The Brook at High Falls Nursing Home and Rehabilitation Center
February 23, 2018 Certification 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: February 23, 2018
Corrected date: April 23, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a Recertification Survey it was determined that for one (Resident #12) of one resident reviewed for elopement, the facility did not ensure each resident's care plan was revised to reflect the resident's current condition. The issue involved the lack of a care plan revision for actual and attempted elopements. This is evidenced by following: Resident #12 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/19/18, revealed the resident had severely impaired cognition, ambulated with supervision, and wandered one to three days in the look back period. The Comprehensive Care Plan (CCP), dated 8/7/17, revealed that the resident was at risk for wandering and the inability to find her way back if she gets outside. Approaches included to ensure the resident's wander guard bracelet was in place and functional, and to gently redirect the resident, if possible. Actual attempts to exit from doors was not checked. Review of an Incident/Accident Report, dated 11/7/17, revealed that the resident was outside the building. The alarm sounded and the staff found the resident walking outside on the ramp. Measures to prevent reoccurrence included staff were instructed to monitor the resident closely and respond to alarms immediately. The CCP, dated 11/7/17, revealed an elopement attempt. Review of an Incident/Accident Report, dated 1/1/18, revealed the resident attempted an elopement through the beauty shop. The alarm sounded and resident was redirected to the dining room. Measures to prevent reoccurrence included the beauty salon door was closed and locked. Review of an Incident/Accident Report, dated 2/3/18, revealed the resident was found outside of the building walking up the ramp to the entrance of the building. The nurse heard the alarm and responded to the main entrance as indicated by the wander guard system, and the resident was not in sight. Another staff member exited the building and found the resident walking up the ramp towards the entrance. Measures to prevent reoccurrence include quicker response when wander guard alarm sounds. The Resident Plan of Care, updated 2/12/18, documented that the resident exit seeks when she sees someone in a coat. During observations on 2/21/18 at 9:19 a.m. and 11:09 a.m., the resident was in the dining room and was ambulating with a walker independently down the hall several times. During an interview 2/23/18 at 9:51 a.m., the Social Worker (SW) stated that she was responsible for addressing the resident's risk for elopement and interventions on the CCP. The SW stated the CCP should have been revised following the resident's elopements. (10 NYCRR 415.11(c)(2)(iii))

Plan of Correction: ApprovedMarch 19, 2018

F657 Care Plan Timing/Revisions
Resident #12's care plan has been developed by the IDT to include targeted behaviors/wandering/elopement specifically with measurable goals, individualized interventions, her medications have been reviewed and adjusted by the Psych NP and PMD.
Each Resident determined to be at risk of elopement is at risk for deficient practice. Each identified Resident's care plan will be reviewed and revised by the IDT.
The new Comprehensive Care Plan Policy and Procedure will include timing and revisions. An audit tool will be developed to monitor timely revisions to care plans post elopement.
The Audit will be completed monthly times 3 then quarterly until compliance is met.
Responsible Party:(NAME)L.(NAME) RN,DON

E3BP 402.7(a)(3)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (3) Where the criminal history information of a prospective employee reveals a conviction for any crime other than one set forth in paragraph (2) of this subdivision, the Department may, consistent with article 23-A of the Correction Law, propose disapproval of eligibility for employment. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the prospective employee's criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

Based on an interview and record reviews conducted during the Recertification Survey, it was determined that for one of seven employee files reviewed for Criminal History Record Check (CHRC), the facility did not remove the employee who received a hold in abeyance letter from positions of direct care to residents. This is evidenced by the following: A review of facility records on 2/22/18 between 10:22 a.m. and 10:47 a.m., revealed that Certified Nursing Assistant (CNA) #2 was hired on 1/19/18 and was submitted for a CHRC check on 1/11/18. A CHRC hold in abeyance charges/convictions was issued on 1/30/18. Time sheets provided for CNA #2 revealed that the employee worked for nine days after the 1/31/18 date, with the last day being on 2/15/18. A 105 Termination Form revealed that CNA #2 was terminated on 2/20/18. In an interview at that time, the Director of Nursing (DON) stated that she did not terminate the employee until after the surveyor asked for the CHRC documentation. The DON said they saw that there was a hold in abeyance letter for the employee and then terminated CNA #2 immediately. A review of the facilities CHRC Policy and Procedure revealed that if the report is negative, and the employee is determined to not be employable the employee is not hired or is terminated immediately. (10 NYCRR 402.7(a)(3)(i))

Plan of Correction: ApprovedMarch 21, 2018

R814 CHRC
The involved CNA was terminated as soon as DON saw the CHRC hold in abeyance letter in personnel file.
The HPN CHRC file has been checked for any further letters of abeyance and/or denial. Any agency or staff member with negative letters were terminated via CHRC 105. None were currently employed or used through an agency.
The HPN CHRC is being checked each business day at least daily. A checklist has been developed that is to be completed by authorized staff each time a CHRC is completed.
This checklist includes CNA Registry check, completed CHRC forms 102, 103, 104 and CHRC determination letter.
The current audit tool was revised. The audit tool includes: Employee initials, CNA registry check, OP verification, if licensed, CHRC 102, 103, 103, Supervision in place, if needed, CHRC letter, CHRC 105 if terminated from list.
This tool will be completed monthly times 3, then quarterly and reported to the QA Committee at each corresponding meeting.
Responsible Party:(NAME)L.(NAME) RN,DON

FF11 483.12(b)(1)-(3):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95,

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of seven employee records reviewed, the facility did not properly implement policies and procedures to prevent abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check prior to hiring an employee. This is evidenced by the following: A review of employee files on 2/22/18 between 10:22 a.m. and 10:47 a.m. revealed that Activity Aide #1 was hired on 11/29/17, but a Nurse Aide Registry Check was not conducted until 2/20/18. In an interview at that time, the Director of Nursing stated that they had to re-run the Nurse Aide Registry Check on Activity Aide #1 because when the surveyor asked for the employee's records, they were unable to find the original Nurse Aide Registry Check. A review of the facility's, Resident Abuse Policy, directed that the facility shall not employ individuals who have been found guilty by a court of law of abusing, neglecting or mistreating other individuals. The State Nurse Aide Registry shall be queried as part of the hiring process for all unlicensed staff positions. If a finding has been entered into the State Nurse Aide Registry concerning abuse, neglect or mistreatment of [REDACTED]. (10 NYCRR 415.4(b)(1)(ii)(b))

Plan of Correction: ApprovedMarch 19, 2018

Activity Aide file was checked 2/20/18 and a CNA Registry check was done at that time.
All new hires for last 90 days and pending new hire files will be checked for CNA Registry check.
A new hire/agency checklist has been developed and implemented. This checklist will be completed for each potential new hire/agency. The business office will complete an independent checklist as well when the new hire completes new hire paperwork.
The current CHRC audit tool has been updated to include the additional information needed. This audit will be completed every month times 3, then quarterly until compliance is met. This audit will be reported to the QA team at each meeting.
Responsible Party:(NAME)L.(NAME) RN, DON

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 3 of 15 residents reviewed for Comprehensive Care Plans (CCP), the facility did not develop or implement a plan of care for each resident that included measurable objectives and interventions to address the resident's medical, physical, mental, and psychosocial needs. The issues involved the lack of applying [MEDICATION NAME] as per the physician orders [REDACTED].#9), not following the care plan for transfers when using a redi-stand mechanical lift (Resident #1), and not following the care plan for a low air loss alternating air mattress (Resident #16). This is evidenced by the following: 1. Resident #9 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/17/18, revealed the resident had moderately impaired cognition, required extensive assist of one staff person for personal hygiene, had disorganized thinking and inattention that fluctuated, and received an antipsychotic medication daily during the seven-day look back period. A Physician Admission History and Physical, dated 1/11/18, included that the resident was admitted to the facility following hospitalization for a stroke. The resident had ongoing [MEDICAL CONDITION] that was probably worsening due to dementia and was started on [MEDICATION NAME] 12.5 milligrams (mg) at bedtime at the hospital. The physician orders, dated 1/11/18, included that the resident was to receive [MEDICATION NAME] 12.5 mg at bedtime for dementia with behavioral disturbances. [MEDICATION NAME] 20 mg was ordered on [DATE] to be given on Mondays, Wednesdays, and Fridays for hypertension, to check weight weekly, to call the physician with a three pound weight change, and apply ace wraps to bilateral legs in the morning and remove at bedtime. On 1/23/18, the [MEDICATION NAME] was changed to be given daily. On 2/1/18, the ace wraps were discontinued and a double layer of [MEDICATION NAME] (tubular-shaped compression bandages) were ordered for bilateral lower extremities that were to be applied in the morning and taken off at bedtime for [MEDICAL CONDITION]. On 2/5/18, a new order directed to keep the resident's legs elevated as much as possible due to [MEDICAL CONDITION]. On 2/7/18, the [MEDICATION NAME] was increased to 40 mg daily due to [MEDICAL CONDITION]. The CCP, last reviewed on 1/29/18, did not include specific symptoms of [MEDICAL CONDITION], the specific behaviors for the use of an antipsychotic medication, and did not include specific non-pharmacological interventions. Also, the CCP did not address [MEDICAL CONDITION] or the use of [MEDICATION NAME]. The Resident Plan of Care, last updated 2/16/18, did not include the use of [MEDICATION NAME] or nonpharmacological interventions for behaviors (only lists animals, bingo, and big band music). Progress notes reviewed since admission included that on 1/16/18 the resident packed his belongings and stated he was waiting for his sister to come and get him but was redirectable. On 1/24/18, the resident wandered at night, closed the doors to other resident rooms, and was disrobing. The (MONTH) (YEAR) Treatment Administration Record (TAR) included that the resident was to have double layered [MEDICATION NAME] applied to the bilateral extremities in the morning and taken off at bedtime, but was not signed off as being completed on 2/22/18 or 2/23/18. Observations on 2/22/18 at 11:14 a.m., 2:29 p.m., 3:57 p.m. and 2/23/18 at 9:19 a.m., the resident did not have [MEDICATION NAME] applied and had [MEDICAL CONDITION] to the lower extremities. When interviewed at that time, the resident said he does not wear anything on his legs to help with the [MEDICAL CONDITION]. When interviewed on 2/22/18 at 11:17 a.m., CNA #1 said the resident had no hallucinations or delusions. CNA #1 said the resident will wander and look in other resident rooms, pack his belongings, and change his clothes but was able to be redirected. CNA #1 said she would look at the CNA book, behavior report, and nursing report to determine if a resident has behaviors and interventions are in place. CNA #1 said the resident did not have anything applied to his lower extremities. Interviews conducted on 2/23/18 included the following: a. At 9:47 a.m. and 10:20 a.m., the Licensed Practical Nurse (LPN) said the resident was on [MEDICATION NAME] because of aggressive behaviors but she works days and evenings and has never seen him exhibit aggression, mood issues, delusions, or hallucinations. She said the only behavior the resident has is that sometimes he will pack up his belongings, but he is easily redirectable. The LPN said if the resident exhibited behaviors, it would be documented in the behavior logs and/or progress notes. The LPN said that the night nurse or the CNA apply the resident's [MEDICATION NAME] and then the nurse documents on the TAR that they were applied. b. At 9:49 a.m., the LPN/Nurse Manager said that the resident is receiving [MEDICATION NAME] for dementia with behavioral disturbances. After reviewing the physician notes, she said the resident was having [MEDICAL CONDITION] at the hospital but he has not exhibited [MEDICAL CONDITION] or behaviors since he has been at the facility. When asked about a care plan for the targeted behaviors and nonpharmacological interventions related to the use of the antipsychotic medication use, she was unable to answer what should be included. c. At 10:23 a.m., the Social Worker (SW) said that she has been working at the facility since (MONTH) (YEAR) and was still trying to understand who writes what section of the CCP. She said she had not received any training on how to complete the CCP. The SW said she was told at times not to write a CCP because it was included in the Standard of Cares. The SW said when the resident first came to the facility he got up one night and closed the doors of other resident rooms and another time he packed his belongings wanting to go home. She said he has not exhibited any distress or dangerous behaviors, and has had no delusions or hallucinations. When the SW reviewed the CCP, she said it was not individualized for target behaviors and interventions to address the use of the antipsychotic medication. d. At 11:04 a.m., CNA #2 said that the resident had not exhibited any behaviors, hallucinations, or mood concerns. She said that the night nurse was supposed to apply the [MEDICATION NAME] on the resident because he has [MEDICAL CONDITION]. CNA #2 said if she noticed that the resident did not have the [MEDICATION NAME] on, she would apply them. CNA #2 said the resident should have two pairs of [MEDICATION NAME] with his name on them. At 11:08 a.m., CNA #2 said she found a pair of [MEDICATION NAME] in the closet. She said they were not his but she would put them on him. e. At 1:48 p.m., the Director of Nursing (DON) said that all the staff complete the CCP, but nursing completes the section on [MEDICAL CONDITION] medications. She said there is a Standard of Care but nothing individualized for the resident that included type of medication, target symptoms, the outcome that should be achieved, or the approaches used. The DON said if there is an order for [REDACTED]. The facility policy, Standard of Care, dated 1/3/17, directed that each of the MDS Care Area Assessments that triggered would have a Standard of Care attached. If a resident has an issue not covered by the established Standard of Care, an individualized CCP would be developed for that resident. 2. Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/8/17, revealed that the resident had moderately impaired cognition, and required the assistance of two staff members for transfers. The Resident Plan of Care, dated 7/12/17, revealed that the resident required the assistance of two staff members for transfer using a mechanical standing lift. When interviewed on 2/20/18 at 2:30 p.m., the resident said that he has a special chair and he has been told that he should be transferred with the assistance of two people. He said that one CNA transfers him alone. Interviews conducted on 2/22/18 included the following: a. At 3:37 p.m., the CNA said that she knows the resident requires the assistance of two people for transfers but she does not always have time to get another staff member to help. The CNA said she has asked the nurse to assist with the transfer and the nurse will tell her that she is too busy, so she just transfers the resident by herself. The CNA said she has things to do and does not have time to wait. b. At 4:03 p.m., the LPN said there was no reason for the CNA to transfer the resident alone. She said staff were always around to help. c. At 4:16 p.m., the LPN Manager said there was no reason for the CNA to transfer the resident alone. She said that staff are available, and the CNA just needs to ask for assistance. The LPN Manager said that the resident requires the assistance of two staff for transfers, otherwise it would not be considered safe. 3. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/7/18, revealed the resident had severely impaired cognition, required extensive assistance of one person for bed mobility, was at risk for developing a pressure ulcer, and had a pressure relieving device for the bed. The initial Pressure Ulcer Risk Evaluation Form, dated 1/31/18, revealed a score of 11 which means the resident was at high risk for skin breakdown, and a prevention protocol should be initiated immediately. The Standard of Care, dated 2/13/18, included all mattresses are pressure relief, and a low air loss alternating air mattress. During observations on 2/21/18 at 11:03 a.m., 2/22/18 at 10:43 a.m., 1:37 p.m., and 4:05 p.m., the resident did not have a low air loss alternating air mattress on the bed. When interviewed on 2/22/18 at 12:18 p.m., the DON said that residents identified as high risk for pressure ulcers should have an alternating air mattress on their bed. She said the resident should have had an alternating air mattress in place. (10 NYCRR 415.11(c)(1))

Plan of Correction: ApprovedMarch 21, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F656
Resident #9: The [MEDICATION NAME] qhs was discontinued 2/27/18 and changed to qd prn x 14 days. The 14 day prn is concluded and he no longer has a [MEDICAL CONDITION] med therefore,a care plan for [MEDICAL CONDITION] meds is no longer needed.
The nurses involved with not signing/ensuring the [MEDICATION NAME] were on as ordered will be counseled by(NAME)Jones. LPN, NM.
Resident #1: The CNA involved will be counseled by(NAME)Jensen, RN Resident #16: An alternating air mattress was applied to her bed 2/22/18 by DON.
Each Resident on an anti-psychotic medication is at risk for the deficient practice. A care plan with measurable goals, targeted behaviors, interventions, and GRD's will be implemented for each resident on an anti-psychotic drug.
Each Resident requiring a stand lift transfer is at risk for deficient practice. A random audit will be completed for each resident to ensure 2 assist transfer.
Each Resident with a score of 8 or greater is at risk for deficient practice. Each resident with a score of 8 or greater on the pressure ulcer risk assessment will be evaluated for an alternating air mattress.
A new Comprehensive Care Plan Policy & Procedure will be developed to include person centered care that addresses the Resident's measurable goals, time frames, individualized interventions and targeted behaviors. An in-service for all Nursing Staff will be held on (MONTH) 3, (YEAR). An in-service on Safe Resident Handling/Standing Lift Transfers will be held (MONTH) 17, (YEAR).
Audit tools will be developed to monitor anti-psychotic/behavior care plans, [MEDICATION NAME] use, stand lift transfers and pressure ulcer risk/alternating air mattress application. Audits will be completed monthly times 3 then quarterly until compliance is met. Audit results will be shared with the QA committee at each corresponding meeting.
Responsible Party:(NAME)L.(NAME) RN,DON

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one facility Infection Control Program and one of one potable water systems, the facility did not 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. Specifically, the facility did not have an Infection Control Program for Legionella, did not review and update the Infection Control Program annually, and a shower room was left uncleaned. This is evidenced by the following: 1. A review of the facilities potable water testing reports revealed that water sample sets were tested and found to be positive for Legionella on 3/27/17, 5/9/17, 6/26/17 and 12/28/17. The facility was unable to provide documentation for any control measures taken after receiving the positive sample results. Between 6/26/17 and 12/28/17, the facility did not take any further Legionella samples and was unable to provide any documentation of control measures taken during this 6 month period. Documentation provided showed that the chlorine [MEDICATION NAME] system was installed and started to operate on 11/2/17. When interviewed on 2/21/18 at 1:07 p.m., the Administrator stated that they did a heat and flush of the water system after each positive sample but it did not work. He stated that in (MONTH) (YEAR), the facility started the process of getting a chlorine [MEDICATION NAME] system for their potable water system. He said it took a few months, that is why there were no samples taken between (MONTH) (YEAR) and (MONTH) (YEAR). He said they have not had anyone get sick from Legionella. A review of the facilities Infection Control Program revealed there were no policies related to Legionella, and the Infection Control Program was dated as reviewed (MONTH) 2009. A review of the Infection Control Tracking Data revealed eight residents were diagnosed with [REDACTED]. During an interview on 2/23/18 at 10:01 a.m., the Director of Nursing /Infection Control Nurse stated the facility purchased an Infection Control Program from Med Pass, and they were in the process of reviewing the program and adopting it as best they can for the facility. She stated the facility was currently using their old Infection Control Program and have not implemented or educated staff on the new program yet. The DON stated she did not know when the current program and or policies were reviewed last but said it was not completed annually. The DON stated the facility did not have a policy for Legionella. She stated she was aware of the water test results being positive for Legionella but the Administrator informed her the levels were minute. The DON stated the residents identified with pneumonia from (MONTH) (YEAR) through (MONTH) (YEAR) were not tested for Legionella as they would need a sputum sample and they do not suction residents. The DON stated she did not realize you could test a urine sample for Legionella. The DON stated she did not discuss the residents with pneumonia or the Legionella in the water with the Medical Director or the medical providers. During an interview on 2/22/18 at 10:54 a.m., the Medical Director stated she was unaware of Legionella in the water system between (MONTH) (YEAR) (when she began as Medical Director) and (MONTH) (YEAR). The Medical Director stated she was unaware of the pneumonia cases amongst the residents from (MONTH) (YEAR) through (MONTH) (YEAR). The Medical Director said if she had been aware of the pneumonia cases and the water testing positive for Legionella she would have tested the residents. The Medical Director stated antibiotic use was reviewed monthly. When interviewed on 2/23/18 at 11:54 a.m., the Medical Provider stated she was not aware of Legionella testing positive in the water from (MONTH) (YEAR) through (MONTH) (YEAR). She stated had she been aware she would have checked for the Legionella [MEDICATION NAME] in the urine of residents diagnosed with [REDACTED]. 2. During observations of a shower room on 2/20/18 at 9:40 a.m., and 2/21/18 at 11:06 a.m., a foul odor was noted in the shower room, brown debris in the form of a nugget and brown accumulation 8.5 inches wide and 8.5 inches long was on the shower room floor. During an interview on 2/21/18 at 11:13 a.m., a Certified Nursing Assistant stated the brown nugget in the corner of the shower room was stool. She stated she cleans the shower after it is used. (10 NYCRR 415.19)

Plan of Correction: ApprovedMarch 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F880 Infection Control
The Med-Pass Policy and Procedure Manual has been accepted as our manuals for guidance for Infection Control. The Manual includes policies and procedures for Surveillance/Reporting, Antibiotic Stewardship, Legionella and other communicable diseases, Immunization, etc. Any policy not applicable to the(NAME)will be removed. The QA Committee accepted manuals 3/15/2018.
Legionella Sampling & Management Plan Manual has been developed and implemented.
The shower room will be cleaned and disinfected daily bu Housekeeping Staff daily.
The IDT will choose a policy and procedure to review and update weekly ongoing.
Each Resident diagnosed with [REDACTED].
The IC & LSMP manuals will be reviewed at least annually. An in-service
will be held to educate all staff.
Management Staff will do a random surveillance audit at least weekly.
The QA Committee will review and sign off on both manuals at least annually. The audits will be presented to the QA Committee at each corresponding meeting until compliance is met.
Responsible Party:(NAME)L.(NAME) RN,DON

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #2) of four residents reviewed for non-pressure related skin conditions, the facility did not thoroughly investigate the resident's bruises to rule out abuse, neglect, or mistreatment. This is evidenced by the following: Resident #2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/5/18, revealed the resident had moderately impaired cognition, required the total assistance of staff for transfers, bathing and dressing, and had impaired functional limitations in one upper extremity and both lower extremities. Review of the facility's current policy, Accident and Incident Investigation, directed the purpose of the policy was to investigate all marks, discolorations, skin breaks and injuries that have not been witnessed. Review of an Incident and Accident Report, dated 12/10/17, revealed a 2 centimeter (cm) bruise on the top of the left hand, a 1 cm bruise on the top of the right hand, and a less than 1 cm bruise on the underneath side of the right wrist. The Incident and Accident Report documented that the nature of the incident was an injury and blood work was completed on 12/5/17. Review of the Nursing Progress Notes from 12/2/17 through 12/13/17 revealed that on 12/10/17, a Registered Nurse Progress Note documented that the resident had a discoloration on the left hand that measured 2 cm in size, a 1 cm discoloration on top of the right hand, and a less than 1 cm discoloration on the underneath side of the right wrist. A Progress Note, dated 12/11/17, revealed that the Licensed Practical Nurse documented that the resident had a shower and no new skin issues were observed. During an interview on 2/21/18 at 1:11 p.m., the Director of Nursing (DON) stated the resident had blood work on 12/5/17. The DON stated the bruise on the left hand was not investigated. The DON reviewed the Incident and Accident Report, dated 12/10/17, and said it was incomplete. The DON stated she did not know what color the bruises were when they were found. She said if she knew the color of the bruises it would be beneficial in determining the age of a bruise. The DON stated she reviewed all Incident and Accident Reports, and that she does not always read the reports before she signs them. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedMarch 19, 2018

Directed P(NAME) F610
The I&A of 12/10/17 had two areas of discoloration that needed to be investigated. The I&A was incomplete. Therefore, the NM, DON, PMD and Medical Director all missed investigating both areas of concern.
Each area of concern must have a correlating I&A.
All Nurses will be re-educated on proper completion of I&A's, separate I&A's for each area of discoloration, initializing investigation and consequences at the Directed In-service by(NAME)Lake, Consultant, on (MONTH) 3, (YEAR).
The IDT will review I&A's at each AM meeting and complete an audit.
Incomplete and combined I&A's will be sent back to reporting nurse to be completed and/or rewritten.
Audit results will be reported to the QA Committee at each meeting until compliance is met, then quarterly.
Directed In-service F610
In-service Date (MONTH) 3, (YEAR)
Consulting Instructor:(NAME)Lake, B.S.B.A., (MI)S.S.G.B.
Agenda: Proper completion of I&A's
Separate I&A's for each discoloration
There should be no blanks
Includes size, shape and color of any discoloration
Initializing Investigation:
Attempts to determine cause of injury needs to be started
ASAP. Staff interviews are to be completed before end of
shift. These are interviews!!! Staff are not to fill them out
themselves.They are intended to be done by a Nurse so
additional questions can be prompted/asked for more details.
Accountability:
Nurses will be called back in to complete incomplete I&A's.
Noncompliance will result in Disciplinary Action up to and
including termination.
Quality Assurance
IDT will be reviewing all I&A's on a weekly basis for
completion and compliance. Audits will be conducted weekly
and reported to the QA Committee at each corresponding
meeting.
P(NAME) F610 I&A's
Resident#2: The I&A report of 12/10/17 will be reviewed. All staff in 24 hour look back will be re-interviewed for more details.
Each Resident with an I&A is at risk for the deficient practice. Each discoloration I&A will be reviewed for completeness to include size, color and shape.
A mandatory in-service for all nursing staff is scheduled for (MONTH) 3, (YEAR). Current Policy and Procedure for completion of I&A's have been reviewed and revised. A new audit tool has been developed to monitor proper completion of I&A's.
The audit will be conducted monthly times 3 then quarterly until compliance is met. The audit results will be shared with the QA committee at corresponding meeting.
Responsible Party:(NAME)L.(NAME) RN, DON

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: N/A

Citation Details

Based on observations and record reviews conducted during the Life Safety Code Survey, it was determined that for one (1954 building) of three residential living spaces, the facility did not properly maintain a compliant building construction type. Specifically, a three-story wood framed section of the nursing home was used for housing residents. This is evidenced by the following: Observations on 2/20/18 between 9:05 a.m. and 9:32 a.m. revealed the 1954 section of the facility consisted of three floors and a basement. The construction of this section appeared to be comprised primarily of wood as its structural vertical and horizontal elements. The second and third floors of the 1954 building were unoccupied and the first-floor level was observed to have three single resident sleeping rooms (#14, #15, and #17), and other occupied spaces including: the Director of Nursing office, the Social Work office, the beauty shop, a resident tub and bathroom, and a meeting room. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.1.6.1)

Plan of Correction: ApprovedMarch 22, 2018

K161
The Facility will submit a Time Limited waiver to The New York State Department of Health Center for Health Care Facility Planning, Bureau of Architecture and Engineering Review. Submission date 3-29-2018
The facility has also secured a design professional to study and recommend possible solutions.

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

E-001 S/S = C This STANDARD is not met as evidenced by: Based on interview and record review conducted during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code Survey completed on 2/22/18, it was determined that the facility did not comply with Emergency Preparedness requirements. Specifically, the facility did not develop a compliant Emergency Preparedness Plan. This is evidenced by the following: In an interview on 2/22/18 at 10:00 a.m., the Administrator stated that the facility has not completed their new Emergency Preparedness Plan (EPP) yet. He said that they have hired a contractor to complete the plan for them, and it is not completed yet. The Administrator stated that the contractor had sent portions and pieces of the plan to him, but they are not yet implemented. The Administrator stated that he believes the plan will be completed by next week, and he would be implementing it then. The old EPP was provided to the surveyor for the review. A review of the old EPP provided revealed a revision date of (MONTH) (YEAR), but there was no risk assessment provided that was associated with that plan. The Evacuation Plan, located within the EPP, was dated 2009. (42 CFR 483.73)

Plan of Correction: ApprovedMarch 19, 2018

E001
The Nursing Home worked with Russell(NAME)& Associates and have completed the Nursing Home emergency preparedness plan. The plan will be fully implemented (MONTH) 23, (YEAR).
All Staff and Volunteers will be trained on the new EEP thru a series of in-services that will be given by Russell(NAME)& Associates and will
include a post test to show staff competence in training. All new staff or volunteers at time of orientation will also be educated on the EPP and take a post test.
The Administrator will monitor these in-services; review the plan on an annual basis and update as needed. The Administrator will also report to QA Committee on a monthly basis any changes or updates to the Plan as needed.
Responsible Party:(NAME)T Heard, Owner/Administrator

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 23, 2018
Corrected date: April 23, 2018

Citation Details

Based on an interview and record reviews conducted during the Life Safety Code Survey, it was determined that for two (CNA #2, Nurse Manager) of three staff members interviewed were not familiar with fire procedures. Specifically, staff did not know door tag locations or door tagging procedures. This is evidenced by the following: A review of the facility fire plan on 2/21/18 revealed that the fire site door was to be tagged with the yellow door tag as well as the adjacent room sharing a bathroom. Additionally, mark the door with an orange tag to indicate evacuated room. The tags were stored in the Nurse Manager's office. In staff interviews conducted on 2/22/18 between 1:46 p.m. and 1:59 p.m., Certified Nursing Assistant (CNA) #2 stated that the door tags were located with the fire extinguishers. The Nurse Manager stated that the red tag meant fire and the other tag meant the room had been checked so one does not need to go back in there. When asked, the Nurse Manager stated that the tag is put on the door even if the resident was in the room as long as the room was checked. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.7.1.2)

Plan of Correction: ApprovedMarch 22, 2018

K712
The two CNA's and the Nurse Manager have been instructed on door tagging procedures and the locations of the tags (MONTH) 13, (YEAR). An in-service by Russel(NAME)and Associates is scheduled for all staff on (MONTH) 10, (YEAR) to address door tagging procedures and the locations of the tags
Additionally the door tagging procedures will be reviewed at the facility's two mandatory disaster in-services that are presented yearly by Russell(NAME)and Associates.
The Administrator will monitor these in-services for attendance and report to the QA Committee of any findings.
Responsible Party:(NAME)T Heard, Owner/Administrator