Queens Nassau Rehabilitation and Nursing Center
August 28, 2018 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and staff interviews conducted during the recertification survey, it was determined that the facility did not ensure that assessment accurately reflected the residents' status. Specifically, The (MDS) Minimum Data Set assessments for Residents #11 and #134 did not accurately reflect the active [DIAGNOSES REDACTED]. This was evident for 2 out 33 of sampled residents reviewed. The findings are: 1) Resident # 11 was observed in a private room on 8/20/18 at 10:33 AM. The room is directly across from the nursing station. During subsequent observations of the resident on 8/23/18 12:008 PM the CNA (Certified Nurses Assistant) was setting up the resident's lunch plate and then fed the resident. The resident refused most of the meal. The resident was also observed in bed fully clothed on most days during the recertification survey. The MDS dated [DATE] documented the following Diagnoses: [REDACTED]. The MDS dated [DATE] only documented the [DIAGNOSES REDACTED]. The resident's most recent medical record documented that the resident was still being treated for [REDACTED]. On 2/27/18 the consultant Opthalmologist documented a [DIAGNOSES REDACTED]. Further documented [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The CCP (Comprehensive Care Plan) dated 7/30/18 Documented the following identified problems and interventions: 1) Dementia, Mood state indicated by easily annoyed, restless, sad affect, little energy, may urinate on floor 2) cognitive deficit 3) [MEDICAL CONDITION] OU dense cataract OD s/p retinal detachment OS [MEDICAL CONDITION] no tx. 4) decreased communication, 5) self care deficit 6) activities 7) psychosocial well being 8) Behavioral problem 9) at risk for falls and injury related to cognitive deficit, sensory deficit, communication deficit, incontinence, handheld assist, [MEDICAL CONDITION] drug use, aggressive behavior, likes to go back to bed after meals, dx [MEDICAL CONDITION], rhobdo[DIAGNOSES REDACTED] and [MEDICAL CONDITION] with interventions to orient to surrounding & environment PRN, call bell within reach, keep bed low & locked, instruct res to request for assistance from staff, PT/OT screen assist with transfers & ADL's as necessary, continual assessment of mobility & need for assist, psych f/u & meds as ordered with eval doc 5/10/18 res has non injurious fall in room - neurocheck done x 24hrs CCP continue no injury. 8/20/18 res was obs on floor lying on left side no injury no s/s of distress, intervention= neurocheck, body check. 2) Resident #134 was observed on 08/23/18 at 2:18 PM seated in high back wheel chair, clean, well groomed, lap tray on wheel chair with lunch tray on top. The resident independently feeding self with use of right hand and left hand splint in place. both feet supported on stirrups. The MDS dated [DATE] documented the resident with [DIAGNOSES REDACTED]. The MDS dated [DATE] only documented that resident with the following Diagnoses: [REDACTED]. The resident's medical record documented that the resident was receiving treatment for [REDACTED]. On 08/28/18 at 1:17 PM the MDS coordinator who was responsible for all assessments was interviewed. The MDS coordinator stated that she missed the review of that section of the MDS that documents diagnoses. 415.11(b)

Plan of Correction: ApprovedOctober 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. MDS assessments for resident #11 and resident #134 did not accurately reflect the active [DIAGNOSES REDACTED].
a. The medical records were reviewed on active [DIAGNOSES REDACTED].#134 by the Assessor along with the physician. The active [DIAGNOSES REDACTED].?s #11 and #134 were corrected and re-submitted at the time of the findings.
II. All residents? MDS assessments were identified to be at risk for this deficient practice.
a. The policy and procedure for MDS assessment which includes protocols and data sources for assessments per CMS requirements, was reviewed by the MDS Coordinator, MDS Assessor, Director of Nursing, and Administrator and revised as necessary
b. All MDS Assessors were immediately re-educated by a qualified MDS Assessor on accurate assessment and coding for the MDS assessment per CMS requirements.
III. To assure accuracy of MDS assessments reflecting the residents? status and to prevent recurrence the following measures have been initiated:
a. All MDS assessors will continue to be educated on accurate assessment for MDS.
b. The MDS coordinator will monitor compliance with completion of all MDS sections for accuracy.
IV. As part of our QA program the MDS Coordinator/ Assessor will perform the following tasks:
a. An Audit tool was developed to monitor for compliance with accuracy.
b. The MDS Coordinator/ designee will audit the MDS books as follows: ten MDS books for the first month, then five books per month for the remainder of the four quarters.
c. Any negative findings will be reported to the Director of Nursing/ Administrator and reviewed at quality assurance meetings every quarter for the next year.

Responsible person: Director of Nursing

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: August 28, 2018
Corrected date: October 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review staff interview the facility conducted during the recertification survey it was determined that the facility did not ensure that residents comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment. Specifically, The CCP (Comprehensive Care Plan) for Resident #11 identified the resident as at risk for falls and had interventions in place in an attempt to prevent falls. However, the resident had multiple falls and the facility did not review the effectiveness of the interventions. This was evident for 1 out of 33 sampled residents. The findings are: On 08/20/18 at 10:33 AM Resident #11 was observed in private bedroom room located across from the nurse's station. The resident was observed lying in supine on side in bed fully clothe with headboard of bed facing door to hallway and foot of bed facing window. The resident's quarterly MDS assessment dated [DATE] documented the following: unclear speech, sometimes understand/understood, severely impaired vision, no corrective lens, short/long memory problems, severely impaired decision making, mood of trouble sleeping, feeling tired occurs 12 - 14 days, trouble concentrating, moving slowly occurs 7 - 11 days, required limited assistance of 1 person with bed mobility. Required extensive assistance of 1 person with transfers, and locomotion on/off unit, Total dependence of 1 person assistance with toilet use, personal hygiene, and bathing, It also documented 1 fall since prior assessment with no injury. The resident's CCP dated 7/30/18 documented the following: 1) Dementia, Mood state indicated by easily annoyed, restless, sad affect, little energy, may urinate on floor 2) cognitive deficit 3) [MEDICAL CONDITION] OU dense cataract OD s/p retinal detachment OS [MEDICAL CONDITION] no tx. 4) decreased communication, 5) self care deficit 6) activities 7) psychosocial well being 8) Behavioral problem 9) at risk for falls and injury related to cognitive deficit, sensory deficit, communication deficit, incontinence, handheld assist, [MEDICAL CONDITION] drug use, aggressive behavior, likes to go back to bed after meals, dx [MEDICAL CONDITION], rhobdo[DIAGNOSES REDACTED] and [MEDICAL CONDITION] with interventions to orient to surrounding & environment PRN, call bell within reach, keep bed low & locked, instruct res to request for assistance from staff, PT/OT screen assist with transfers & ADL's as necessary, continual assessment of mobility & need for assist, psych f/u & meds as ordered with eval doc 5/10/18 res has non injurious fall in room - neurocheck done x 24hrs CCP continue no injury. 8/20/18 res was observed on floor lying on side with no injury no signs or symptoms of distress. The intervention in place was neurocheck, body check. documented that the interventions were ongoing. No documented evidence that the IDT reviewed the interventions in place to prevent falls on 7/30/18. The CCP documented that the interventions were ongoing, however it does not document that the IDT reviewed the current interventions to determine if they were effective to prevent further incidents of falls. The CCP documented neuro checks and body check as intervention. Neuro checks are a standard of practice after a fall it is not considered an intervention to prevent a fall or mitigate an injury of a fall. There was no documented evidence that the facility implemented new interventions after each fall. On 08/27/18 at 12:58 PM the ADNS (Assistant Director of Nursing) was interviewed. The ADNS the it was her responsibility to revise the CCP after 8/20/18 fall as the current charge nurse is new to the facility. However, it was the responsibility of the former RN who was the charge nurse to have updated the CCP after the fall in May, (YEAR). The RN who was the charge nurse should have revised the care plan and the nurse no longer works here. She further stated that the MDS coordinator is in charge of care planning. When a resident has an accident or incident the CCP is reviewed for a new intervention if required. If assessed then discussed would the resident benefit from something more then there would be a change to the CCP. She further stated that the resident has a behavior of laying himself on the floor If the incident is unwitnessed they still make out an incident report. In the evening monitoring is done every 30 minutes, but not same during day. His room is right across from nursing station and easily seen by the nurse 08/27/18 01:16 PM RN#1 was interviewed. RN # stated that when the resident has an accident or incident it is her responsibility to initiate the neurocheck for 24hrs, to make sure no neurological changes. Assess for injuries an any distress. After an accident or incident the CCP should show a different intervention than what was there. The protocol is to assess and do neuro and body checks. RN #1 acknowledged that this would be done for anyone found on the floor and was not specific to this resident. On 08/28/18 at 11:55 AM ADNS was interviewed again to verify the process. The ADNS stated that the CCP identified that the resident was at risk for falls. However, although the resident was found twice on floor a new CCP for actual fall would not be done. What would be updated would be the identified problem of at risk for falls to reflect actual fall. She further stated that a CCP would be generated for actual falls if there was an injury. No new interventions were added after the 2 falls of 5/10/18 and 8/20/18 and a new intervention should have been added. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedOctober 4, 2018

I. The survey finding for Resident #11 determined that the fall risk care plan was not updated with new interventions. Despite current interventions the Resident experienced a non-injurious fall.
A. The comprehensive care plan for Resident #11 was reviewed by the interdisciplinary team and updated to reflect different interventions to prevent falls.
b. The incident report was reviewed by the Risk Manager/ Fall Committee.
c. Both policy and procedure for Care Planning and Accidents/ Incidents were reviewed and revised as necessary.
II. All residents care plans were identified to be at risk for this deficient practice.
A. All IDT members involved in care-planning will be re-educated on the importance of accurate assessment, individualized interventions for each resident and timely evaluation to determine effectiveness.
b. The Risk Manager/fall committee/ IDT team will continue to meet and review interventions for fall prevention and evaluation of effectiveness within 24-72 hours.
III. To ensure the highest standard of care/services are provided by qualified persons/per care plan and to prevent recurrence with review and update of care plans for fall prevention, the following measure have been initiated.
a. The Risk Manager/MDS Coordinator/ Designee will continue to educate IDT members on the care planning procedure with emphasis on the timely initiation of interventions and evaluation for effectiveness.
b. The Risk Manager/ Fall Committee/ Inter Disciplinary Team will review each accident/ incident and CCP for suitable fall prevention interventions and evaluations for efficacy after every incident/accident.
c. An audit tool was developed to ensure that the care plan was updated with appropriate new interventions post a fall related incident/accident.
IV.As part of our QA program the Risk Manager/ Designee will perform the following tasks:
a. The Risk Manager/ ADNS/Designee will audit 10% of fall related accidents/incidents monthly for the 1st quarter, then 5% quarterly for the next 3 quarters.
b. Any negative findings will be reported to the Director of Nursing/ Administrator and be reviewed at quality assurance meetings every quarter for the remainder of four quarters for the next year.
Responsible Party: Director of Nursing

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey it was determined that the facility did not ensure that two quarterly MDS (Minimum Data Set) resident assessments were transmitted to CMS (Centers for Medicare/Medicaid Services) within 14 days of completing the residents' final assessment. This was evident for 2 out 5 residents reviewed for accuracy and timely submission of assessments out of a sample of 33 residents. ( Resident #1, and #2) The findings are: The policy and procedure on Minimum Data Set (MDS 3.0) reviewed on ,[DATE] documents IDC (Interdisciplinary) team members completes discipline specific assessments. Completes appropriate section of MDS 3.0. Signs completed MDS 3.0 attesting to its completion. Submission and Filing of MDS: MDS coordinator review completed MDS assessments after performing logic checks and corrections. The administrator submits MDS to the state. The MDS assessment for Resident # 1 was completed on [DATE], but was not submitted until [DATE]. The MDS assessment for Resident #2 was completed on [DATE], but was not submitted until [DATE]. An interview was conducted on [DATE] at 9:21 AM with the RN ( Registered Nurse) MDS assessor. The surveyor interviewed the MDS assessor about residents assessment for resident #1 and #2. The RN MDS assessor stated that they submitted both quarterly assessments late. The ARD (Assessment reference date ) was [DATE] end [DATE] and the quarterlies were submitted on (MONTH) 22,2018. The state agency surveyor (SA) asked the RN MDS what the process once there are ready for submission she determines when to submit the MDS complete books. Both assessments were information in Section O (psychotherapy total number of therapy days). Both resident was not receiving psychotherapy. The RN who suppose to complete the section was unaware that the section was completed by the RN MDS assessor. An interview with the Administrator was conducted on [DATE] at 3:15 PM. The MDS process is they have a MDS coordinator and different professional go into the books and complete there sections and once the books are ready for submission the MDS coordinator, and MDS assessor and RN MDS person who covers the coordinator can give the administrator a list of books that are completed to be submitted. Once they provide the list of completed MDS the administrator submits the books right away. The SA asked the administrator what happen to resident # 1 and #2? The administrator responded that the coordinator never gave the assessments to the administrator to submit. The administrator states that his role is to submit the books that are completed, he submits all assessments the day he gets the completed one, whether it is a resident who expired, transferred, or left to the community. If the book is rejected he notifies the MDS personnel right away and they would fix it. Another interview was conducted on [DATE] at 9:45 AM with the MDS assessor. She stated it would be the MDS coordinator responsibility to ensure the MDS is complete and submitted. An interview was conducted with the MDS coordinator on [DATE] at 12:07 PM. The MDS coordinator stated the following is my responsibility: coordinating and completion of the MDS books, care planning schedule for care plans, schedule MDS books along with care plan meeting. The MDS coordinator is responsible Monthly for medicare MDS assessment to be completed reviewed and submitted. She is responsible for all residents MDS assessments. The surveyor asked if she reviews that all books are completed and submitted in a timely manner and what occurred with resident #1 and resident #2 assessments. The MDS coordinator missed looking at Section O to ensure it was completed (the psychotherapy). The new MDS assessor did not want to put in the wrong information and it was missed.

Plan of Correction: ApprovedSeptember 17, 2018

I. MDS assessments for resident #1 and resident #2 were not completed or transmitted as specified by CMS within 14 days after completion as required.
a. Both Resident MDS assessments were reviewed, completed and submitted by the MDS Assessor on the date of the findings.
b. The policy and procedure for MDS which includes encoding and transmitting resident assessments per CMS requirements was reviewed by the MDS Coordinator, MDS Assessor, Director of Nursing, and Administrator and revised as necessary.
II. All Resident MDS assessments were identified to be at risk for this deficient practice.
a. All MDS assessors were immediately re-educated by a qualified MDS Assessor on completeness of Resident MDS assessments and timely submission in order to ensure compliance with regulatory requirements.
III. To ensure the highest standard is met for MDS completion and timely submission, the following measures have been initiated:
a. All MDS assessors will continue to be educated and updated on current CMS requirements and standards for utilization of MDS resident assessments.
b. MDS Coordinator will review for completeness of assessments at the end of each assessment period including use of hard copy schedule and MDS software. The MDS coordinator will report complete assessments to Administrator for submission in a timely manner.
c. IDT team members will be contacted for issues with completion of assessments, which will be finalized immediately.
IV. As part of our QA program the MDS Coordinator and In-service director will perform the following tasks:
a. The MDS Coordinator/ designee will continuously monitor all MDS assessor entries and provide education on the most current MDS versions per CMS requirements annually and as necessary to ensure compliance.
b. MDS coordinator will monitor for MDS compliance. Any findings will be reported to the Director of Nursing and/or Administrator and reviewed at quarterly quality assurance meetings.
Responsible Party: Director of Nursing

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation the facility failed to ensure that its staff demonstrates proper hand hygiene between residents to prevent the spread of infections. Specifically the Licensed Practical nurse (LPN#1) was observed on 2 occasions administering medications and not [MEDICATION NAME] hand hygiene. 2) LPN#1 was also observed not [MEDICATION NAME] hand hygiene after assisting a resident with care and then opening medication to give to another resident. This deficient practice was observed by one nurse on multiple occasions. The findings are: The facility Policy and Procedure on Standards Precaution dated (MONTH) (YEAR) documented wash hands immediately after gloves are removed, between patient contacts, and otherwise indicated to avoid transfer of microorganisms to other patients or environments. It may be necessary to wash hands between tasks and procedures. Use plain, non-antimicrobial soap for routine hand washing. Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances such as outbreaks. The facility general guidelines on infection control stipulates that standard precautions shall be used when caring for residents at all times regardless of their infection status , it must be used in the care of all residents , in all situations, before preparing or handling medications. 1) On 8/22/18 at 9:00 am during medication observation LPN #1 on 2 south was preparing to administer medication when she noticed a resident was having difficulty propelling his chair. She had stopped, held onto the wheelchair handles and assisted the resident moving. The LPN had not washed her hands but proceeded opening the medication cart and was reaching out for medication packages . She was stopped by the surveyor. The LPN stated: I should have washed my hand prior going into the medication cart. On 8/22/18 at 9:15 AM LPN #1 was interviewed on infection control and prevention, she replied: I did wrong, I should have washed my hands before touching the medication on the cart or used the hand sanitizer, I have it right here on the cart. I did touch the handles of the chairs, a lot of people touch these handles. She was asked about her education regarding infection control as it relates to medication administration. She replied that she was educated in hand hygiene procedure and policies. LPN #1 was interviewed about details regarding the in-service and education. She stated: I was instructed that we must wash our hands before starting medication administration and afterwards, between residents we must maintain universal precautions when caring for residents at all times. The in-service coordinator was interviewed on 8/22/18. She stated that LPN#1 was enrolled in a in-service class on hand washing on 1/17/18, the in-service attendance record indicated the same. 415.19(b)(4)
2) On 8/24/2018 10:00 AM on the 2nd floor LPN #1 was randomly observed giving resident #165 his medication at the medication cart. The LPN then proceeded to position resident #35 in his wheelchair, he was sitting in front of his room. No hand hygiene was observed between giving resident #165 medication and providing direct assistance to Resident #35. 3) After assisting resident #35, the LPN returned to the medication cart and proceeded to retrieve medication from the cart and then proceeded to pop out medication from the blister pack. LPN #1 did not perform hand hygiene after assisting resident #35; or prior to retrieving medication from the medication cart and opening the blister pack and popping out the medication. On 08/28/18 at 11:29 AM a second interview was conducted with LPN #1. She stated hand washing is performed when giving and after medication, between residents, when touching resident equipment, when residents are on contact precautions and residents' bodily fluids. She stated antimicrobial agent is used when given medication between residents. Soap and water is used after medicating three patients, or being in contact with blood or bodily fluid. Hand washing is performed for a duration of 3-4 minutes. She stated that the last time she received in-services were two months ago. On 08/27/18 at 10:27 AM the Infection preventionist was again interviewed. She stated that the protocol on hand washing for example are performed after using the bathroom, visibly soiled and contaminated, before feeding after taking care of residents, nursing care and procedures. She stated that the staff get in-services at least twice per week and when need arises. The staff gets demonstration and then the facility does return demonstration. The staff can also use an online learning service that staff for education. There is also a competency that is performed to ensure compliance. On 08/28/18 at 08:28 AM the ADON (Assistant Director of Nursing) was interviewed. She stated that staff should be washing their hands before care, after care, between residents and during medication administration. Before using the rest room and after using the rest room and if hands become soiled staff are supposed to wash their hands right away. She stated that there is alcohol based hand rub that is available for hand hygiene on each unit, on medication carts and communal areas within the facility. If a resident has [MEDICAL CONDITION] the staff must use soap and water and performed proper hand hygiene. She stated that in-services are given by the infection control nurse. 415.19 (b) (4)

Plan of Correction: ApprovedOctober 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The survey finding was that LPN #1 was observed not [MEDICATION NAME] hand hygiene consistently after assisting residents and during medication administering.
a. The policy and procedure for infection prevention and control policy (IPCP) was reviewed by the director of nursing, medical director and in-service director and revised as necessary.
b. The director of nursing and the in-service director met with LPN #1as identified on survey, and provided 1:1 education and counseling on following the (IPCP) with emphasis on hand-washing during medication administration and between Residents. LPN #1 appropriately verbalized and provided return-demonstration on proper hand-washing protocol and technique during medication pass, between resident care and per protocol.
II. All Residents are identified as at risk for this deficient practice.
a. The In-service Coordinator reviewed and revised the competency tool for evaluation with return demonstration on hand hygiene for Licensed Nurses.
b. All Licensed Nurses will be re-educated by the in-service director on the IPCP with emphasis on hand-washing during Medication administration and between resident care per protocol.
III. To ensure the highest standard of care/ services by Licensed Nurses
a. All Licensed Nursing staff continue to be educated with competency on the IPCP on orientation, annually and as needed to ensure infection prevention and control is provided by qualified persons.
b. The Infection Preventionist / In-service Coordinator/ Designee will continue to monitor for compliance of Licensed Nursing Staff with hand hygiene during Medication administration, between resident care and per protocol.
c. An audit tool was developed by the ADON to ensure compliance with evaluations of hand hygiene/ IPCP practices.
IV. As part of our QA and Infection Control program and to ensure compliance the in-service director will perform the following tasks:
a. The in-service director/ Designee will continue to provide education to Licensed Nurses on infection prevention/ hand hygiene with medication administration, between resident care and per protocol.
b. The In-service Director/ Designee will evaluate all Licensed Nursing staff with the use of a competency validation test. Staff will also be observed for return-demonstration of proper hand-washing technique upon hire, annually and as necessary. 1:1 on-site in-service with immediate return demonstration will be provided as necessary to ensure compliance.
c. The In-service Director/ Designee will audit hand hygiene for 5 licensed Nurses per month for the 1st quarter, then 2 Nurses per month for the next three quarters.
d. Any negative findings with compliance will be reported to the Director of Nursing/Administrator. Results will be reviewed at quarterly quality assurance meetings for the next year.
Responsible Party: Director of Nursing

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: Pattern
Severity: Potential to cause minimal harm
Citation date: August 28, 2018
Corrected date: N/A

Citation Details

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver(s) to be continued. Time Limited Waiver Expires 10/02/2018. K161 S/S=B The facility did not ensure that the nursing home building that is built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000)) was not more than two stories in height with a complete automatic sprinkler protection system. 10NYCRR 711.2(a)(1) NFPA 220 NFPA [PHONE NUMBER]: 19.1.6.1

Plan of Correction: ApprovedAugust 29, 2018

Facility wishes waiver to be continued.
Facility has an approved waiver # 181w052 dated 05/07/2018.
The Waiver is based upon FSES prepared by(NAME)H. Pinner of Pinner Architecture PLLC dated (MONTH) 21, (YEAR).

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: November 16, 2018

Citation Details

Based on observation, and staff interview, it was determined that facility did not ensure the egress pathway leading from the outside patio was kept free of impediments. References are made to various storage items. This was observed on 1 out of 5 floors. The Finding is: On (MONTH) 21 (YEAR), at approximately 10:15 AM, during the Annual Recertification Survey of the facility, the outside patio was surveyed. It was observed that items such as air conditioning units and a barbeque grill were partially blocking the egress pathway from the patio to the public way. The facility must ensure all exits are maintained free of impediments in the event of a fire or other emergency. In an interview with the Maintenance Director at approximately 10:20 am, on the same day, he stated that all the items would be removed and would ensure that it would remain unimpeded. 711.2 (a)(1)

Plan of Correction: ApprovedAugust 29, 2018

The Director of Maintenance and/or maintenance staff immediately removed all items that were found to be partially blocking the egress pathway from the patio to the public way.
The Director of Maintenance and/or maintenance staff immediately inspected all of the facility's floors to ensure that all exits are maintained free of impediments and corrected any noted.
The Director of Maintenance and/or maintenance staff will monitor and ensure that all exits are always maintained free of impediments in the event of a fire or other emergency.
The Director of Maintenance will report any findings to the Administrator and Q/A committee.