Bethel Nursing Home Company Inc
April 17, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not review and revise the comprehensive person-centered care plan for 2 of 2 residents reviewed for accidents (#16 and #19). It was determined that, (1.) Resident #16 - thorough investigation and root-cause analysis were not conducted to determine the cause of the fall in order to identify and implement appropriate interventions to prevent or minimize recurrence and avoid serious injuries; and (2.) Resident #19 (Complaint #NY 287) - the care plan was not revised to reflect the type and level of care related to transfer, to and from the bed or chair, in accordance with the comprehensive assessment. The findings are: 1. Resident #16 is a [AGE] year old female and was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) of 10/26/17 indicated that the resident had moderately-impaired cognition; required extensive assistance with 1-2 persons in most aspects of activities of daily living; was on antipsychotic, antidepressant and anticoagulant medications for the last seven days of the assessment period; and did not have any falls since the last admission or prior assessment. The nursing progress notes of 1/9/18 indicated that at approximately 8:40 PM, an alarm and a thump was heard at the nurses' station. The nursing staff responded to the resident's room and found the resident on the floor with face her down. First aid treatment was provided, 911 call was initiated and the resident was transferred to the hospital. The resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was subsequently assessed on the Annual MDS of 1/22/18 and indicated that the resident had moderately impaired cognition (decision poor; cues/supervision required); no mood or behavior problems; required extensive assistance with bed mobility, transfer, dressing and personal hygiene; was taking antipsychotic, anticoagulant and diuretic medications for the last seven days of the assessment period; and had a fall that resulted in a major injury. The care plan for Falls last updated on 3/7/18 indicated the resident has had an actual fall related to history of falls, decreased cognition, [MEDICAL CONDITION] and anxiety. The fall history documented on the care plan indicated that since (MONTH) (YEAR) the resident has had no falls. No new and appropriate interventions were developed to address the circumstances surrounding the fall of 1/9/18 that resulted in a serious injury. Review of the monitoring notes pertaining to the previous falls care plan indicated that the last fall the resident had prior to 1/9/18 was on 12/14/16 where she was found on the floor mat next to her bed without any injury. Review of the interventions enumerated in the care plan included were but not limited to monitor resident closely for attempts to get up without assistance in order to establish a behavior pattern, consult with pharmacy/physician regarding medication side effects as needed, and anticipate resident's needs. The newer interventions included wheel chair alarm, non-skid socks, bed alarm, get the resident up first in the morning, floor mats and perimeter mattress, toilet first on rounds, safety checks every two hours and if restless offer resident option to sit up in the wheelchair and monitoring to done by nurses. There was no documented evidence that the facility conducted a review and root-cause analysis of these interventions before the falls and determine whether these new interventions were appropriate in accordance with the resident's condition, assessed risk and outcome of investigation. The ADON was interviewed on 4/13/18 at 10:49 AM regarding which of the new interventions were identified to be the appropriate interventions initiated following the 1/9/18 fall, she stated she knows the floor mats were new but she couldn't say what else was added based on that particular fall. The acting director of nursing (ADON) and the day shift Registered Nurse were interviewed on 4/13/18 at 11:00 AM as to the probable cause of the incident of 1/9/18. They stated that the resident apparently was sitting by the nursing station and then wheeled herself into the dining room without anyone realizing she had done so. They stated that the resident fell in the dining room and sustained a major injury. The RN supervisor who was working the night the resident fell was interviewed 4/13/18 at 12:15 PM and she stated that the resident got up from her wheelchair and fell . She stated that the resident has periods of quiet inactivity and can suddenly have periods of great activity. She stated that when that happens the resident can move very quickly in her wheelchair. She stated the resident was sitting by the nursing station charting on some records. The nurse stated that from where she was sitting, her view of the resident was obstructed due to the manner the nursing station was constructed. This RN did not know that the resident made her way to the dining room which is a short distance from the hallway. The RN stated she heard the chair alarm and ran to find the resident on the floor. She stated that the other CNAs (Certified Nurse Aide) were with other residents getting them ready for bed. The administrator was interviewed on 4/13/18 at 3:00 PM and she stated that there was no additional information she could provide. She stated it was a witnessed fall and did not think there was a need for more information. (The fall was recorded as unwitnessed). The assigned 3-11 shift CNA was interviewed on 4/13/18 at 3:15 PM she stated that the resident is pretty active and could wheel herself all around the floor. She stated further that the resident sits in her spot by the nurses station. She stated that on the night the resident fell , she (the CNA) was caring for another resident and she did not witness what happened. Review of the incident/accident report revealed that it did not include a root cause analysis and evidence that the care plan interventions that were in place at the time of the fall and the new interventions were appropriate to prevent further recurrence.
2. Complaint #NY 287 Resident #19 is a [AGE] year-old female and was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS dated [DATE] documented that the resident has moderately impaired long and short-term memory problems, was totally dependent on two persons for bed mobility and required extensive assistance with two persons for transfers. The CNA tracker of 9/1/17 to 11/6/17 showed inconsistencies in the level of staff assistance that the resident required with transfers and bed mobility. The care tracker showed that the CNAs provided varying levels of assistance with transfer and bed mobility from 1 to 2 persons on multiple occasions during this time period. The CNA Accountability Guide dated (MONTH) (YEAR) indicated the resident required extensive assistance and did not indicate the specific number of persons required to provide assistance to the resident. Transfer was recorded as requiring extensive assist of one person contrary to the above MDS assessment. The resident's care plan and the CNA care guide did not match or accurately reflect the type and level of care to be provided to the resident based on comprehensive assessment and MDS. The nurse's notes dated 11/5/17 at 11:30 PM indicated the resident was checked on rounds and a small red circle was noted on the left knee which was warm to touch and no swelling was noted. On 11/6/17 at 10:30 AM, the nurses note further documented the resident was observed with red circle on left leg that appears to look like a puncture wound. The resident's left leg was noted with internal rotation and plantar flexion. The physician was then called and ordered to transfer the resident to the hospital for further evaluation at that time. The hospital discharge record revealed the resident had an open reduction internal fixation of the [MEDICAL CONDITION] femur. The physician in the hospital documented there was no evidence of abuse or neglect and that the fracture could have been a result of severe [MEDICAL CONDITION] and osteopenia. The incident/Accident (IA) report dated 11/6/17 indicated that a Certified Nursing Aide (CNA) reported on 11/5/17 at 10:55 PM that the resident was observed with facial grimacing when she was giving cares and reported it to the evening Registered Nurse (RN #1) supervisor. The section of the I/A report that indicated whether the care plan was followed and if any interventions were taken by staff was left blank. The assigned CNA was interviewed on 4/13/18 at 3:10 PM and she stated she is the resident's regular CNA and has known the resident for many years. She stated she did not notice anything different when she put the resident back to bed before dinner. She stated she only noticed the facial grimacing at around 10 PM during cares and reported it to the supervisor. She stated she transferred the resident by herself to bed because the resident was assist of one person for transfers. She stated that she uses the care guide to get her instructions regarding the types and levels of care to provide the resident during activities of daily living. The assigned Licensed Practical Nurse was interviewed on 4/16/18 at 2:33 PM and stated she thought the resident required the assistance of two persons for transfers but she could not be certain. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedMay 3, 2018

Plan of correction:
P(NAME) for affected resident:
Resident # 16 Care Plan was updated; new and appropriate interventions were developed and implemented to prevent or minimize recurrence to avoid serious injuries from fall on 1/9/18. Review and root-cause analysis has been conducted of these new appropriate interventions to prevent further recurrence.

Plan of correction to prevent reoccurrence:
Accident and incident reports will be reviewed after a resident falls to include a root cause analysis. Care plan interventions that are in place at the time of the fall will be reviewed and new interventions to ensure appropriateness to prevent further recurrence.
A & I will be reviewed by Administrator and DNS upon notification of an unwitnessed fall or injury of unknown origin to conduct timely and appropriate assessment and investigation to rule out abuse, neglect, and mistreatment.
Review all resident care plans and CNA care guides based on comprehensive assessments and MDS?s to indicate type and level of care the resident?s require with transfers and bed mobility.
MDS Coordinator will review all residents' MDS to ensure that the appropriate care plans are in place and updated according to the resident?s status.
Re-educate nurse staff about fall risk and prevention and accurate documentation
Re-educate CNAs about transfers and bed mobility and the importance of following plan of care.

Plan for monitoring corrective action:
Audits by nurse staff will be conducted which include review of new accidents and incidents, root cause analysis, and new appropriate interventions to prevent further recurrence.
MDS Coordinator will audit 50% of the resident?s medical records x 3 months or until 100% compliance, then 25% per month x 6 months or until 100% compliance is achieved. Audits will reflect review of care plans, comprehensive assessments and care guides to be consistent with MDS to ensure type and level of care resident?s require with transfers and bed mobility are all consistent.
Audit results will be reported quarterly to the Quality Management Meeting.

FF11 483.20(f)(1)-(4):ENCODING/TRANSMITTING RESIDENT ASSESSMENTS

REGULATION: §483.20(f) Automated data processing requirement- §483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not electronically transmit in a timely manner all encoded, accurate and complete MDS (Minimum Data Set; a federally-mandated process for clinical assessment of residents in Medicare or Medicaid certified nursing homes) to CMS (Centers for Medicare and Medicaid Services) as required for quality measure purposes. This was evident for 13 out of 13 residents (R) (#4, #8, #9, #14, #17, #21, #25, #27, #29, #30, #34, #35, and #40) reviewed for Resident Assessments. The MDS requirement states that the facility must electronically submit all the MDS information to the QIES (Quality Improvement Evaluation System) ASAP (Assessment Submission and Processing) system. According to MDS 3.0 RAI (Resident Assessment Instrument) User's Manual, comprehensive assessments must be submitted no later than the Care Plan Completion Date plus 14 days; all other assessments, including Entry and Discharge assessments, must be submitted not later than the MDS Completion Date plus 14 calendar days; and Death in Facility Tracking requires that transmission be done no later than the Discharge (death) Date plus 14 calendar days. The findings are: The facility's MDS 3.0 Nursing Home Final Validation Report and the facility's assessment data completion and submission activities were reviewed on 4/16/18 during the annual survey. It was revealed that the following resident records exceeded the required 14-day timeframe for submission/transmission of the MDS into the QIES ASAP system. R #4 - Annual Assessment with a target date of 8/23/17 for a new record was submitted on 4/12/18; R #8 - Discharge Assessment with target date of 12/20/17, 3/5/18 Entry Tracking Record, and 3/10/18 Discharge Assessment were all submitted on 4/16/17; R #9 - Death in Facility Tracking with target date of 12/14/17 was submitted on 4/16/18; R #14 - Quarterly Review with a target date of 11/20/17 was submitted on 3/7/17; R #17 - Prospective Payment System with a target date of 11/12/17 was submitted on 2/16/18; R #21 - Annual Assessment with a target date of 11/27/17 for a new record was submitted on 3/7/18; R #25 - Discharge Assessment with a target date of 11/16/17 for a new record was submitted on 2/16/18; R #27 - Quarterly Review with a target date of 3/8/18 was submitted on 4/12/18. R # 29 - Annual Assessment with a target date of 11/18/17 for a new record was submitted on 3/7/18; R #30 - admitted on [DATE], Discharge Assessment of 12/12/17 was submitted on 4/16/17; R # 34 - Quarterly Review with a target date of 11/24/18 was submitted on 3/7/18 R #35 - Discharge Assessment with a target date of 11/27/17 was submitted on 4/16/18; R #40 - Discharge Assessment with a target date of 10/26/17 was submitted on 2/16/18. The MDS Registered Nurse Coordinator was interviewed and reviewed the above records with a state surveyor on the morning of 4/16/18 and stated that the the above MDS assessments were not submitted timely. She stated that she oversees three facilities and that another MDS assessor was responsible for this facility. 415.11

Plan of Correction: ApprovedMay 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Plan of correction for resident affected:
As identified the following resident records exceeded the required 14-day timeframe for submission/transmission of the MDS to CMS and the QIES ASAP system.
R #4 - Annual Assessment with a target date of 8/23/17 for a new record was submitted on 4/12/18;
R #8 - Discharge Assessment with target date of 12/20/17, 3/5/18 Entry Tracking Record, and 3/10/18 Discharge Assessment were all submitted on 4/16/17;
R #9 - Death in Facility Tracking with target date of 12/14/17 was submitted on 4/16/18;
R #14 - Quarterly Review with a target date of 11/20/17 was submitted on 3/7/17;
R #17 - Prospective Payment System with a target date of 11/12/17 was submitted on 2/16/18;
R #21 - Annual Assessment with a target date of 11/27/17 for a new record was submitted on 3/7/18;
R #25 - Discharge Assessment with a target date of 11/16/17 for a new record was submitted on 2/16/18;
R #27 - Quarterly Review with a target date of 3/8/18 was submitted on 4/12/18.
R # 29 - Annual Assessment with a target date of 11/18/17 for a new record was submitted on 3/7/18;
R #30 - admitted on [DATE], Discharge Assessment of 12/12/17 was submitted on 4/16/17;
R # 34 - Quarterly Review with a target date of 11/24/18 was submitted on 3/7/18
R #35 - Discharge Assessment with a target date of 11/27/17 was submitted on 4/16/18;
R #40 - Discharge Assessment with a target date of 10/26/17 was submitted on 2/16/18.
Plan to identify other residents potentially affected:
The MDS Coordinator will check the MDS Assessment of all the current residents and from the past 3 months to ensure all were submitted timely. Date of Completion: 5/31/18

Plan of correction for systems changes and measures to prevent recurrence:
The MDS Coordinator will check the census daily for Admissions and Discharges including Death in the Facility and ensure that an MDS is scheduled with a completion date of not more than 14days from the ARD and entered in the EMR. The MDS schedule will be checked weekly for timely completion and submission according to CMS Requirements.
The MDS Coordinator will check the MDS schedule weekly for PPS Assessments and OBRA Assessments (Admission, Quarterly and Annual) for any MDS due to ensure completion not more than 14day from ARD and not more than 14days from admitted for the Admission MDS. The MDS schedule will be checked weekly for timely completion and submission according to CMS Requirements.
Audit results will be submitted to the Director of Quality Management.

Plan of correction monitoring corrective action:
The MDS Coordinator will submit to the Director of QM/Designee the Validation Report from CMS every 2 weeks x 3 months and continue until 100% compliant for 3 months. Quarterly audits will continue to be submitted to the Director of Quality Management. All negative findings will be reported to the Quality Management Committee.

Completion Date: 05/31/18 and ongoing

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 26, 2018

Citation Details

Based on record review and interview conducted during a recertification survey, the facility did not develop and implement policies and procedures that inhibit microbial growth in the facility's potable water system in accordance with the regulation and to define specific actions that will be taken when control limits are not met. Additionally, the facility did not conduct facility-wide water safety risk assessment and implement a water management program based on ASHRAE (American Society of Heating, Refrigeration and Air-Conditioning Engineers) and CDC (Center for Disease Control) guidelines. Legionella can cause a serious type of pneumonia in persons at risk. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including long-term care facilities. The Public Health Law Section 225(5)(a) Subpart 4-2.4 Sampling and Management Plan states that all covered facilities shall adopt and implement a legionella culture sampling and management plan for their potable water systems. The finding is: The facility administrator and maintenance director were interviewed on 4/16/18 at 11:00 AM. The maintenance director stated that the facility does not have a cooling tower (a specialized heat exchanger in which air and water are brought into direct contact with each other in order to reduce the water's temperature) and therefore water sample testing was not required. The maintenance director further stated that the facility does not have a plan in place and there were no policies and procedures for legionella. They both stated they were not aware that the facility needed to have these mandates in place. The administrator and the maintenance director were referred to the CMS (Center for Medicaid and Medicare Services) website for the federal mandate regulation and to the New York State (NYS) website for the NYS Public Health Law governing Legionella. Following surveyor intervention, the administrator and the maintenance director stated on 4/16/18 at 3:00 PM that 12 samples were collected by the water company today and the results will be available within 2-3 weeks. 415.19(a)(1-3)

Plan of Correction: ApprovedMay 7, 2018

Plan of correction:
Policies and procedures developed and implemented for conducting and testing the facility?s water supply to ensure there is no microbial growth in the facility?s portable water system.
Plan of correction to prevent recurrences:
Water safety risk assessment and implementation of a water management program by adopting a legionella culture sampling and management plan.
10 samples of water were collected from sample locations at the facility immediately upon notice from the surveyors for testing of Legionella.
In-service education on Legionella Disease outbreak and poorly maintained water systems will be conducted for all staff and will include facility developed guidelines with regard to water sampling and the importance thereof.
Plan of correction to prevent recurrences:
Culture sampling and analysis intervals not to exceed 90 days for the first year following adoption of the sampling and management plan, and annually thereafter.
Maintain an environmental assessment and all sampling results, on the facility?s premises for at least three years and be made available to the department immediately upon request.
Ninety day findings will be presented at the following quarterly Quality Management Meeting, and then annually thereafter for monitoring and compliance.

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 26, 2018

Citation Details

Based on record review and interview conducted during a recertification survey, the facility did not ensure that it complied with the timely submission of records required for the initiation and completion of the long-term care survey process. Specifically, the facility did not submit the complete Roster/Sample Matrix form within 4 hours of the start of the survey process as required for resident review. A Roster/Sample Matrix form is used by the facility to list all current residents (including residents on behold) and to note pertinent care categories. The finding is: The survey team entered the facility on 4/11/18 at 9:15 AM (first day of the survey) for its annual recertification survey. The survey team coordinator (TC) conducted a brief entrance conference with the facility administrator at about 9:45 AM and requested for a copy of the resident census, new admissions matrix, an alphabetical list of all residents to note any resident out of the facility and a list of residents who smoke, designated smoking times and locations. During this conference, the survey TC informed the administrator that the complete roster matrix that includes the care area categories was due within four hours of this entrance conference. At 12:15 PM on the same day, the facility administrator submitted a copy of the new admissions matrix to the survey TC following numerous reminders to this administrator to submit the new admission matrix and the facility Roster/Sample Matrix. The administrator stated that she thought the team had received it and will follow it up with the Director of Nursing (DON). At 3:45 PM, the survey TC spoke with the administrator again that the team has not received the complete Roster/Sample Matrix. The following day, 4/12/18, at 9:15 AM, the administrator submitted a copy of the Beneficiary Notice - Residents discharged Within the Last Six Months form and informed her again that the facility Roster/Sample Matrix has not been submitted. At 11:15 AM, the covering DON brought in a copy of the Roster/Sample Matrix form and stated that she did not realize she had to do a matrix for the facility. She stated that she thought the admission matrix was all she had to do. 400.2

Plan of Correction: ApprovedMay 7, 2018

Plan of correction:
DNS will submit Roster/Sample Matrix form within 4 hours of the start of the survey process as required for resident review during next survey by updating daily and reporting to the Administrator on a daily basis.
Plan of correction to prevent recurrences:
DNS was educated on the importance of the submission of Roster/Sample Matrix form for resident review during survey.
DNS will update Sample/Roster Matrix on a daily basis.
DNS will report to the Administrator on a daily basis that the Sample/Roster Matrix was updated from the day before, at morning report.
Plan for monitoring corrective action:
DNS will maintain a current Roster/Matrix for all residents and update Roster/Sample Matrix form for new residents and report additions at the Quality Management Meeting on a quarterly basis.

FF11 483.10(g)(10)(11):RIGHT TO SURVEY RESULTS/ADVOCATE AGENCY INFO

REGULATION: §483.10(g)(10) The resident has the right to- (i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-- (i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 26, 2018

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not ensure that residents were aware of the location of the results or reports pertaining to the outcome of the most recent surveys. There was no posted notice of the location and availability of such reports in areas of the facility frequented by most residents, visitors and other individuals wishing to examine the survey results without having to ask for them. This was evident for 29 out of 29 residents who attended the resident council meeting. The finding is: A Resident Council meeting was conducted on 4/12/18 at 10:30 AM with 29 residents of the facility in attendance. The residents were asked if they had knowledge of where the most recent survey results were posted or located. None of the residents responded affirmatively. Upon facility inspection immediately following the meeting, it was revealed that the survey results were located in the lobby of the facility on the First Floor. This location is not frequented by the residents who all reside on the Second Floor. In addition, the was no prominently posted signage in the facility, including on the Second Floor unit where all the residents reside, noting the location, availability and accessibility of the survey results. The Social Worker (SW) who assists the residents with the monthly Resident Council meetings was interviewed on 4/17/18 at 12:30 PM and stated that she was not aware that residents should be notified of the location of the survey results. The SW stated that she was unaware that a notice of the availability and location of the latest survey results should be posted prominently in the facility. The administrator was interviewed on 4/17/18 at 1:23 PM and she stated that she was unaware that a sign should be posted prominently in the facility to direct the residents on the Second Floor of the location of the survey results. 415.3(1)(c(1)(v)

Plan of Correction: ApprovedMay 9, 2018

Plan of correction:
Measures were immediately put in place to ensure the deficient practice does not reoccur by posting a sign on the second floor of where the survey results can be found, which is in the first floor lobby. Additionally, survey results are available to resident's and their families for viewing on the second floor.
Plan of correction to prevent reoccurrences:
Survey results are posted on the second floor, where the residents gather.
Social Services reviewed, at Resident Council, where the survey results can be found.
Administrator and Social Services will be in-serviced on resident's rights to availability and accessibility and location of the survey results.
Audit will include direct observation of the survey result being posted on both floors monthly x 12 months.
Plan for monitoring corrective action:
Resident?s will be reminded monthly at Resident Council Meeting their right to review the results of the most recent survey monthly x 12 months.
Resident Council Meeting minutes will be presented at Quality Management meeting to ensure residents are being made aware of their right to view current survey results monthly x 12 months and ongoing.
Activities Director will ask the resident's if they are aware of where they can find survey results for viewing, monitor their answers, and present at the Quality Management Meeting to ensure compliance monthly x 12 months.

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not provide the care and services in accordance with professional standards of practice for 1 of 2 residents reviewed for accidents (Resident #19). Specifically, following a report by the assigned CNA that the resident has a skin discoloration on the left knee, the Registered Nurses (RN) did not conduct timely and appropriate assessments to rule out abuse, neglect and mistreatment. The resident was re-assessed by a Physical Therapist and was transferred to the hospital per the physician's orders [REDACTED]. Complaint #NY 287 The finding is: Resident #19 is a [AGE] year old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment and screening tool) dated 9/19/17 documented that the resident has moderately impaired cognition, has long and short-term memory problems, was totally dependent on two persons for bed mobility and required extensive assistance of two persons for transfers. The nurse's notes dated 11/5/17 at 11:30 PM indicated the resident was checked during rounds and was noted with a small red circle on the left knee which was warm to touch with no swelling. On 11/6/17 at 10:30 AM, the nurses note documented the resident was observed with red circle on left leg that appeared to look like a puncture wound and was noted with internal rotation and plantar flexion. The physician was then called at that time and ordered to transfer the resident to the hospital for further evaluation. The hospital record revealed that the resident had an open reduction internal fixation of the [MEDICAL CONDITION] femur. The physician in the hospital documented there was no evidence of evidence of abuse or neglect and that the fracture could have been the result of severe [MEDICAL CONDITION] and osteopenia. The Incident/Accident (IA) report dated 11/6/17 indicated that a Certified Nursing Aide (CNA) reported at 10:55 PM on 11/5/17 that the resident had facial grimacing when she was giving cares to the resident. The CNA then reported her observation to the evening Registered Nurse (RN #1) supervisor who then initiated and IA report. Review of the IA Report revealed no documented evidence that RN #1 conducted an assessment of the resident at the time when it was reported to her by the CNA and the section of the I/A report that would indicate if the care plan was followed and if any interventions were taken by staff was left blank. The assigned CNA (#1) was interviewed on 4/13/18 at 3:10 PM and stated she is the resident's regular aide and has known the resident for many years. She stated she did not notice anything different when she put the resident back to bed before dinner on the evening of 11/05/17. CNA #1 stated she only noticed the grimacing on the resident's face at around 10 PM during cares and reported it to the supervisor. RN #1 was interviewed on 4/13/18 at 4:00 PM and stated that she was busy taking care of another resident and was not able to assess this resident at the time when it was reported by CNA #1. She stated she did not assess the resident's left leg but gave a report to the incoming night shift supervisor (RN #2) about the incident. The day shift supervisor (RN #3) was interviewed on 4/16/18 at 2:30 PM and stated that the director of rehabilitation and a Licensed Practical Nurse (LPN) were the two people who assessed the resident after morning report on 11/6/17 to assess the resident. It was determined at that time that the resident's left leg was externally rotated. RN #3 stated that the decision was made by physician to send the resident out to the hospital for further evaluation. The LPN was interviewed on 4/16/18 at 2:33 PM and she stated after morning report on 11/6/18, she went with the director of rehab to see the resident. She stated the resident was sent out to the hospital after rehab assessed the resident. The director of rehab was interviewed on 4/16/18 at 2:50 PM and he stated he saw a little red mark like a mosquito bite on the left leg and upon closer inspection, he noticed something protruding the skin and that the leg was rotated externally. He stated he told the LPN to call the physician immediately to transfer the resident out. RN #2 was interviewed on 4/16/18 at 4:09 PM, and stated when she came on duty on the evening of 11/5/17, she got a report from RN #1. She stated that during rounds, she went into the resident's room and noticed the resident appeared to be sleeping at that time. She stated the resident woke up when she pulled the covers down to assess the resident's left knee. RN #2 stated she saw a small red bump, took the residents' temperature which was within normal range, and decided to wait until the morning to call the physician to assess the resident. She stated the resident went back to sleep. The physician was interviewed on 4/17/18 at 10:38 AM and stated that he spoke with the surgeon who stated that based on resident's age and [DIAGNOSES REDACTED]. 415.11(c)(3)(i)

Plan of Correction: ApprovedMay 8, 2018

Plan of correction:
Resident #19 passed away on 2/23/18.
DNS and Administrator will be notified 24 hours a day/7 days per week by telephone or in person by the RN Supervisor of any injury of unknown origin and conduct timely and appropriate assessment to rule out abuse, neglect, and mistreatment.

Plan of correction to prevent reoccurrence:
DNS will be notified by RN Supervisor 24 hours a day/ 7 days per week by telephone or in person of any injury of unknown origin and conduct timely and appropriate assessment to rule out abuse, neglect, and mistreatment.
Accident and incident reports will be reviewed after a resident falls to include a root cause analysis. Care plan interventions that are in place at the time of the fall will be reviewed and new interventions to ensure appropriateness to prevent further recurrence.
A & I will be reviewed by Administrator and DNS upon notification of an unwitnessed fall or injury of unknown origin to conduct timely and appropriate assessment and investigation to rule out abuse, neglect, and mistreatment.
Review all resident care plans and CNA care guides based on comprehensive assessments and MDS?s to indicate type and level of care the resident?s require with transfers and bed mobility.
MDS Coordinator will review all residents' MDS to ensure that the appropriate care plans are in place and updated according to the resident?s status.
Re-educate nurse staff about fall risk and prevention and accurate documentation
Re-educate CNAs about transfers and bed mobility.

Plan for monitoring corrective action:
Audits by nurse staff will be conducted which include review of new accidents and incidents, root cause analysis, and new appropriate interventions to prevent further recurrence.
MDS Coordinator will audit 50% of the resident?s medical records x 3 months or until 100% compliance, then 25% per month x 6 months or until 100% compliance is achieved. Audits will reflect review of care plans, comprehensive assessments and care guides to be consistent with MDS to ensure type and level of care resident?s require with transfers and bed mobility are all consistent.
Results will be reported quarterly to the Quality Management Meeting.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on observation, interview, and record review, the facility did not ensure the non patient care related electrical equipment was visually inspected in accordance with NFPA 99. Reference is made to the lack of documentation of visual inspections for all non-patient care related electrical equipment in use in resident rooms. The findings are: During the life safety recertification survey on 4/18/18 between the hours of 11:00 AM - 2:30 PM, a tour of resident rooms was conducted and revealed that inspection stickers were not affixed to resident televisions, clocks or radios, etc. as evidence that the equipment had been inspected. There was no other documentation provided for the inspection of non-patient care related electrical equipment. In an interview at the time of the findings, the Director of Maintenance stated that all personal electrical equipment in resident rooms will be inspected and documented. 2012 NFPA 101 2012 NFPA 99: 10.4.2.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMay 3, 2018

P(NAME) for affected areas:
The Director of Maintenance ensured that the non patient care related electrical equipment, in use in resident rooms, was visually inspected and documented, in accordance with NFPA 99.

P(NAME) for potentially affected areas:
100% audit will be visually conducted and documented of the non patient care related electrical equipment, in use in resident rooms, in accordance with NFPA 99 by 5/11/18.

P(NAME) for systems changes and measures to prevent recurrence:
Update policy to ensure all equipment will be inspected visually and documented of the non patient care related electrical equipment, in use in resident rooms, in accordance with NFPA 99.

P(NAME) for monitoring corrective action: All auditing will be presented to the Quality Management meeting for monitoring and compliance.

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on documentation review and interview, the facility did not provide documentation of staff roles and participation, or review and analysis, of drills that had been conducted. Reference is made to reports of an actual weather emergency and a community based drill for which direct actions taken by staff, analysis of the facility's response, and staff attendance sheets were not provided. The findings are: Documentation review of the facility's emergency preparedness plan was conducted during the life safety recertification survey on 4/19/18 at approximately 11:25 AM. Documentation was provided for a full- scale community based exercise conducted on 2/22/18 and an actual weather emergency on 3/12/17. However, neither report included specific staff roles, signed and dated staff attendance sheets, or a facility analysis of the drills. In an interview at the time of the findings, the Director of Maintenance stated that he will revise the way the reports are written to include staff participation, roles and the facility's analysis. 483.73(d)(2)

Plan of Correction: ApprovedMay 3, 2018

Plan of correction:
The Maintenance Director will test the emergency plan at least annually by conducting unannounced exercises such as staff drills using the emergency procedures. The exercises will be in the form of a full-scale exercise that is community-based or individual, facility-based. A second full-scale exercise that is community-based or individual, facility-based, and a table-top exercise.
Plan of correction to prevent reoccurrences:
The Maintenance Director will analyze the facilities response to and maintain documentation of all drills, table-top exercises, and emergency events, and revise the facilities emergency plan as needed. The Maintenance Director will document staff roles and participation, and document attendance.
Plan for monitoring corrective action:
Drills will be reviewed and analyzed at the quarterly QA Meeting by the committee and revised pursuant to the QA process.

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on staff interview and documentation review, the facility did not ensure that a formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99. Reference is made to the lack of documentation of a risk assessment describing the facility's building system categories. The findings are: During the recertification survey on 4/18/18 and 4/19/18 between the hours of 11:00 AM and 3:00 PM, maintenance documentation had been provided for review. However, the facility was not able to provide documentation of a building systems risk assessment. In an interview on 4/19/18 at approximately 2:15 PM, the Director of Maintenance stated that the building system categories assessment had not been performed. 2012 NFPA 99: 4.2 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedMay 3, 2018

P(NAME) for affected area:
A formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99
P(NAME) for potentially affected areas:
A 100% review of all building systems categories will be conducted and documented in accordance with NFPA 99

P(NAME) for systems changes and measures to prevent recurrences:
A 100% review of all building systems categories will be conducted, documented and monitored for compliance.
P(NAME) for monitoring corrective action:
The 100% review will be presented to the Quality Management Meeting.
Annually thereafter for all building systems categories in accordance with NFPA 99.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on observation and interview, the facility did not ensure that hazardous areas were separated from other spaces by smoke partitions and doors in accordance with 8.4. This was evidenced by openings in the sheet rock ceiling in the mechanical room, missing ceiling tiles in the boiler room and the generator room, and a penetration in the concrete wall above the ceiling tiles in the generator/switch gear room that communicated to the corridor side of the wall. The findings are: During the recertification survey conducted on 4/18/18 between the hours of 11:00 AM and 3:00 PM, the following issues were noted: - At approximately 12:15 PM, a tour of the mechanical room accessible via the stairwell revealed that there were various openings in the sheet rock ceiling that measured approximately 2 in x 2 in, 4 in x 6 in, and 4 in x 5 in. Electrical switch gears, IT equipment and the HVAC system are in this room. In an interview at the time of the findings, the Director of Maintenance stated that the openings in the sheet rock ceiling are due to the installation of the threading rods for the sprinkler system. He further stated that the openings will be sealed. - At approximately 1:20 PM, a tour of the boiler room was conducted and revealed that a suspended ceiling tile was missing in the room. In an interview at the time of the findings, the Director of Maintenance stated that there was a leak above the ceiling tile that was recently repaired. but that the ceiling tile had not been put back in place. He further stated that the ceiling tile will be replaced. - At approximately 1:55 PM, a tour of the generator/switch gear room revealed that there were a number of suspended ceiling tiles missing in the room. In addition, an examination of the concrete wall above the ceiling in this room revealed a penetration from the room that communicated to the corridor side of the wall. In an interview at the time of the findings, the Director of Maintenance stated that the penetration will be sealed and the ceiling tiles will be replaced. 2012 NFPA 101: 19.3.2.1, 8.4.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMay 3, 2018

P(NAME) for affected area:
On 4/18 openings in sheet rock ceiling were sealed
On 4/18 missing suspended ceiling tile was replaced
On 4/18 the penetration was sealed and the ceiling tiles were replaced.

P(NAME) for potentially affected areas:
Quarterly audits will be performed to ensure that hazardous areas are free from penetrations and ceiling tiles are in place.
P(NAME) for systems changes and measures to prevent recurrences:
Maintenance staff will inspect and audit hazardous areas to ensure they are free from penetrations and that ceiling tiles are in place.
P(NAME) for monitoring corrective action:
Maintenance Director will review audits to ensure compliance is achieved and will report findings at the quarterly Quality Management Meeting.

LOCAL, STATE, TRIBAL COLLABORATION PROCESS

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on documentation review and interview, the facility did not ensure that its emergency preparedness (EP) program included a process for cooperation and collaboration with local, regional, State and Federal officials' efforts to maintain an integrated response during a disaster, and did not include documentation of its efforts to contact such officials about participating in collaborative planning efforts. The findings are: On 4/19/18 at approximately 12:25 PM during the recertification survey, the facility's emergency preparedness plan was reviewed. Although the facility provided the telephone numbers for the American Red Cross, local police, and the local fire department, documentation did not include the facility's efforts to contact local, regional, State and Federal officials to cooperate and collaborate plans for integrated responses during a disaster and or emergency situations. In an interview at the time of the findings, the Administrator stated that efforts to collaborate with emergency officials will be documented. 483.73 (a)(4)

Plan of Correction: ApprovedMay 8, 2018

Plan of correction:
Measures were put in place to ensure that the deficient practice does not reoccur by documenting the facilities efforts to contact the Commissioner of the Department of Emergency Services of Westchester County and requesting participation in collaborative and cooperative planning efforts with local, tribal, regional, State and Federal officials? efforts to maintain an integrated response during a disaster or emergency situation.
Plan of correction to prevent reoccurrences:
Policy and Procedure will be developed which will include a process for cooperation and collaboration with local, regional, State and Federal officials efforts to maintain an integrated response during a disaster, which will include documentation of its efforts to contact such officials about participating in collaborative planning efforts.
The Administrator will review and update the emergency preparedness plan at least annually.
All staff will be educated on the new policy and procedure as a part of the emergency preparedness program.
Annual audit will be conducted to ensure documentation is updated on an annual basis.
Plan for monitoring corrective action:
The Administrator will update the agreement with the Commissioner of the Department of Emergency Services of Westchester County annually.
Annual audit will be presented at the Quality Assurance Committee meeting.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on documentation review and interview, the facility did not develop and implement policies and procedures for the use of volunteers in an emergency, and other staffing strategies as part of the emergency plan. The findings are: Documentation review conducted during the recertification survey on 4/19/18 at approximately 12:15 PM revealed that the facility did not develop policies and procedures for the use of volunteers in an emergency, or other staffing strategies, such as the process and role for the integration of State and Federally designated health care emergency professionals to address surge needs during an emergency. In an interview at the time of the findings, the Administrator stated that she will provide written policies and procedures to include volunteers and other staffing strategies in an emergency. 483.73(b)(6)

Plan of Correction: ApprovedMay 3, 2018

Plan of correction:
Low Staffing policy and procedure was revised to include the use of volunteers by contacting local hospitals for availability of their nurse staff not on duty, contacting area staffing agencies for available staff, and reaching out to 1199 Union for other local staff availability for staffing strategies to address surge needs during an emergency. The Administrator will review and update the policy at least annually.
Plan of correction to prevent reoccurrences:
The Administrator will educate the staff on the policy revision
Plan for monitoring corrective action:
Policy will be enacted during a table-top exercise to reinforce procedures
Table-top exercises will be presented at QA meeting for discussion and monitoring of the revised procedure to ensure it is sufficient in the event of an emergency.

PROCEDURES FOR TRACKING OF STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on observation, interview, and documentation review, the facility did not ensure that e-FINDS bracelets were available for use in the event of an emergency or disaster. Reference is made to the lack of e-FINDS bracelets for use in a potential evacuation of residents. Only the training bracelets were available. The findings are: The facility's emergency preparedness plan was reviewed at approximately 10:20 AM on 4/19/18 during the recertification survey. The plan stated that the e-FINDS system would be used to track residents in the event of an emergency requiring evacuation. However, the e-FINDS training bracelets were the only bracelets available. In an interview at the time of the findings, the Administrator stated the she was unable to locate the actual bracelets and had recently ordered the bracelets for the e -FINDS system. She further stated that the bar coded sheets that are part of the e-FINDS equipment would be used in the event residents are evacuated to other facilities. 483.73 (b) (2)

Plan of Correction: ApprovedMay 3, 2018

Plan of correction:
A comprehensive search was conducted to find the e-FINDS bracelets and were discovered and are now available for use in the event of an emergency or a disaster for tracking residents who are moved to other facilities.
Plan of correction to prevent reoccurrences:
The Administrator will review and update the emergency preparedness plan at least annually. Policy and Procedure will be reviewed and revised to include where the bracelets will be kept at all times for use in an emergency or a disaster for safeguarding resident who are moved to other facilities.
The Administrator will educate staff on the e-FINDS Resident Tracking System.
The Administrator will re-educate staff about the importance of the e-FINDS Resident Tracking System and safeguarding the equipment.
Audit tool will be created to monitor the equipment and will be completed quarterly to ensure it is readily available if needed in an emergency or disaster.
Plan for monitoring corrective action:
Audits will be presented at the quarterly QA Meeting. Findings will be reported to the QA committee and reviewed and revised pursuant to the QA process.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 17, 2018
Corrected date: June 15, 2018

Citation Details

Based on documentation review and interview, the facility did not have policies and procedures in the emergency plan describing the facility's role in coordinating efforts required during a declared emergency, and the facility's responsibilities during the duration of a 1135 waiver. The findings are: Emergency preparedness documentation review was conducted during the recertification survey on 4/19/18 at approximately 12:35 PM. Although the facility had transfer agreements with other facilities, as well as policies in place to address the potential transfer of residents, it did not have policies and procedures for coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary, or the responsibilities of staff during the duration of the waiver. In an interview at the time of the findings, the Administrator stated that she will develop a written policy and procedure to include the facility's coordination efforts with physicians that are not under contract with the facility, and expected staff roles during the waiver process. 483.73(b)(8)

Plan of Correction: ApprovedMay 8, 2018

Plan of correction:
Policies and procedures were put in place for coordination efforts during a declared emergency in which a waiver of Federal requirements under section 1135 of the Act has been granted by the Secretary, in order to deal with the response to a disaster. Such policy and procedures will include what the facility will do if they have to provide care and treatment at an approved alternate site under such waiver, or in the event where physicians outside of normal practice would be needed to assist in an emergency.
Plan of correction to prevent reoccurrences:
The Administrator will educate the staff on the newly created policy and procedures for the 1135 Waiver.
Plan for monitoring corrective action:
A facility-based exercise will be enacted to reinforce the procedure
A facility-based exercise will be presented and analyzed at the Quarterly QA Meeting by the committee and revised pursuant to the QA process.