201 located in the ventilator unit, Unit 22, contained loads from both the Life Safety Branch (Emergency Lighting) and the Critical Branch (Nurse Call). 2) Emergency power panel EL-201A located in the ventilator unit, Unit 22, contained loads from both the Life Safety Branch (Oxygen Control Panel) and the Critical Branch (Room Receptacles). At the time of the survey, it was noted that the facility has 21 certified ventilator beds with a current census of 10 residents requiring life support equipment (electrically connected ventilators). In an interview on [DATE], at 10:45am, the Administrator stated that the facility had a time limited waiver for the installation of a Type 1 Essential Electrical System that expired and that an extension for the waiver was filed with the Bureau of Architectural and Engineering Review (BAER). The Administrator further stated that the work to complete the separation of the wiring and for a new generator hasn't commenced. A review of NYSDOH records revealed that the facility application for a time limited waiver to address this issue is pending approval. 2012 NFPA 101 2012 NFPA 99 NYCRR 711.2(a) 10 NYCRR 415.29 | Plan of Correction: ApprovedJune 6, 2022 K 915 ? Type 1 Essential Electrical System 1. No residents were affected by this deficiency. 2. Type 1 Essential Electrical System needed to conform to 2012 NFPA 99 and 2011 NFPA 70 3. The Type 1 Essential Electrical System project is slated to begin on (MONTH) 18, 2022. Lizardos and Wiedersum have completed drawings for the multi-prime project (per Wicks Law), which will be monitored by the A&E team. The project is funded through the Statewide Transformation 1 grant and has an anticipated completion date of (MONTH) 30, 2022. 3A. 4. All electrical items that were deficient will be corrected by this company, slated to start (MONTH) 25th 2022. They were informed of the deficiencies stated and will address theses situations when they start their work. The electrical contractor, was informed to file a time limited waiver for this particular job, from the Bureau of Architecture and Engineering by (MONTH) 9th 2022 There will be an project manager on site daily, from the company, directing the project, until completion, with weekly meetings, on how the project is moving along, until completion. 5. The director of engineering will be responsible to coordinate with the project manager overseeing the electrical project. 6. The director of engineering will give weekly updates on this project to the administrator until completed. The administrator will give monthly updates to the QAPI committee. Date of correction: 05/9/2022 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: May 8, 2022
Citation Details 2010 NFPA 110: 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. Based on observation, documentation review and staff interview, the facility failed to ensure that emergency generator shut off switches were located outside the room housing the prime mover and that the transfer time for the emergency generator was within 10 seconds. This occurred for 4 of 4 generators that supply emergency power to the facility. During the Life Safety Code recertification survey conducted on 03/01/2022 to 03/04/2022, between the hours of 9:00AM - 4:00PM, it was observed that the three emergency generators located in the Facility's basement (serving the A -Building, B/C Building and D Building), have manual stop stations fixed to the wall inside the rooms housing said generators and not outside the rooms. On 3/4/2022 between 8:45am and 4:00pm the generator testing logs were reviewed. It could not be determined that the transfer time for emergency power occurred within 10 seconds. This was noted for the emergency generator testing logs for the year of 2022. In a interview on 3/3/2022 at 12:00pm, the Supervisor of Plant Operations stated that all the generators located within the basement contain shut off switches within the rooms that house the generators. In an interivew on 3/4/2022 at 4:00pm, the Administator, Director of Environmental Services and the Supervisor of Building Operations were made of aware of the generator issues. 2010 NFPA 110 2012 NFPA 101 10 NYCRR 711.2(a)(1) | Plan of Correction: ApprovedMay 2, 2022 918 - NFPA 101 Electrical Systems - Essential System Maintenance and Testing 1. No residents were affected by this deficient practice. 2. The measures that were implemented are as follows: A. The cut off switches for the outside of the generators have been ordered. B. PO 73 has been issued to vendor. The company doing the installation of the outside switches of the generator room is Magna IV Inc, 96 Inverness Drive East,(NAME) CO. The work has been scheduled for immediate installation as soon as the parts come in, with expected completion by 5/8/2022. C. When installation and inspection complete, electrical supervisor will inform the administrator. D. The electrical supervisor will test the newly installed switches and keep a log as per manufacturer's recommendations. E. The director of electrical shop is responsible to ensure this deficiency is corrected. 3. Generator testing logs were revised to include transfer time for emergency power. A copy of test logs will be given to the administrator. 4. The director of engineering will be responsible for this deficiency. 5. The administrator will report findings at the monthly QAPI meeting. Correction date:05/8/2022 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2010 NFPA 72: 14.3 Inspection. 14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. Based on observation, record review and staff interview, the facility failed to ensure that the fire alarm system was inspected, tested and maintained in accordance with NFPA 72, 2010 edition. This occurred for the fire alarm system that serves the entire facility. On 3/1/2022 to 3/4/2022 between the hours of 8:45am and 4:30pm during the life safety recertification survey, the following was noted. Upon review of the fire alarm system testing documentation, it could not be verified that all smoke detectors had been tested semi-annually for the year of 2021. Additionally, third-party vendor documents dated 1/7/2022 and 4/6/2021 were provided for the sprinkler system tamper and water flow switch testing. The inspection results summary stated 3 tamper switches and 1 water flow switch tested on [DATE] and on 1/7/2022, had failed to report to the fire alarm control panel. In an interview on 3/4/2022 at 12:28pm the facility staff that oversees the sprinkler and fire alarm testing stated that there was no smoke detector testing done in 2021. The facility used a new 3rd party vendor and they have not released the report because it is in litigation. Additionally, they stated they are aware of the issues with the sprinkler tamper and flow switches not relaying to the fire alarm control panel, but the valves are locked and chained. They have submitted the requisition for the vendor to fix the issues, but the requisition has not been approved yet. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1) | Plan of Correction: ApprovedApril 5, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K345 Fire Alarm System and Testing and Maintenance No residents were affected by this deficient practice. 1.Smoke detector testing was conducted by the prior 3rd party vendor, however, the test report has not been released due to on-going legal issues. 2. Fire Alarm Testing P(NAME): To ensure A. Holly Patterson?s fire alarm equipment is tested and maintained according to code, a blanket order has been created to retain (NAME)son Controls as the facility?s primary testing and maintenance vendor. 3. Sprinkler System Deficiency: 3 tamper switches tested on [DATE] and on 1/7/2022 failed to report to the FACP: AHP P(NAME): The following tamper devices were repaired on (MONTH) 22, 2022 and now report to the FACP as required ? A Building East PIV IO53; A Building West PIV IO54; D-Building tamper switch I063; all chains have been removed. 4. Sprinkler System Deficiency: 1 water flow device tested on [DATE] and on 1/7/2022 did not report to FACP. AHP P(NAME): The Fire Alarm vendor will begin troubleshooting the device to trace power source on 4/1/2022; The estimated date of correction is (MONTH) 4, 2022. 4a.The director of engineering along with the safety officer, will conduct random audits on all floors concerning these issues related to the deficiency's and report back to the administrator. 5. The director of engineering or his designee during weekly rounds will report any findings to the administrator. The administrator will report findings to the QAPI committee. 5A. The director of engineering is responsible for ensuring this corrective action is implemented. Please note: (NAME)son & (NAME)son our fire alarm company was just here to test all smoke detectors and found no problems. Correction date: 04/29/2022 |
Scope: N/A
Severity: N/A
Citation date: March 9, 2022
Corrected date: May 8, 2022
Citation Details 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel, and the public. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey it was noted that the nursing home building was not maintained in good repair. Reference is made to peeling and flaking paint in emergency exit stairwells, in utility rooms, storage closets, and in common use areas. Additionally, leaking plumbing pipes were noted in the basement. The findings are: During the environmental survey on 3/1/2022 to 3/4/2022 between 8:45am and 4:30pm, the following was noted: 1. Peeling and flaking paint was noted in the following areas: - Emergency exit stairwell from unit 42 and 22, and from Unit 21 and 11. - The ceiling of the Auditorium - Unit 22 common toilet room - Unit 15 Housekeeping Closet, and Litigation Medical Records storage closet. - Unit 17 clean linen closet - Unit 16 clean linen closet - Unit 11 common shower room 2. Active leaks were observed from the plumbing pipes located in the ceiling space of the B-West corridor and at the intersection of the C and A corridors. In an interview on 03/02/2022 at 3:15pm, the Superintendent of Plant Operations and Maintenance, acknowledged the flaking and peeling paint, and stated that the maintenance department was dispatched to address the issue. In a separate interview on 03/03/2022 at 11:15am, the Superintendent of Plant Operations and Maintenance acknowledged the leaking plumbing pipes and stated that they will need to be addressed. 415.29 (h)(1)(2) | Plan of Correction: ApprovedMay 2, 2022 The AHPECF during survey on 3/1/22 to 3/4/22 under FTAG 415.29 had residents affected by this deficient practice. To address these issues the facility implemented the following: 1. The director of engineering or designee will make weekly rounds for the next 3 months in the emergency exit stairwells, noted utility rooms, storage closets, and common areas to ensure that all walls are painted. 2. Plumbing Supervisor has addressed the leaks in B-West corridor by requesting proposals for repairs from three vendors. 2a. The contractor was selected and P.O.# 86 has been issued. Repairs were started on (MONTH) 27th 2022, with completion date expected by (MONTH) 8, 2022. 3. The person responsible for ensuring correction of this deficiency is the director of engineering. 4. The director of engineering will report any findings to the Administrator. The Administrator will report these findings to our monthly QAPI meetings. Correction date: 5/08/2022 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details 2012 NFPA101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5 2010 NFPA 13: 8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development. 8.5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2. 8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. 8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. Based on observation and staff interview, the facility failed to ensure that the facility was fully sprinklered in accordance with NFPA 101, 2012 edition and NFPA 13, 2010 edition. This occurred on the 1st floor and in the basement of the facility. The findings are: On 3/1/2022 to 3/4/2022 between the hours of 8:45am and 4:30pm during the life safety recertification survey, the following was observed. In the Honey Auditorium, a storage closet located behind the stage did not contain sprinkler coverage. On Unit 12, Office #121 lacked sprinkler coverage. The basement air handler room adjacent to room A5, contained ductwork greater than 4ft in width that obstructed sprinkler coverage to the area below. In an interview on 3/2/2022 at 2:45pm, the Director of Environmental Services stated they were unaware the closet existed and will address the sprinkler issues. 2012 NFPA 101 2010 NFPA 13 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedApril 22, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 351 - Sprinkler System - Installation 1. No residents were affected by this deficiency practice. 2. The closet behind Honey auditorium stage was removed on 3/5/22. room [ROOM NUMBER] (unit 12) closet doors were removed on 3/5/22. 3. Basement Air Handler room adjacent to room A5 contained ductwork greater than 4ft in width, which obstructed sprinkler coverage. The vendor, (NAME)son Controls, was called in 3/31/22 to assess and provide quote for correction of the issue, to alleviate the sprinkler head obstruction. The estimated date of completion is (MONTH) 29, 2022. 3a. The director of engineering will monitor and evaluate the time frame and the schedules of the vendors that have been called to repair the deficiency. 4. The director of engineering or designee will report findings to the administrator upon completion. Administrator will report findings to QAPI. 4a.The director of engineering and the safety officer is responsible for this deficiency. Note: we have schedule the trades to come in and repair indicated deficiency issues, 4b. All audits will be conducted by the director of engineering, throughout the building, which will be done every week, for 3 months. The audits done so far, did not indicate any additional sprinkler deficiency's. All other sprinklers inspections were up to code. 4c. The director of engineering will perform weekly audits for 3 months, in various areas of the basement to included the mentioned deficiency area, and other areas to ensure that all areas fall into compliance, following all rules and regulations, and the completion of mention deficiency. Date of correction: 04/29/2022 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details 2012 NFPA101: 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). Based on observation and staff interview, the facilty failed to ensure that smoke barriers were constructed to have a ½ hour fire resistance rating. This occurred in the basement of the facility. The findings are: On 3/3/2022 between the hours of 8:45am and 4:30pm during the life safety recertification survey the following was observed. In the A Building basement, the smoke barrier doors near the classroom contained unsealed conduit penetrations. In the D Building basement, the smoke barrier doors near the generator room contained unsealed conduit penetrations. In an interview on 3/3/2022 at 11:40am, the Supervisor of Plant Operations stated they will order some firestopping to seal the holes. 2012 NFPA 101 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedApril 11, 2022 K372 NFPA 101- Subdivision of Building Spaces - Smoke Barriers 1. No residents were affected by this deficient practice. 3. The identified areas: building A basement smoke barrier doors near the classroom, and building D basement smoke barrier doors near the generator room, contained unsealed conduit penetrations which will be re-sealed with 3M Fire Red Barrier Sealant-CP-25WB-4hr Rated-ASTM-E814(UL1479)-ASTM E84(ul723)compound. 4. Any other penetrations identified by director of engineering or designee during building rounds will be repaired immediately. The administrator will report these findings to the monthly QAPI meeting. 5. The facility director of engineering will check the above quarterly to ensure that the above problem does not recur. The director of engineering will report findings and repairs to the administrator. Correction Date: 04/29/2022 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2022
Corrected date: April 29, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required. (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.4.3.4* Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2012 NFPA 101: 8.5.4.1 Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of ¾ in (19 mm). 2012 NFPA 101: 8.3.3.2.3 Labels on fire door assemblies shall be maintained in a legible condition. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. 2010 NFPA 80: 4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly. 2010 NFPA 80: 6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1?8 in. ± 1?16 in. (3.18 mm ± 1.59 mm) for steel doors and shall not exceed 1?8 in. (3.18 mm) for wood doors. This standard is not met as evidence by: Based on observation and staff interview the facility did not assure that smoke door assemblies were maintained without gaps between the door leaves to resist the movement of smoke, and with legible Fire Resistance Rated labels. The findings are: During the Life Safety Code recertification survey conducted on 03/01/2022 to 03/04/2022, between the hours of 9:00AM - 4:00PM, it was observed that smoke barrier swinging doors did not close completely when manually released. A gap of approximately 1/2 inch, was observed between the meeting edges of the doors. This was noted for smoke door by room [ROOM NUMBER] on unit 21 of Building A, and for smoke door on unit 16 of Building D. During the Life Safety Code recertification survey conducted on 03/01/2022 to 03/04/2022, between the hours of 9:00AM - 4:00PM, it was observed that Fire Resistance Rated labels on smoke barrier doors were painted and not legible. This was noted for smoke door by room [ROOM NUMBER] on Unit 43 of Building B and smoke door on Unit 46 of Building D. These findings were acknowledged by the Building Operations & Maintenance Superintendent and by the Director of Environmental Services who were both present at survey time and who said they will fix it. 2012 NFPA 101: 19.3.7.8, 8.3.3.2.3, 8.5.4.4, 7.2.1.15.2. 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1*, 4.2.2., 6.3.1.7.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedApril 5, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K374 - NFPA 101 Subdivision of Building Spaces- Smokes Barrier Doors 1. No residents were affected by this deficient practice. 2. Measures that were put into place: 1) the director of engineering re-adjusted and re-aligned all concerned smoke barrier swinging doors; 2)smoke door by room [ROOM NUMBER] on unit 21 of building A, and smoke door on unit 16 of building D - astracles were installed where a gap of 1/2 inch was identified by director of engineering; 3) smoke barrier doors on unit 43 by room [ROOM NUMBER] of building B, and smoke door on unit 46 of building D, where the fire resistance rated labels were painted, director of engineering removed the paint from the labels with paint remover. 3. During rounds the director of engineering or designee will check doors for painted labels, and create a list for the painters to remove the paint from the labels. 5. The facility director of engineering will check the smoke barrier doors quarterly to ensure that the above problem does not recur. The director of engineering will report findings and repairs to the administrator. 4. The director of engineering will report findings to the administrator. The administrator will report findings at the next monthly QAPI meeting. Correction date:04/29/2022 |