Rutland Nursing Home, Inc.
May 11, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.35(a)(3)(4)(c):COMPETENT NURSING STAFF

REGULATION: §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2018
Corrected date: July 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, during the Recertification survey, the facility did not ensure that nurses aides are able to demonstrate competency in skills and techniques necessary to care for resident's needs as identified through resident assessments and described in the plan of care. Specifically, a Certified Nursing Assistant (CNA) did not know how to apply a resident's knee device. This was evident for 1 of 3 residents reviewed for Range of Motion (Resident # 78). The finding is : The facility policy and procedure on Restorative Nursing Programs dated 03/2018 documented: Nursing personnel are trained on basic or maintenance restorative nursing care that does not require the use of qualified therapist or licensed nurse oversight. This training may include, but is not limited to: maintaining proper positioning and body alignment --- assisting residents in adjustment to their disabilities and use of any assistive devices- assisting residents with range of motion exercises, performing passive range of motion for residents unable to actively participate. Resident # 78 a resident admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ( MDS ) assessment dated [DATE] documented that the resident had severely impaired cognition and was non-verbal. The MDS further documented the resident required total assistance for all Activities of Daily Living (ADLs), including dressing, bathing, and transfers. On 5/08/2018 from 10:00 am to 1:10 PM , the resident was observed in her room sleeping in a gerichair appropriately dressed, with contractures of bilateral upper and lower extremities . Right upper extremity was contracted more than the left upper extremity. There was no device on the right hand. The Right hand splint and Knee orthosis were observed lying on the resident's lap. The Occupational Therapy Screening Form dated 3/26/18 documented the resident had range of motion impairment on both sides of the upper and lower extremities. The Splints/Braces Screening Form dated 4/24/17 documented recommendations for Bilateral Elbow Corrective Orthosis (ECO), Bilateral Resting Hand Splints (RHS), and Bilateral Knee Corrective Orthosis (KCO). The form also documented the resident needed a Left KCO. The Comprehensive Care Plan (CCP) for impaired ability to move independently dated 4/24/2017 documented the resident had Bilateral elbow, hand, and wrist contractures and a Left knee contracture. The interventions listed were R KCO, Bilateral RHS, and Bilateral ECO to be worn during the day. The Splint/Braces Screening Form and the CCP have conflicting information regarding whether the resident requires a knee corrective orthosis on the left, right, or both knees. The Certified Nursing Assistant (CNA) was interviewed on 5/8/18 at 1:15 PM and stated that she gave the resident a bath earlier planned to come back and apply the devices. She then applied the right hand splint. She stated she did not know how to apply the right knee corrective orthosis splint, and the rehab CNA usually applies the knee splint. During the interaction, the CNA stated she had been employed in the facility for 8 years. The Certified Nursing Assistant (CNA) inservice file was reviewed and training on the use of devices was part of her inservice during her orientation. On 5/11/18 at 1:10 PM, the Rehab CNA was interviewed and stated she works Monday through Friday and applies the devices. She further stated all CNAs should know how to apply the devices because she worked as a CNA on the unit previously and they frequently gave us training. When asked who applies the devices on days she is not available, she stated I don't know. On 5/11/2018 at 1:30 PM , the Director of Education and the Director of Nursing (DNS) were interviewed and both stated all CNAs are trained on the application of the devices . The Clinical Nurse Managers are responsible for the annual competency and to enhance and re-inservice the staff. It is our expectation that all CNAs know how to apply the devices. 415.26(c)(I)(iv)

Plan of Correction: ApprovedJune 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F726 COMPETENT STAFF
I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #78 sustained no adverse reaction. The Director of Rehabilitation, Physical Therapist and Occupational Therapist performed an assessment on the resident. It was determined that secondary to the resident?s contractures the resident would benefit from continued use of bilateral Elbow Corrective Orthosis (ECO), bilateral Resting Hand Splint (RHS), right Knee Corrective Orthosis (KCO). There was no decline in range of motion and no increase in contractures. As per rehabilitation assessment physician orders [REDACTED].?s room. The nurse transcribed the order to the cna accountability record and the Director of LTC Rehabilitation in-serviced the staff on the floor to properly apply them.
The cna who failed to correctly apply the assistive device was disciplined and is no longer an employee of Rutland Nursing Home.

DATE OF COMPLETION: (MONTH) 31, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by this practice.
To prevent and correct these issues, all residents with splinting devices were identified and reassessed by rehabilitation for appropriateness of splint, need to continue use of the splint or that the splint is no longer necessary all residents with orthosis devices will be reevaluated every three months by rehabilitation. Nursing staff will be re-educated on the proper application of orthosis devices.
DATE OF COMPETION: JULY 8, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of rehabilitation in collaboration with the Director of Nursing reviewed the policy on assistive devices. Revisions to the policy were made to ensure that splint/brace screening form all residents with splints is properly followed. The policy explains the reason for assistive devices, the different types of assistive devices, in addition that the rehabilitation therapist must in-service unit staff whenever any new assistive devices are ordered.
The Director of LTC Rehabilitation has in-serviced all Physical and Occupational therapist as well as all nurse managers and Rehabilitation cna's on correct application of splints.

The Director of LTC Rehabilitation along with the Director of Staff Education will re-in-service all nursing staff on the policy and proper application of assistive devices.
Nursing supervisors will monitor compliance with the above protocols during routine care. Immediate corrective action, including staff re-education, will be implemented, as needed.
DATE OF COMPLETION: (MONTH) 9, (YEAR)

IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to splints. Nurse Managers will audit 20% of residents with splints monthly for one year to ensure that the resident is wearing their splints and that it is properly applied.
Audit findings will be reported to the Director of Nursing (DON). The DON will report the audit findings to the Administrator monthly or sooner as warranted.
The DON will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate.
Responsibility: Director of Nursing
DATE OF COMPLETION: JULY 9, (YEAR)


FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2018
Corrected date: July 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews , the facility did not ensure that resident with limited range of motion and mobility receives appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion . This was evident in 1 of 3 residents reviewed for Range Of Motion (ROM ). (Resident # 78). The finding is : The facility policy and procedure Prevention of Decline in Range of Motion dated 03/2018 documented the following: residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Assessment and appropriate care planning will be in place, the facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to appropriate services -- specialized rehabilitation, restorative, maintenance and appropriate equipment -- braces or splints. Resident #78 a resident admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ( MDS ) assessment dated [DATE] documented that the resident had severely impaired cognition and was non-verbal. The MDS further documented the resident required total assistance for all Activities of Daily Living (ADLs), including dressing, bathing, and transfers. On 5/08/2018 from 10:00 am to 1:10 PM , the resident was observed in her room sleeping in a gerichair appropriately dressed, with contractures of bilateral upper and lower extremities . Right upper extremity was contracted more than the left upper extremity. There was no device on the right hand. The Right hand splint and Knee tortoises were observed lying on the resident's lap. The Occupational Therapy Screening Form dated 3/26/18 documented the resident had range of motion impairment on both sides of the upper and lower extremities. The Splints/Braces Screening Form dated 4/24/17 documented recommendations for Bilateral Elbow Corrective Orthosis (ECO), Bilateral Resting Hand Splints (RHS), and Bilateral Knee Corrective Orthosis (KCO). The form also documented the resident needed a Left KCO. The Comprehensive Care Plan (CCP) for impaired ability to move independently dated 4/24/2017 documented the resident had Bilateral elbow, hand, and wrist contractures and a Left knee contracture. The interventions listed were R KCO, Bilateral RHS, and Bilateral ECO to be worn during the day. The Splint/Braces Screening Form and the CCP have conflicting information regarding whether the resident requires a knee corrective orthosis on the left, right, or both knees. The Certified Nursing Assistant (CNA) was interviewed on 5/8/18 at 1:15 PM and stated that she gave the resident a bath earlier planned to come back and apply the devices. She then applied the right hand splint. She stated she did not know how to apply the right knee corrective orthosis splint, and the rehab CNA usually applies the knee splint. During the interaction, the CNA stated she had been employed in the facility for 8 years. The Certified Nursing Assistant (CNA) inservice file was reviewed and training on the use of devices was part of her inservice during her orientation. On 5/11/18 at 1:10 PM, the rehab CNA was interviewed and stated she works Monday through Friday and applies the devices. She further stated all CNAs should know how to apply the devices because she worked as a CNA on the unit previously and they frequently gave us training. When asked who applies the devices on days she is not available, she stated I don't know. On 5/11/2018 at 1:30 PM , the Director of Education and the Director of Nursing (DNS) were interviewed and both stated all CNAs are trained on the application of the devices . The Clinical Nurse Managers are responsible for the annual competency and to enhance and re-inservice the staff. It is our expectation that all CNAs know how to apply the devices. 415.12(e)(2)

Plan of Correction: ApprovedJune 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F688 RANGE OF MOTION ASSISTIVE DEVICES
I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
Resident #78 sustained no adverse reaction. The Director of Rehabilitation, Physical Therapist and Occupational Therapist performed an assessment on the resident. It was determined that secondary to the resident?s contractures the resident would benefit from continued use of bilateral Elbow Corrective Orthosis (ECO), bilateral Resting Hand Splint (RHS), right Knee Corrective Orthosis (KCO). The assessment was to continue to using the assistive devices.There was no decline in range of motion and no increase in contractures. As per rehabilitation assessment physician orders [REDACTED]. The nurse transcribed the order to the cna accountability record and the Director of LTC Rehabilitation in-serviced the staff on the floor to properly apply them.

DATE OF COMPLETION: (MONTH) 31, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by this practice.
To prevent and correct these issues, all residents with splinting devices were identified and reassessed by rehabilitation for appropriateness of splint, need to continue use of the splint or that the splint is no longer necessary All residents with orthosis devices will be reevaluated every three months by rehabilitation. All nursing staff will be re-educated on the proper application of assistive devices.
DATE OF COMPETION: JULY 8, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of rehabilitation in collaboration with the Director of Nursing reviewed the policy on splints. Revisions to the policy were made to ensure that the splint/brace screening form for all residents with splints is properly followed. The policy explains the reason for assistive devices, the different types of assistive devices, in addition that the rehabilitation therapist must in-service unit staff whenever any new assistive devices are ordered.
The Director of LTC Rehabilitation has in-serviced all Physical and Occupational therapist as well as all nurse managers and Rehabilitation cna's on correct application of splints.
The Director of LTC Rehabilitation along with the Director of Staff Education will re-in-service all nursing staff on the policy and proper application of orthosis devices.
Nursing supervisors will monitor compliance with the above protocols during routine care. Immediate corrective action, including staff re-education, will be implemented, as needed.
DATE OF COMPLETION: (MONTH) 9, (YEAR)

IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to application of assistive devices. Clinical Nurse Managers and Nursing Care Coordinators will audit 20% of residents with orthosis monthly for one year to ensure that the resident is wearing their orthosis and that it is properly applied.
Rehabilitation will audit 20% of residents with orthosis devices monthly for one year to ensure the splint/braces screening form and the comprehensive Care Plan match.
Audit findings will be reported to the Director of Nursing (DON). The DON will report the audit findings to the Administrator monthly or sooner as warranted.
The DON will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate.

Responsibility: Director of Nursing
DATE OF Completion (MONTH) 9, (YEAR)

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2018
Corrected date: July 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews during the re-certification survey, the facility did not ensure housekeeping and maintenance services maintained a sanitary and orderly interior. Specifically, (1) Tube feed drippings were observed splattered on a resident wardrobe closet door (Resident #197) (2) A resident wardrobe closet door was observed with one missing and one loose door handle (Resident #578) (3) A resident privacy curtain was observed to be torn (Resident #316) and (4) 2 resident tube feed pumps and poles were observed stained with a green colored substance (Resident # 78 and # 284 ). This was evident on 3 of 7 resident floors (Floors 3, 5, and 9W). The findings are: The facility policy and procedure titled, Preventative Maintenance (Dated 3/2018) was reviewed. The director of safety, nurse manager, and assistant director of housekeeping makes weekly rounds on clinical units and resident rooms to identify items that need repair. The facility Building Services Aide Task Assignment was reviewed. Daily duties include damp wipe closets and IV poles. The facility Infection Control Round Worksheet was reviewed. Items checked in patient's room include if the environment and curtains are clean and safe. Items checked under equipment include if IV poles are clean. The facility Building Services Inspection Checklist was reviewed. Items checked include if room curtains are in good working order. (1) Multiple observations were made in Resident #197's room on the fifth (5th) floor on 5/7/18 at 8:35 AM, 5/8/18 at 9:43 AM, and 5/9/18 at 11:29 AM of tube feed drippings splattered on the wardrobe closet. (2) Observations were made in Resident #578's room on the 5th floor on 5/8/18 at 9:54 AM and 5/9/18 at 11:47 AM. There was a missing right handle and a loose left handle on the wardrobe closet doors. Floor five log book was reviewed. There were no reports of above concerns observed documented. On 5/10/18 at 12:04 PM, the Certified Nursing Assistant (CNA #1) on the 5th floor was interviewed and stated he noticed the tube feed drippings on the closet door, but he could not recall when he reported it to the charge nurse. He further stated he reports to the charge nurse if he sees spills and stains on resident furniture so that housekeeping will be notified. On 05/10/18 at 11:55 AM and 12:10 PM, the Registered Nurse (RN #1) on the 5th floor was interviewed and stated each floor has a housekeeper for all shifts. Staff will notify the housekeeper of anything that needs to be cleaned. She stated maintenance will be contacted, and staff will document resident furniture in disrepair in the Maintenance Log Book. She further stated she did not notice the broken and loose handles on the closet doors. On 05/10/18 at 12:12 PM, the Clerk (#1) on the 5th floor was interviewed and stated they used to contact maintenance via computer, but the program has not been working since some time last year. Instead, maintenance is contacted directly. She stated she created a book so staff can document concerns when she is not there, and she follows up the next day. She stated maintenance and building services are contacted for reports of concerns with resident furniture. The clerk #1 stated a housekeeper is assigned to the floor. On 05/10/18 at 12:50 PM, the housekeeper (#1) on the 5th floor was interviewed and stated it is his responsibility to clean the resident furniture when he sees stains. He calls his supervisor if he sees broken furniture. The housekeeper #1 further stated he had not noticed anything broken or not clean on the floor. (3) Multiple observations were made in Resident #316's room on the third (3rd) floor on 05/07/18 at 08:18 AM, 10:59 AM, and 12:06 PM, and on 05/09/18 at 12:23 PM of the resident's privacy curtain torn on the top of the mesh portion of the curtain. The 3rd floor Maintenance log book was not reviewed. Staff were unable to locate the log book. On 05/10/18 at 12:27 PM, the Assistant Director of Building Services (ADBS #2) was interviewed and stated he does continuous environmental rounds daily, where he identifies cleanliness and items in disrepair. He stated he usually gets a call from the nurse or the nurse calls directly to facilities to report concerns. The ADBS #2 stated his department is responsible for replacing privacy curtains. On 05/11/18 at 10:11 AM, RN #2 was interviewed and stated administration and herself do environmental rounds into resident rooms. She stated they have a log to document concerns, but she was unable to locate it for surveyor review. RN #2 also stated if she sees something in disrepair, she will call building services as well. RN #2 further stated she noticed the torn privacy curtain and had reported it, but it was not replaced. On 05/11/18 at 12:11 PM, the Assistant Director of Building Services (ADBS #1) was interviewed. He stated the current process for staff to report concerns is to call his department directly. He stated he is in charge of the housekeepers. Housekeepers are responsible for cleaning resident room furniture, including stained closets. If the housekeepers see any broken furniture or torn privacy curtains they are supposed to notify him or the nurse so building services will be aware. Building services will determine if furniture can be fixed and privacy curtains can be replaced. On 05/11/18 at 02:21 PM, the Director of Facilities stated he is responsible for maintenance and engineering. He stated the resident units can call or email the help desk to submit a facility service request. He further stated he was not aware of the broken wardrobe closet handles, and if it is not reported he won't know.
4) On 05/07/2018 at 7:00AM, the following was observed during the initial tour: Resident #78, in room [ROOM NUMBER]B, was observed with a tube feeding pump with a dried, cream colored substance on the body, pole, and pedestal of the pole. In the corner of the closet, there was a rat trap. The corners of the room had accumulated dust, and the wooden siderails had peeled off varnished. Resident #284, in room [ROOM NUMBER]A, was observed with accumulated dust in the corners of the floor. The tube feeding pump had a dried cream colored substance on the body of the pump, pole, and pedestal. On 05/08/2018 at 10:30 AM, both feeding pumps in room [ROOM NUMBER]B and 1914A were observed again with dried cream-colored substance on the same body of the pump and the poles. On 05/08/2018, the Licensed Practical Nurse (LPN ) Charge Nurse was interviewed and stated it is housekeeping's responsibility to clean the tube feeding pump and poles, but nurses should clean if they notice or see any spillage of formula. On 05/11/2018 at 11:25 AM, the Housekeeper was interviewed and stated they were not working for one week. The Housekeeper further stated that feeding pumps are cleaned twice per week, usually on Tuesdays and Thursdays, and as needed. Upon returning to work last Tuesday, they noticed the unit and floors were dirty. They had to clean the unit first. The feeding pumps were not cleaned until yesterday and today. The Assistant Director of Building Services #2 was interviewed on 05/11/2018 at 11:45 AM and stated that someone was sent to the unit to clean daily when the regular Houskeeper was out. 415.5(h)(2)

Plan of Correction: ApprovedJune 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Plan of Correction for Affected Residents
The following actions were accomplished for the residents identified in the sample:
A. resident #197: Tube feeding drippings were observed splattered on a resident wardrobe closet. The Assistant Director of Building Services inspected resident #197's room (1531) and ensured that housekeeping thoroughly cleaned the room ensuring the resident's wardrobe closet was clean from tube feeding drippings.
B. Resident #578's room (1534)was inspected by the Assistant Director of Facilities. The wardrobe closet door was repaired. The missing handle was replaced and the loose door handle was tightened.
C. Resident #316's room (1301) privacy curtain observed to be torn on the top mesh portion of the curtain. The torn curtain was replaced.
D. Resident #78 in room [ROOM NUMBER] and resident #284 in room [ROOM NUMBER] as well as other floors tube feeling pumps and poles were observed stained with a green colored substance. The feeding tube pump in the observed rooms were cleaned by nursing and the feeding pump pole was cleaned by housekeeping. In addition the mouse trap was removed from the closet of room [ROOM NUMBER]B, and the corners of the room where dust had accumulated was cleaned by housekeeping. In addition the resident's bed was replaced due to the fact that the side rails had peeled-off varnish.
Completion date: (MONTH) 31, (YEAR)
II. Plan of correction to identify other residents potentially affected by this deficiency
All residents have been identified as potentially being affected by the same practice.
A. The Director of Building Services in-serviced the Assistant Director of Building Services and all building services supervisors to inspect all resident rooms to ensure that all resident wardrobe closets are clean from tube feeding drippings.
B. The Assistant Director of facilities will make monthly rounds with the Director of Safety to identify and repair any items needing maintenance in the resident rooms including the resident's wardrobe closets and any bed rails with peeled off varnish.
C. The Director of Building Services in-serviced the Assistant Director of Building Services and all building services supervisors to inspect all resident rooms to ensure that no resident curtains are torn and if any are found, they are to be replaced immediately.
D. All nurses have been in-serviced that tube feeding pumps are to be cleaned daily by the nurse. All staff were in-serviced that any beds identified with peeling varnish is to be called in directly to facilities. The Director of Housekeeping has in-serviced their staff that feeding tube poles are to be cleaned daily as well as all corners of rooms.(NAME)robe closets are to be inspected to ensure that no mouse traps are found.
Completion date: 7/9/2018
III. Plan of correction for system changes and measures to prevent re-occurrence
A. The Director of Nursing in collaboration with the Director of Building Services and the Director of facilities revised the policy of notification of housekeeping and maintenance issues. Revisions to the policy were made to ensure that employees can directly contact housekeeping and facilities to have resident issues addressed expediently. The housekeeping supervisor will monitor compliance daily by random inspection of resident rooms that no tube feeding drippings are found on resident wardrobes. The Director of Facilities or designee will make monthly rounds with the Director of safety to identify and repair or replace any wardrobe closets identified with missing or loose door handle; also any varnish missing on bed rails. Immediate corrective action, including staff re-education, will be implemented as needed. All nursing staff will be educated regarding the maintenance/housekeeping phone number.
B. All staff will be in-serviced regarding the maintenance call in procedure, to report any areas that need repair including resident wardrobe closets, and bedrails peeling varnish.
C. All staff will be in-serviced regarding the housekeeping call in procedure. This number will be used to report any housekeeping issues including torn curtains that need to be replaced. The housekeeping supervisor will monitor compliance daily by making random inspections of resident rooms that the above protocols are being followed. Immediate corrective action, including staff re-education, will be implemented, as needed.

D. The policy on tube feeding pump cleaning was revised and the tube feeding record was revised to reflect that the tube feeding pump is cleaned every shift and that it is documented on the tube feeding record. All nurses will be in-serviced to clean the tube feeding pump daily.
Feeding tube poles: The housekeeping supervisor will monitor compliance daily by making random inspections of resident rooms that housekeepers are cleaning the feeding tube poles, the corners of the room are cleaned and no mouse traps are placed in resident?s wardrobe closet.
Immediate corrective action, including staff re-education, will be implemented, as needed. The Director of Housekeeping has in-serviced their staff that feeding tube poles are cleaned daily and corners of the room are cleaned. The outside pest control company has been informed not to place mouse traps in resident wardrobe closets.
Completion date: 7/9/2018
IV. The Facility's compliance will be monitored utilizing the following quality assurance system:
A. The facility has developed an audit tool to monitor compliance with protocols related to timely cleaning the resident's room of tube feeding drippings. The Director of Building Services or Designee will complete monthly audits on 20% of residents' rooms in Rutland Nursing Home for one year. Audit findings will be reported to the Administrator monthly or sooner as warranted. The Director of Building Services will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate.
The Director of Building Services is responsible for compliance.
B. The Director of Facilities/Safety or designee will complete monthly audits for one year on 20% of resident rooms in Rutland Nursing Home to monitor compliance with protocols related to resident's room wardrobe with loose or missing handles or any other repair concerns for one year. Audit findings will be reported to the Administrator monthly or sooner as warranted. The Director of Facilities will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate.
The Director of Facilities/Safety is responsible for compliance.
C. The facility has developed an audit tool to monitor compliance with protocols related to timely replacement of torn curtains in resident rooms. The Director of Building Services or designee will complete monthly audits on 20% of resident rooms in Rutland Nursing Home for one year. Audit findings will be reported to the Administrator monthly or sooner as warranted. The Director of Building Services will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate. The Director of Building Services is responsible for compliance.
D. The Nurse Manager will complete monthly audits on 20% of residents on tube feeding to ensure tube feeding pumps are clean for one year. The Housekeeping supervisors will complete monthly audits on 20% of residents' rooms in Rutland Nursing Home for one year to ensure resident tube feeding poles are clean, to ensure that no mouse traps are found in the resident wardrobe closets and that corners of the rooms have no accumulating dust. The Assistant Director of facilities will make monthly rounds with the safety officer and will audit 20% of resident rooms for one year to ensure that resident beds wooden side rails have no peeling varnish.
The Director of Building Services/Director of Nursing and Director of Facilities is responsible for compliance.

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 11, 2018
Corrected date: July 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews conducted during the re-certification survey, the facility did not ensure sufficient nurse staffing levels were available to maintain the highest practicable level of well-being of each resident. Specifically, (1) There were less staff on duty on the 11 PM to 7 AM shift during weekends and holidays (2) There were less CNA's (Certified Nurses Assistants) to assist residents with their ADL's (Activities of Daily Living). This was evidenced by grievances presented to the facility by the Resident Council, staff interviews, and review of staff scheduling over the past few months. The Nursing Staffing policy dated (MONTH) (YEAR) documented that the number of staff required for meeting resident needs daily are determined through the facility assessment. The findings are: On 5/7/18 the State Survey Team entered the facility. The facility has 466 beds and at the time of the survey a census of 442. There are 13 resident units. The patient census on all units ranged from 33-40 residents except for the Rehabilitation unit which can have 60 or more residents. On 05/10/18 at 10:18 AM, an interview was conducted with members of the Resident Council. Res #188 stated that on weekends and holidays the facility is short-staffed. We are left in bed especially on the weekends. The resident stated that the supervisors and the Director of Nursing had been spoken to about the issue and the residents were told that they will be hiring staff and they are working on it. Resident #188 also stated that it takes a long time for call bells to be answered. Resident #304 stated that sometimes residents miss outside appointments due to insufficient staff and that residents lie in bed for extended periods waiting for assistance to get out of bed and go to the bathroom. Resident # 204 stated that sometimes residents will miss activities, especially on weekend mornings as there is not sufficient staff to get residents out of bed in time to attend. Resident # 336 stated that on occasion medications and dressing changes can be done as late as 11 am and 1. Resident # 39 complained of many call outs resulting in floating staff who are unfamiliar with the residents. The Resident Council gave permission for the State Surveyors to review the minutes of their Resident Council Meetings for the preceding six months. The Resident Council Minutes (RCM) dated 11/16/17 documented that 10th, 9th and 7th floor residents were concerned that the call bells were not responded to in a timely manner. 9th Floor residents stated more CNA's are needed and the DNS responded that more staff are going through orientation now. RCM dated 2/15/18 documented the 9th floor finger sticks were taken late. RCM dated 3/15/18 documented the 7th floor nursing staff were not answering the call bells in a timely manner. The RCM dated 4/12/18 and 4/24/18 documented that residents were concern about the shortage of CNA's on Saturday (MONTH) 7th, (YEAR). The response from the Director of Nursing Services (DNS) confirmed that there was a staffing issue on 4/7/18. Nursing Supervisors made every effort to replace call outs, but were not able to. The Facility assessment dated (YEAR) included Appendix D Nursing Staffing Schedule. This schedule documented the projected staffing levels per unit as of 4/10/17. The projected needs do not include 1:1 (one to one) assignments or additional staff needed for appointments. The staffing needs per unit were as follows: The Long-Term Care (LTC) units -- 6 East, 6 West, 8 East, 8 West, 9 East, 9 West, 10 East, and 10 West require 2 Licensed Practical Nurses (LPN's) and 4 Certified Nursing Assistants (CNA's) for the Day (D) and Evening (E) shifts, and 1 LPN and 2 CNA's are needed for the Night (N) shift. The other units, which are specialty units, are broken down as: Unit 3 West required 2 RN's and 3 CNA's for D, E, and N shifts. Unit 5 North required 4 nurses and 4 CNA's for D and E shifts, and 4 nurses and 3 CNA's for the N shift. Unit 5 South-Day and Evening. 5 nurses mix or RN's or LPN's. 5 CNAs' if census is over 28, and 4 nurses and 4 CNA's if less than 28. Night 4 nurses and 4 CNA's regardless of census. 7 West- Day and Evening 5 nurses, 7 CNAs', Night 4 Nurses, 6 CNA's if census is over 60. If census is less than 60 4 nurses, 6 CNAs' Day and Evening, at Night 4 nurses, 5 CNA's. Staffing schedules for the past 6 months were requested and reviewed. The staffing schedules for 12 resident units from a (MONTH) (YEAR) to Present documented the following in respect to the weekend, holidays, evening and day shift. Review of sample of staffing from 11/12/17 to present documented the following: Sun 11/12/17- Day shift 8 West 2 LPN's, 4 CNA's with one 1:1, census 36, 10 East 2 LPN's, 3 CNA's, census 35, 10 West 2 LPN's, 3 CNA's, census 32. Sun 11/12/17-Evening Shift 10 West 2 LPN's, 3 CNA's, census 32. Thursday 11/23/17- Day Shift 5 North 3 RN's, 2 LPN's, 3 CNA's, census 24. Thursday 11/23/17- Evening Shift 5 North-3 RN's, 1 LPN's, 3 CNA's, census 24, 10 West 2 LPN's, 3 CNA's, census 31. Friday 11/24/17- Day Shift 5 North 1 RN, 2 LPN's, 3 CNA's, census 24, 10 East 2 LPN's, 3 CNA's, census 34, 10 West 2 LPN's, 3 CNA's, census 31. Friday 11/24/17- Evening Shift 5 North 2 RN's, 2 LPN's, 3 CNA's census 24, 9 West 2 LPN's, 3 CNA's census 32, 10 West 2 LPN's, 3 CNA's census 31. Saturday 11/25/17- Day and Evening Shift 10 West 2 LPN's, 3 CNA's, census 31. Sunday 11/26/17-Day and Evening Shift 10 West 2 LPN's, 3 CNA's, census 31. Saturday 12/23/17-Day and Evening Shift 10 West 2 LPN's, 3 CNA's, census 30 and 29 respectively Sunday 12/24/17- Day and Evening Shift 10 West 2 LPN's, 3 CNA's, census 28. Monday 12/25/17- Day and Evening Shift 10 West 2 LPN's, 3 CNA's, census 28. Saturday 3/10/18-Day Shift 10 West 2 LPN's, 3 CNA's, census 32. Saturday 3/10/18-Evening Shift 5 South 3 RN's, 2 LPN's, 4 CNA's, census 29, 10 East 2 LPN's, 4 CNA's with 1 1:1, census 36, 10 West 2 LPN's, 3 CNA's Census 32. Sunday 3/11/18- Day Shift 8 West 2 LPN's, 5 CNA's, 2 1:1's, census 38, 10 West 2 LPN's, 3 CNA's, census 32. Sunday 3/11/18- Evening Shift 3 West 2 RN's, 2 CNA's, census 16, 5 North 1 RN, 3 LPN's, 3 CNA's, census 30, 8 East 2 LPN's, 3 CNA's, Census 39, 10 West 2 LPN's, 3 CNA's, census 32. Saturday 3/17/18- Day Shift 7 West 5 Nurses, 6 CNA's, census 62, 10 West 2 LPN's, 3 CNA's, census 30. Saturday 3/17/18- Evening Shift 10 West 2 LPN's, 3 CNA's, census 31. Sunday 3/18/18 Day Shift 5 South 4 RN's 1 LPN's, 3 CNA's, census 26, 6 West 2 LPN's, 3 CNA's, 10 West 2 LPN's, 3 CNA's, census 30. Friday 3/30/18 Day Shift- 3 West 1 RN, 1 LPN's, 2 CNAs', census 16, 5 South 2 RN's, 3 LPN's, 4 CNA's, census 29, 5 North 1 RN, 2 LPN's, 3 CNA's, census 29, 7 West 2 RN's, 3 LPN's, 6 CNA's, census 62, 10 East 2 LPN's, 4 CNA's, 1 1:1, census 35, 10 West 2 LPN's, 3 CNA's, census 28. Friday 3/30/18- Evening Shift 5 South 3 RN's, 2 LPN's, 4 CNA's, census 29, 5 North 2 RN's, 2 LPN's, 3 CNA's, census 29, 7 West 2 RN's, 3 LPN's, 6 CNA's, census 61, 9 West 2 LPN's 3 CNA's, census 38, 10 East 2 LPN's, 4 CNA's, 1 1:1, census 35, 10 West 2 LPN's, 3 CNA's, census 28. Saturday 4/7/18-Day Shift 6 West 2 LPN's, 3 CNA's, census 38, 7 West 2 LPN, 3 RN's Nurses, 6 CNA's, census 64, 9 East 2 LPN's, 4 CNA's with 1 1:1, census 39, 10 East 2 LPN's, 4 CNA's, 1 1:1, census 35, 10 West 2 LPN's, 3 CNA's, census 31. Saturday 4/7/18- Evening Shift 6 East 2 LPN's, 4 CNA's with 1 1:1, census 39, 8 West 2 LPN's, 4 CNA's with 1 1:1, census 38, 7 West 2 RN's 3 LPN's, 6 CNA's, census 64, 9 West 2 LPN's, 3 CNA's census 36, 10 West 2 LPN's, 3 CNA's census 31. Thursday 4/12/18- Day Shift 10 West 2 LPN's, 3 CNA's, census 30. Thursday 4/12/18- Evening Shift 10 West 2 LPN's, 3 CNA's, census 30. Tuesday 4/24/18- Evening Shift 10 West 2 LPN's, 4 with 1 1:1 CNAs' census, 32. Saturday 5/5/18- Day Shift 5 South 2 RN's, 2 LPN's, 3 CNA's, census 27, 6 West 2 LPN's, 3 CNA's census, 36, 7 West 3 RN's, 1 LPN's, 6 CNA's, census 64, 9 West 2 LPN's, 3 CNA's, census 36, 10 East, 2 LPN's, 5 CNA's with 2 1:1's, census 36. Saturday 5/5/18-Evening Shift 6 West 2 LPN's, 3 CNA's, census 36, 7 West 2 RN's, 2 LPN's, 6 CNA's, census 64, 8 East 2 LPN's, 3 CNA's, census 39, 9 East 2 LPN's, 3 CNA's, census 40. Sunday 5/6/18- Day Shift 6 West 2 LPN's, 3 CNA's, census 34, 7 West 3 RN's, 1 LPN's, 6 CNA's, census 64, 9 East 2 LPN's, 4 CNA's with 1 1:1, census 39, 10 East 2 LPN's, 4 CNA's with 2 1:1's, census 36. Sunday 5/6/18-Evening Shift 6 West 2 LPN's, 3 CNA's, census 37, 8 West 2 LPN's, 4 CNA's with 1 1:1, census 38, 7 West 2 RN's, 3 LPN's, 6 CNA's, census 62, 9 East 2 LPN's, 4 CNA's with 1 1:1, census 39, 9 West 2 LPN's, 3 CNA's, census 36. Monday 5/7/18- Day Shift 10 East 2 LPN's, 5 CNA's with 2 1:1's, census 36. Monday 5/7/18- Evening Shift 7 West 2 RN's, 3 LPN's, 6 CNA's, census 64. The facility staffing was below the recommended levels for RNs, LPNs, and/or CNAs for multiple units on numerous days. During the interview conducted with the Staffing Associate on 5/11/18 at 9:13 AM, he stated that when there are call outs the night shift supervisors will make calls to fill the spots. He also begins looking for people to fill the spots when he arrives to work. This is done by calling staff at home relentlessly and calling in-house staff to stay for a double shift. There are days we cannot find people and the units will work short. Mostly on the weekends are when the challenges come, as weekends are half staffed- as everyone has alternate weekends off. Weekend staffing consists of part-timers, over-timers, and agency nurses. Sick calls over the weekend throw the schedule, as it is already at a critical level. He informs the DNS about staffing shortages for the weekend on Friday afternoon. The real challenge is the holidays, such as Christmas, New Years, and Thanksgiving. We also have people out on Leave of Absence. We know when the challenging seasons are, and there is nothing per say that can be done. If we have residents on 1:1 observation, there are additional challenges. We try as best we can to manage but there are circumstances over which we really have no control. Over the past six months, the facility has had challenging days and weekends, but generally staffing is fine. The facility does not have a float pool, and staffing on LTC units is not based on the census. They schedule additional staff for appointments the day before, however, the staffing for the holidays are the same. On 5/11/18 at 12:02 PM, an interview was conducted with a Certified Nursing Assistant #1 (CNA) who stated there are three CNA's on the unit. There are 32 residents so two CNA's have 10 on their assignment, and one person gets 11 residents assigned to them on the day shift. The unit should have 4 CNA's, but there are only 3 working. They have support from the Registered Nurse Manager. On 5/11/18 at 12:09 PM, an interview was conducted with CNA's #2 who stated sometimes they do work a double shift. She is responsible for 10 residents as there are only three CNA's. On good days there are 4 CNA's, but normally there are 3 so we work with what we have. On 5/11/18 at 12:33 PM, an interview was conducted with the RN Manager who stated that she does not speak with the DNS and the staffing clerk about the staffing matter. The staffing is 3 CNA's, 2 LPN's and herself. The number of LPN's is fine, but for the acuity of the unit, the number of CNAs is not enough. There are a lot of sick calls. Sunday evening, for example, there was one CNA for the night shift. Sunday, during the day shift, there were only 2 CNAs for the unit. On 5/11/18 at 2:37 PM, the Director of Nursing Services (DNS) was interviewed and stated she must put more staff on the specialty units first. The weekends are a challenge because the staff works every other weekend. She could not say which floors are the most challenging to staff. The facility had an orientation for new staff in January, and facility plans to have another orientation soon. She stated staff have come to her with workload concerns. Staffing on the weekends is the issue. The staffing associate, night supervisors, and herself make phone calls in efforts to get coverage. The grid for staffing was reviewed on the facility Assessment that indicated that the units were always working with 3 CNA's versus 4 CNA's, but the facility assessment is not accurate and should have been updated about [AGE] years ago. The DNS did not state if any input from the staff was included in the assessment. In a subsequent interview on 5/11/18 at 2:45 PM, the MDS Coordinator/QA RN, stated that there was a QA on staffing in (MONTH) (YEAR). Concerns were identified from a study conducted on nursing staffing overtime for call outs and holidays. This is scheduled to report in (MONTH) of (YEAR). The plan is to hire more staff to fill vacancies to prevent the excessive overtime. The issue is intensified because the turnover rate is high as the staff moves to the hospital side or vice versa. 415.13 (a)(1)(i-iii)

Plan of Correction: ApprovedJune 20, 2018

I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:

For the residents cited #188, # 304, #204 and #336: The medical records were reviewed by the interdisciplinary team to ensure that there were no adverse reaction in any delays related to staffing.
Resident #188 stated that he was left in bed and there was a delay in answering call lights. The resident's medical record was reviewed by the interdisciplinary team and there was no indication of any adverse condition in being left in the bed or delay in answering the call bell.
In addition the resident was interviewed and stated the staff are getting him up in bed earlier and the calls bells answering has also improved. The resident requests to get up out of bed at 8 AM. The nurse manager has documented the resident preferences in the resident care plan and instructed the staff to get the resident up at 8 AM
Resident#304 Stated sometimes residents miss appointments and residents do not get out of bed. The residents medical record was reviewed for the past six months and the resident did not miss any appointments. The nursing staff was in-serviced to ensure that the resident is getting out of bed.
The resident was interviewed with the Director of Recreation and stated that he does not have any outside appointments and he is not aware of residents missing appointments due to insufficient staff. The resident further stated that sometimes staff gets him up latter than he prefers and he sometimes misses coffee social activity. The resident is requesting to get up out of bed at 9:30 AM. The nurse manager has documented the resident preferences in the resident care plan and instructed the staff to have the resident up at 9:30 AM.


Resident #204 Stated sometimes residents missed activities especially on weekends morning as there is not sufficient staff to get residents out of bed on time. There was no documentation in resident council minutes that residents missed activities due to staffing. The residents medical record was reviewed by the interdisciplinary team and there was no indication of any adverse medical effects or psychosocial effects.
The resident was interviewed and stated that she does not have any issues getting out of bed or attending activities. She stated that she was repeating the concerns that resident #304 expressed to her.

The Director of Recreation has in-serviced his staff to report any cases to nursing supervisor on duty if residents are late or could not attend activities due to staffing.

Resident #336 stated on occasion medications and dressing changes were done late. The residents medical record was reviewed by the interdisciplinary team and there was no indication of any adverse condition. There were no omissions in treatment record and no omissions in the medication administration record. There was no evidence of any issues related to short staffing and there was no adverse reaction noted.
The resident was interviewed and stated there were some days with short staffing that resulted in his dressing being done late and his medications were given late. The resident stated the situation has improved and his dressings and medications are being given on time.
The 24 hour nursing supervisor's communication book was reviewed from (MONTH) 1, (YEAR)- (MONTH) 7, (YEAR).
There were no evidence of any issues which may be related to short staffing. Any problems with resident's condition were addressed appropriately with expected outcome.


DATE OF COMPLETION: (MONTH) 15, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
All residents have been identified as potentially being affected by any staffing shortages.
Prior to survey; the Administrator requested from the staffing coordinator to prepare the following documents for analysis:
Table of Organization for each unit
List of all vacancies position
List of any frozen positions
List of leave of absences
The number of residents on one to one
The daily number of residents seen at outside clinics escorted by a cna .
Sick call report
The Administrator and Director of nursing reviewed the information and compared it to the facility assessment Appendix D Nursing Staffing. The administrator then approved the hiring of 21.8 CNA FTE positions.

DATE OF COMPLETION: (MONTH) 1, (YEAR)



III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
Dates for orientation were selected. However due to concerns related to adequate staffing, in-service dates were moved up as follows:
June 4 - 6.7 FTE
June 25 ? 5.3 FTE
July 15 ? 9.8 FTE
The administrator and DON reviewed the statement of deficiencies. An analysis noted that there were discrepancies in staffing patterns. The discrepancies occurred on all shifts around national holidays, weekends and some weekdays.
The Staffing Coordinator will prepare monthly reports to the Administrator and DON:
List of all vacancies positions
List of leave of absences
The number of residents on one to one
Average sick calls days, weekend/holidays
The Administrator and Director of Nursing will approve the hiring and training of additional staff whenever a variance to staffing schedule occurs.
The Director of Nursing has in-serviced all managers on all shifts that until all positions are filled the DON or designee is to be called prior to the on-coming shift.
including weekends and holidays. In addition whenever there is any staffing shortages that may impact on resident care the DON or designee is to be called.
The Administrator and DON will provide an update to the resident council as to staffing resources.

DATE OF COMLPETION: (MONTH) 9, (YEAR)


IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to staffing. The Staffing Coordinator will audit all staffing worksheets daily including weekends and holidays for one year to ensure there is no variance in staffing.
Audit findings will be reported to the Director of Nursing. The DON will report the audit findings to the Administrator monthly or sooner as warranted.
The DON will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate.
Responsibility: Director of Nursing
DATE OF COMPLETION: JULY 9, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2018
Corrected date: July 9, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that doors to resident rooms were maintained free of any impediments to closing in their frames. Reference is made to the doors that were obstructed from closing by the waste baskets, overbed tables, adjacent cubicle curtains, and other furnishings left unattended in the doorways to the rooms. Examples were: doors to room #'s 1010, 1009, 1934, 1931, 1926, 1807, 1722 and 1525. The findings include: On 5/15-16/2018 between 10:00 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the doors to resident rooms were impeded from closing by the waste baskets, overbed tables, unoccupied chairs, or other furnishings left unattended in front of the door leaves. Examples include: room #'s 1010, 1009, 1934, 1931, 1926, 1807, 1722 and 1525. On (MONTH) 16, (YEAR) at approximately 12:45 PM, the facility's Director of Engineering stated that the furnishings obstructing the doors to resident rooms were being moved away from the door leaves and the staff will be instructed to remove any obstructions from in front of the door leaves. 711.2(a)(1) 2000 NFPA 101

Plan of Correction: ApprovedJune 6, 2018

K TAG 363 101 CORRIDOR DOORS
I. Plan of Correction for Affected Residents
The following actions were accomplished for the resident identified in the sample:
There we no residents identified in the statements of deficiencies.
DATE OF COMPETION: (MONTH) 31, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS POTENTIALLY AFFECTED BY THIS DEFECIENCY:
The facility acknowledges that all residents at Rutland Nursing Home as potentially being affected by this practice.
To prevent and correct these issues, all residents? doors opening to corridor will not have any impediments, such as waste baskets, over bed tables, adjacent cubicle curtain, unoccupied chairs and other furnishings
DATE OF COMPETION: JULY 9, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
The Director of Safety in collaboration with the Director of Nursing reviewed the policy on egress doors. Revisions to the policy were made to ensure that no impediments, such as waste baskets, over bed tables, adjacent cubicle curtain, unoccupied chairs and other furnishings block resident doors from egress.
All staff will be in-serviced to prevent blockage and impediment of resident doors to the corridor.
Nursing managers and supervisors will monitor compliance with the above protocols during routine care. Immediate corrective action, including staff re-education, will be implemented, as needed.
DATE OF COMPETION: (MONTH) 9, (YEAR)


IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility has developed an audit tool to monitor compliance with protocols related to blocking of resident doors. Nurse Managers will audit 20% of resident rooms to ensure that the resident door is not impeded by waste baskets, over bed tables, adjacent cubicle curtain, unoccupied chairs and other furnishings.
Audit findings will be reported to the Director of Nursing (DON). The DON will report the audit findings to the Administrator monthly or sooner as warranted.
The DON will report results as per the audit findings to the Quality Assurance Committee on a monthly basis for committee guidance, direction and follow-up actions as may be appropriate.
Responsibility: Director of Nursing
DATE OF COMPETION: (MONTH) 9, (YEAR)

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2018
Corrected date: July 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation it was determined that the facility did not ensure that the doors in the means of egress were not provided with locks which required the use of a key to open from the egress side. Reference is made to the doors to the pediatric classrooms that were equipped with locking devices that required the use of a key to open from the egress side. The findings include: On 05/15/18 to 5//16/18 at 10:00 AM to 3:00 PM,during the recertification survey of the facility, it was observed that on the 3rd floor the door to the recreation room [ROOM NUMBER] EC and the doors to at least three classrooms used by the pediatric residents were equipped with key locking dead bolt type locking devices. The locking devices required the use of a key to open from the egress side. On 5/16/18 at approximately 1:00 PM, the facility's Director of Engineering stated that all dead bolt type key locking devices will be removed from all egress doors from the residents' classrooms and the recreation rooms. 10NYCRR 711.2(a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJune 6, 2018

I. PLAN OF CORRECTION FOR OBSERVED CONDITION:
The dead-bolt type locking devices observed on the entrance doors of several classrooms requiring a key to operate from the egress side located on the 3rd floor have been removed from the doors.
RESPONSIBILITY: Director of Facilities
DATE OF COMPLETION: (MONTH) 18, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS OR AREAS POTENTIALLY AFFECTED BY THIS DEFICIENCY:
The facility acknowledges that other areas of the Rutland Nursing Home may be potentially affected by similar existing installations. To identify and then correct any potential similar condition, a building-wide survey all doors located in the means of egress will be conducted. Any similar condition observed will be immediately removed by in-house Door Team Staff.
RESPONSIBILITY: Director of Facilities
TARGET DATE FOR COMPLETION: (MONTH) 11, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
Once the building-wide survey has been conducted and any found conditions have been addressed, the Rutland Nursing Home will be in full compliance. To prevent a reoccurrence of this finding, all new requests for the installation of locking devices will be reviewed by the Facilities Department. Installation of any newly requested locking devices will require the approval of the Director of Facilities or a designee on the submitted Facilities Services Request (FSR). The Director of Facilities will generate a new policy and procedure regarding the submission and approval of new door locking systems. Once adopted, in-service education will be provided to all Facilities Management Staff involved in the generation of FSR?s and the installation of door hardware.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility will develop an audit tool to track and trend compliance with protocols related to the installation of newly requested locking devices. During Facility Department Building Audits, a minimum of 20% of all doors located in the means of egress will be observed. Audit findings will be reported to the Director of Facilities. The Director of Facilities will report the findings to the QAA Committee on a quarterly basis or more often as may be warranted for committee guidance, direction and follow-up actions as may be appropriate.

RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR) and then on-going for 1 year at a minimum.

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2018
Corrected date: July 9, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that all portable fire extinguishers were installed and maintained in accordance with NFPA10 - Standard for the Portable Fire Extinguishers. Reference is made to the wet chemical type portable fire extinguisher located in the kitchen area in the basement, that was not hydrostatically tested at intervals not exceeding 5 years since the year 2012. The findings include: On 5/15/18 and 5/16/18 between 10:00 AM to 3:00 PM, it was observed that the facility had provided a wet chemical type portable fire extinguisher in the kitchen area in the basement. At least one of the wet chemical type portable fire extinguisher provided in the kitchen was not hydrostatically tested at intervals of 5 years since its manufacturing date of the year of 2012. On 5/16/18, at approximately 2:30 PM, the facility's Director of Engineering stated that the wet chemical extinguisher in the kitchen will be replaced. The Director further stated that all portable fire extinguishers will be hydrostatically tested at required intervals. 711.2 (a)(1) 2010 NFPA 10 2012 NFPA 101

Plan of Correction: ApprovedJune 6, 2018

I. PLAN OF CORRECTION FOR OBSERVED CONDITION:
The observed wet chemical fire extinguisher located in the kitchen with an outdated hydrostatic inspection has been replaced with a compliant extinguisher.
RESPONSIBILITY: Director of Facilities
DATE OF COMPLETION: (MONTH) 5. (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS OR AREAS POTENTIALLY AFFECTED BY THIS DEFICIENCY:
The facility acknowledges that other areas of the Rutland Nursing Home may be potentially affected by similar existing installations. To identify and then correct any potential similar condition, a building-wide survey all fire extinguishers will be conducted. Any similar condition observed will be immediately replaced.
RESPONSIBILITY: Director of Facilities
TARGET DATE FOR COMPLETION: (MONTH) 13, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
Once the building-wide survey has been conducted and any found conditions have been addressed, the Rutland Nursing Home will be confirmed to be in full compliance. To prevent a reoccurrence of this finding, Facilities Management is meeting with the Fire Extinguisher Service Vendor to review the audit tools and that are currently in place. Going forward, all fire extinguisher inspections will be documented in the Facility Work Order System, FM-1 and a Facilities Services Request (FSR) will be generated. The Director of Facilities will update the existing policy and procedure regarding the monthly inspection and associated criteria for the inspections. Once adopted, in-service education will be provided to all Facilities Management Staff involved in the generation of FSR?s and the oversight of fire extinguisher inspections.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility will update the existing audit tool to track and trend compliance with protocols related to the inspection of fire extinguishers. During Facility Department Building Audits a minimum of 20% of all fire extinguishers on the unit being surveyed will be observed. Audit findings will be reported to the Director of Facilities. The Director of Facilities will report the findings to the QAA Committee on a quarterly basis or more often as may be warranted for committee guidance, direction and follow-up actions as may be appropriate.

RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR) and then on-going for 1 year at a minimum.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2018
Corrected date: July 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7. Reference is made to obstructed sprinklers; lack of sprinkler coverage for the pressure cookers' area under the kitchen hood system; and the lack of hangers for the excessive length of sprinkler piping in the generator room. The findings include: On 5/15/18 and 5/16/18 between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that the automatic sprinklers were obstructed in a number of areas and/or were not located so as to provide coverage for the entire protected area in accordance with NFPA 13. Examples include the following : (1) In a number of resident rooms, the sprinklers was obstructed by the wall mounted televisions. Examples include: rooms #1807, 1831, 1826, and 1926. (2) In the male and female toilet area in room [ROOM NUMBER] and room [ROOM NUMBER], the sprinklers were obstructed by the solid type privacy curtains so as not as to provide coverage for the entire protected toilet area. (3) In the kitchen area, the sprinklers were obstructed by the metal hood system so as not as to provide sprinkler coverage for the areas containing the Blodgett brand pressure cookers, under the exhaust hood system. (4) In the main food storage room in the basement, the sprinkler was not installed within 6 feet of the wall. The sprinkler was located approximately 8 ½ feet from the wall. (5) In the staff classroom area on the 4th floor, the storage area under the approximately 30 inches wide overhang was not protected by an automatic sprinkler system. The existing sprinkler in the vicinity of the overhang was obstructed by an approximately 18 inches high soffit. (6) In the generator room, an approximately 3 ½ - 5 feet long sprinkler pipe between the end sprinkler and the last hanger lacked a supporting hanger. The unsupported horizontal length between the end sprinkler and the last hanger cannot exceed 36 inches for a 1 inch pipe, as per 9.2.3.4, NFPA 13. On 5/16/18 at approximately 12:30 PM, the facility's Director of Engineering stated that the sprinkler coverage will be evaluated in all areas of the building and unobstructed sprinkler coverage will be provided in all areas of the building in accordance with NFPA 13. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedJune 6, 2018

I. PLAN OF CORRECTION FOR OBSERVED CONDITION:
The observed conditions which included obstructions to the sprinkler head flow due to Resident wall mounted televisions, privacy curtails installed in toilets, a metal hood located over kitchen cooking equipment and a ceiling soffit located in a classroom are acknowledged. Similarly, the location of sprinkler heads in excess of 6 feet from a wall in the kitchen and the distance between hangers in the generator room exceeding 36? are acknowledged. While immediate corrective actions have started to correct the obstructions of the sprinklers to the Resident wall mounted televisions, Facilities Management has contacted our Sprinkler System Service Contractor to review all cited conditions and perform a facility-wide audit of the existing installation. Once conducted, a proposal for the required corrective actions will be generated and reviewed by the Director of Facilities. A purchase order will be issued to perform all required work.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS OR AREAS POTENTIALLY AFFECTED BY THIS DEFICIENCY:
A full survey of the building entire existing sprinkler system will be conducted by our Sprinkler System Service Contractor. Any additional findings will be documented and corrective actions will be taken by the Service Contractor working under a purchase order to be issued.

RESPONSIBILITY: Director of Facilities
TARGET DATE FOR COMPLETION: (MONTH) 9, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
Once the above-noted actions are completed, there will be no further opportunity for a reoccurrence as the entire installed system will have been fully audited. Any new work will be reviewed by Facilities Management. Facilities management will sign-off and approve any new work in collaboration with the design Engineer of Record engaged to perform changes to the approved system.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR) and on-going
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
Once the above-noted actions are completed, the Director of Facilities will report the completion of the work to the QAA Committee. Given the circumstances outlined above, this single report will conclude the reporting requirement on this matter.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR)

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2018
Corrected date: July 9, 2018

Citation Details

Section 7-1.8, 2012 NFPA 101 states that guards in accordance with 7.2.2.4 shall be provided at the open sides of the means of egress that exceed 30 inches (760 mm) above the floor or finished ground level below. This standard is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that guards provided at the open side of the exit stair landings were at least 42 inches high as per 7.2.2.4.5. Reference is made to the stair landings on the top of exit stairs that were approximately 36 inches above the landing floor instead of the minimum of 42 inches in height from the landing floor. The findings include: On 5/15/18 and 5/16/18 between 10:00 AM to 3:00 PM, during the recertification survey, it was observed that the facility had provided guards at the open side of the exit stair landings. The guards provided on the top stair landings of the exit stairs A, C, and D measured approximately 36 inches high from the landing floor instead of the minimum of 42 inches high from the landing floor. On 5/16/18 at approximately 12:00 PM, the facility's Director of Engineering stated that guards will be extended to the required height. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedJune 6, 2018

I. PLAN OF CORRECTION FOR OBSERVED CONDITION:
The height of the guardrails located on the top landing of building stairwells have been confirmed to extend only 36? above the finished floor. It is acknowledged that these guardrails are required to be a minimum of 42? above the finished floor of the landing. Facilities Management has contacted a contractor skilled in this area of work to replace the existing guardrails with code compliant guardrails. The contractor has been interviewed and is scheduled to take field measurement on (MONTH) 5, (YEAR) in order to generate a proposal for the work. The current condition is located in restricted areas of the stairwell where no Residents, Staff or Visitors are permitted. A local alarm will be activated if anyone attempts to enter the stairwell.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 29, (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS OR AREAS POTENTIALLY AFFECTED BY THIS DEFICIENCY:
A full survey of all existing building stairwells has been conducted and no additional issues of this type were observed. A second confirming survey will be conducted by Facilities Management Staff to document the existing condition. Should any similar condition be observed, corrective actions will be taken by the engaged contractor working under a purchase order to be issued.
RESPONSIBILITY: Director of Facilities
TARGET DATE FOR COMPLETION: (MONTH) 29, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
Once the above-noted actions are completed, there will be no further opportunity for a reoccurrence as the stairwells are permanent structural features that cannot be changes easily, This, in and of itself, will prevent a reoccurrence of this finding.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 29, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
Once the above-noted actions are completed, the Director of Facilities will report the completion of the work to the QAA Committee. Given the circumstances outlined above, this single report will conclude the reporting requirement on this matter.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR)

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 16, 2018
Corrected date: July 9, 2018

Citation Details

NYCRR 713-2.21 (e)(2) (iii) Backflow preventers (vacuum breakers) shall be installed on hose bibbs, janitor's sinks, bed pan flushing attachments and on all other fixtures to which hoses or tubings can be attached. This requirement is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that vacuum breakers were installed on all fixtures to which hoses or tubing can be attached. Reference is made to the water fixtures with attached hoses installed for the hair washing sinks in the barber shop on the 10th floor that lacked backflow preventers (vacuum breakers). The findings include : On 5/15-16/2018, at 10:00 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the water fixtures installed for the hair washing sinks in the barber shop on the 10th floor were provided with hose attachments. The water fixtures lacked vacuum breakers (backflow preventers). On (MONTH) 16, (YEAR) at approximately 11:15 PM, the facility's Director of Engineering stated that water fixtures in the barber shop will be provided with backflow preventers (vacuum breakers).

Plan of Correction: ApprovedJune 6, 2018

I. PLAN OF CORRECTION FOR OBSERVED CONDITION:
The observed condition of missing vacuum breakers on the hair washing hoses located at the Barber Shop sinks is acknowledged. The replacement of the hoses with the correct backflow devices is in progress. The proper equipment has been sourced for order and immediate installation, upon receipt.

RESPONSIBILITY: Director of Facilities
DATE OF COMPLETION: (MONTH) 15. (YEAR)
II. PLAN OF CORRECTION TO IDENTIFY OTHER RESIDENTS OR AREAS POTENTIALLY AFFECTED BY THIS DEFICIENCY:
The facility acknowledges that other areas of the Rutland Nursing Home may be potentially affected by similar existing installations. To identify and then correct any potential similar condition, a building-wide survey all hose installations will be conducted. Any similar condition observed will be immediately replaced.
RESPONSIBILITY: Director of Facilities
TARGET DATE FOR COMPLETION: (MONTH) 15, (YEAR)
III. PLAN OF CORRECTION FOR SYSTEM CHANGES AND MEASURES TO PREVENT RE(NAME)CURRENCE:
Once the building-wide survey has been conducted and any found conditions have been addressed, the Rutland Nursing Home will be confirmed to be in full compliance. To prevent a reoccurrence of this finding, Facilities Management will use the Facility Work Order System, FM-1 to generate a Facilities Services Request (FSR) that will require approval of the Director of Facilities or designee prior to proceeding. The Director of Facilities will generate a new policy and procedure regarding the approval of all hose installations and replacements. Once adopted, in-service education will be provided to all Facilities Management Staff involved in the generation of FSR?s and the oversight of vacuum breaker installations.
RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR)
IV. THE FACILITY?S COMPLIANCE WILL BE MONITORED UTILIZING THE FOLLOWING QUALITY ASSURANCE SYSTEM:
The facility will develop an audit tool to track and trend compliance with protocols related to the installation or replacement of all hoses. During Facility Department Building Audits a minimum of 20% of all hose installations on the unit being surveyed will be observed. Audit findings will be reported to the Director of Facilities. The Director of Facilities will report the findings to the QAA Committee on a quarterly basis or more often as may be warranted for committee guidance, direction and follow-up actions as may be appropriate.

RESPONSIBILITY: Director of Facilities
TARGET DATE OF COMPLETION: (MONTH) 9, (YEAR) and then on-going for 1 year at a minimum.