Hempstead Park Nursing Home
March 26, 2018 Certification/complaint Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: May 21, 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 develop or implement a comprehensive person-centered care plan for each resident to meet the resident's needs. This was identified for 2 of 51 sampled residents. Specifically, 1) Resident #115 had Physician order [REDACTED].' There was no documented evidence in the medical record that the extra fluids were provided or were being monitored. 2) Resident #196 was issued a Pommel cushion on 5/4/2017. There was no documented evidence that the Comprehensive Care Plan (CCP) and the Certified Nursing Assistant (CNA) accountability record were updated to reflect the use of the cushion. The findings are: 1) Resident # 115 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #115 had clear speech, could understand and be understood. The resident's Brief Interview for Mental Status score was 10 indicating the resident's cognition was moderately impaired. The MDS also documented Resident #115 had an indwelling suprapubic catheter (SPT - a catheter surgically inserted thru the abdominal wall into the urinary bladder to facilitate the drainage of urine). The Physician Orders' dated 3/13/2018 documented, 'Extra 250 cc (cubic centimeters) fluids every (q) shift.' Schedule: Every day at 11:00 PM - 7:00 AM; 3:00 PM -11:00 PM; 7:00 AM - 3:00 PM. An order to push fluids was also documented in the Physician order [REDACTED]. Review of the Medication Administration Record (MAR) dated (MONTH) (YEAR), Treatment Administration Record (TAR) dated (MONTH) (YEAR), the Monitoring section of the Electronic Medical Record (EMR) and the Certified Nursing Assistant Accountability Record (CNAAR) dated (MONTH) (YEAR) revealed there was no documentation regarding the administration of Extra 250 cc fluids q shift, as ordered by the physician. The Comprehensive Care Plan (CCP) titled Dehydration/Fluid maintenance, dated 7/25/2017 and last evaluated 1/28/2018, did not include fluid intake as an intervention. Review of the CCP titled Indwelling Catheter (SPT) dated 11/29/16 and last evaluated 10/26/17, documented an intervention to encourage fluid intake. On 03/26/18 at 11:36 AM an interview was conducted with the Licensed Practical Nurse (LPN) unit nurse. The LPN stated the order to give an extra 250 cc of fluid should have been on the MAR. The LPN stated that after the Medical Doctor (MD) does the monthly review of the orders, the three shifts of nurses review and sign off on the orders. The LPN stated that the extra fluid was not documented and should have been. The LPN further stated all residents with catheters are encouraged to drink extra fluids. On 03/26/2018 at 11:59 AM the CNA regularly assigned to Resident #115 was interviewed. The CNA stated the meal consumption form is signed for at all meals and that Resident #115 eats and drinks usually 100% what is on the tray. The consumption form documents what the resident consumed from their tray and does not separate food and fluids. The CNA further stated that she was not aware the resident was to receive extra fluids. The Nurse Practitioner (NP) assigned to cover Resident #115's care was interviewed on 03/26/2018 at 12:25 PM. The NP reviewed the resident's medical record and stated there was an order for [REDACTED]. The Dietician assigned to Resident #115 was interviewed on 03/26/18 at 1:10 PM. The Dietician stated that a physician's orders [REDACTED]. The Assistant Director of Nursing Service (ADNS) was interviewed on 03/26/18 at 2:08 PM and stated the order for extra fluids should have been put in the destination section of the EMR to send to the MAR and should have been monitored and documented. The ADNS stated the order must have been missed when reviewed by the nurses. 2) Resident #196 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident's BIMS Score as 10 which indicated moderate cognitive impairment. The resident had no mood or behavior problems and required total assistance of two staff members for transfers. The resident was non ambulatory, utilized a wheel chair for locomotion and had range of motion limitation on one side of her upper extremity and both sides of her lower extremities. The Quarterly MDS assessment dated [DATE] documented the resident required total assistance of two staff members for transfers and utilizes a wheel chair for locomotion. The resident had limitation to both sides of her lower extremities. The resident was observed in 3/20/18 at 11:10 AM in the hallway in a wheel chair, sitting on a Pommel cushion. The Certified Nursing Assistant (CNA) was interviewed immediately on 3/20/18 at 11:10 AM and she stated the cushion prevented the resident from sliding out of the wheel chair. A Occupational Therapy (OT) Progress note dated 5/4/17 documented a new Pommel cushion was given to the resident. An Occupational Therapy Screen Form dated 7/28/17 documented Fall Prevention Devices including front and rear ant-tippers and a Pommel wedge cushion. A CCP dated 2/1/17 for Activities of Daily Living (ADL) Mobility and Rehabilitation Potential documented the resident has functional limitation in range of motion to the right upper extremity and to the left and right lower extremities. Review of the interventions revealed the CCP was not updated to reflect the use of the Pommel cushion. A review of the CNAAR was conducted on 3/23/18 and there was no documented evidence that the record was updated to reflect the use of a Pommel cushion. During a subsequent interview with the 7:00 AM - 3:00 PM CNA on 3/26/18 at 8:20 AM she stated she cared for the resident for the past two years and that the resident had the Pommel cushion since (YEAR). The CNA stated that she did not recall the exact date that the cushion was issued to the resident but remembered it was before (YEAR). The CNA further stated the resident received the cushion because she was always sliding down in the wheel chair and that all cushions were distributed by the Rehabilitation department. During an interview with the Director of Rehabilitation on 3/23/18 at 3:30 PM she stated the resident previously had dycem over a gel cushion. She stated that the resident's wheel chair leg rest was also adjusted for positioning but was ineffective. The Director of Rehabilitation stated that nursing requested the Pommel cushion which seems to be working for the resident. During a subsequent interview with the Director of Rehabilitation on 3/26/18 at 9:00 AM she stated that the Pommel cushion was first initiated on a trial basis. It is the responsibility of the Rehabilitation department and nursing to monitor the effectiveness of the cushion. She further stated the CCP was interdisciplinary and that either nursing or the rehabilitation department could have updated the CCP to reflect the use of the new device. The Director of Nursing Services (DNS) was interviewed on 3/26/18 at 2:20 PM and stated that cushions are distributed based on Rehabilitation Assessment. The DNS stated that both nursing and rehabilitation should monitor the effectiveness of the cushion, however, nursing was responsible for updating the CCP to reflect the use of the Pommel cushion. 415.11(c)(1)

Plan of Correction: ApprovedApril 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F656 Develop/Implement Comprehensive Care Plan
I. Immediate Correction
Resident # 115
1. Resident was seen and examined by NP on 3/26/18 and Primary physician on 4/12/18. Resident was asymptomatic and no negative outcome.
2. The Physician order [REDACTED]. The CNAAR was also updated to reflect the extra fluid ordered by the physician.
3. RN and IDT received educational counseling to ensure that the care plan is developed and implemented in order to maintain highest practical, physical, mental and psychosocial well-being.
4. Educational counselling records on file for validation.
Resident #196:
1. Resident #196 was immediately assessed by the Occupational Therapist as well as the Director of Rehabilitation to ensure that the pommel cushion was the appropriate cushion for her.
2. Resident # 196 was seen and examined by primary physician on 4/10/2018. No negative outcome was noted.
3. The resident?s physician order [REDACTED].
4. Educational counselling was provided to Rehab staff and RNS for failure to ensure that the care plan is developed and implemented in order to maintain highest practical physical, mental and psychosocial well-being.
5. Educational counselling on file for validation.

II. Identification of Other Residents
1. The facility respectfully states that all resident were potentially affected by deficient practice.
2. The DNS reviewed the physician orders [REDACTED]. Immediate corrective action will be taken for any negative findings noted.
3. A full house audit of all wheelchair cushions and wheelchair devices and that a CCP was developed was completed on 3/28/18 by the Rehabilitation Department to ensure cushions and devices used by the resident were consistent with the physician orders, and reflected in CNAAR. There was no other negative outcome identified.
III. Systemic Changes:
A. The DNS, Medical Director and Administrator reviewed the Policy and Procedure on extra Fluid to ensure proper physician order [REDACTED]. The P&P will be in-service to all License Nursing staff, the focus will address the following:
1. RN to develop and implement a person centered comprehensive care plan.
2. The nurse who picks up the physician order [REDACTED].
3. The nurse on the next consecutive shift will document the extra fluid intake of the resident in the EMAR monitoring section.
4. The extra fluid order will also be transcribed and reflected in the CNAAR
5. The plan of care for residents with physician order [REDACTED].
B. Administration, DNS, Rehab Director and the Regional Director for Rehab met to review Policy
And Procedure on Comprehensive Care Plan and found policy and procedure to be compliant.
All Rehab, IDT and Nursing staff will receive in-service. In-service to focus on:
1. Interdisciplinary team to develop and implement a comprehensive person centered care plan for each resident to ensure that resident care and treatment is planned appropriately for the resident?s needs and severity of condition, impairment, disability or disease.
2. To assure a planning process that maximizes and maintains each resident's optimal physical, psychosocial, and functional status.
3. To establish a care-management system in which the care and treatment planning process is timely, systematic and comprehensive and incorporates input from all disciplines.
C. In-service records will be filed for validation.
IV. QA Monitoring
1. The DNS will develop an audit tool to monitor the facility compliance with ensuring that a comprehensive care plan is implemented consistent with resident medical needs for residents with extra fluid orders.
2. The DNS/Designee will complete four audits weekly times four weeks, then four audits monthly times three months and quarterly thereafter.
3. Any negative findings will be corrected immediately.
4. All findings will be presented to QA Committee monthly for the first quarter, then quarterly thereafter for evaluation and follow-up as indicated.
5. The Rehab Director developed an audit tool to track compliance ensuring that CCP is developed and implemented consistent with resident for wheelchair device use and ensure that the care plan, physician order [REDACTED].
6. The audit will be completed weekly for four residents with wheelchair cushions/devices for the first week, four residents for the first month, and quarterly thereafter.
7. Audits with negative findings will have on site corrective actions implemented by the auditor.
8. The Director of Rehabilitation will present findings to the Quality Assurance Committee Monthly for the first quarter, then quarterly thereafter for evaluation and follow up.
V. Responsibility:
Director of Nursing and Director of Rehabilitation

FF11 483.50(a)(1)(i):LABORATORY SERVICES

REGULATION: §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: May 21, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey the facility did not ensure that laboratory services were provided timely to meet the needs of all residents for 1 of 2 residents reviewed for the Urinary Catheter/Urinary Tract Infection investigative care area. Specifically, Resident #195 had a physician's orders [REDACTED]. However, the urine was not collected timely, requiring the physician to place another U/A and C &S order STAT (immediate) four days later. The finding is: The facility's policy and procedure titled Lab Tests/Obtaining Specimens, dated 8/2016, states that it is the policy of the facility to ensure that all laboratory specimens are obtained in a timely manner. Resident #195 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 2/28/2018 Admission Minimum Data Set (MDS) assessment documented no Brief Interview of Mental Status score due short and long-term memory problems. The MDS documented the resident had an indwelling catheter and had received an antibiotic during the last seven days. A Comprehensive Care Plan (CCP) titled Urinary Incontinence and Indwelling Catheter, dated 2/21/2018, documented the resident had a Foley catheter and was at risk for a urinary tract infection [MEDICAL CONDITION]. A CCP titled [MEDICAL CONDITION] Alteration, dated 2/21/2018, documented an intervention to monitor laboratory values as ordered and report any abnormalities to the physician. A physician's progress note, dated 3/15/2018, documented the resident's Foley catheter was draining amber urine and that the resident was recently treated for [REDACTED]. The physician's documented plan was to check U/A and C &S. Nursing notes from 3/17/2018, written by the 11 PM-7 AM Registered Nurse (RN) supervisor, documented the resident had low urine output through the catheter. The physician was contacted and bloodwork for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) were ordered along with an U/A and C &S urine testing. A physician's orders [REDACTED]. Review of the laboratory results revealed that the CBC and BMP were collected on 3/19/2018. However, the U/A and C &S urine testing was not done. The 7 AM-3 PM unit RN supervisor was interviewed on 3/21/2018 at 9:00 AM and stated that she would call the laboratory to inquire about the urine testing. The 7 AM-3 PM unit RN supervisor was interviewed on 3/21/2018 at 9:40 AM. She stated that she spoke to the 11 PM-7 AM RN who wrote the notes on 3/17/2018, and the 11 PM-7 AM RN stated that she collected the urine and placed the specimen in the designated refrigerator where laboratory specimens are kept for pick up by the laboratory technician. The 7 AM-3 PM RN stated that she called the laboratory, but there was no record of the urine having been tested . The 7 AM-3 PM RN further stated that she spoke to the doctor, and the doctor re-ordered the U/A and C &S STAT (immediate) on 3/21/2018. The 11 PM-7 AM RN who wrote the notes on 3/17/2018 was interviewed on 3/26/18 at 9:13 AM. She stated she did not collect the urine. She stated that she received the order for U/A and C &S on 3/17/2018 from the doctor. However, it was the end of the shift and she was the outgoing nurse, so she informed the incoming 7 AM-3 PM shift about the urine to be collected for U/A and C&S testing. She stated she does not remember the name of the nurse she gave the information to. A representative of the laboratory was interviewed on 3/26/2018 at 9:54 AM. She stated the laboratory only has results for a urine specimen that was collected for Resident #195 on 3/21/2018. The Attending Physician was interviewed on 3/26/2018 at 10:30 AM. She stated that the note she wrote on 3/15/2018 regarding check U/A and C&S was just a plan because of the resident's history of UTIs and the Foley catheter. She said she did order the U/A and C&S on 3/17/2018 when the nurse advised her that the resident was having trouble with urine output. The Director of Nursing Services (DNS) was interviewed on 3/26/2018 at 10:52 AM. She stated that 3/17/2018 was the weekend and the original U/A and C&S was not a STAT order. She stated that since it was not a STAT order, the urine should have been collected on Monday (3/19/2018). She stated that the process involves the nursing staff collecting the sample and placing it in the designated refrigerator and then the laboratory technician collecting it from the refrigerator. She stated it was unclear whether the urine was collected or not, and therefore the doctor had to re-order it as a STAT order on 3/21/2018. 415.20

Plan of Correction: ApprovedApril 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F770 Laboratory Services
I. Immediate Corrective Action for Resident Affected:
Resident #195
1. Urinalysis was picked up by Bio Diagnostic Laboratory (BDL) on 3/21/2018.
2. Urinalysis returned 3/24/18. RN supervisor contact primary physician with results. Primary Physician ordered [MEDICATION NAME] 100mg BID x 7 days. Primary physician examined resident on 3/27/2018, stable and to continue [MEDICATION NAME].
3. BDL respectfully states that the laboratory technician scheduled 3/19/2018 and 3/20/2018 is no longer employed by BDL.
4. RN supervisor who picked up Urinalysis order will receive an educational counselling for not ensuring that Urinalysis specimens had been collected. In addition for not documenting urinalysis wasn?t collected for follow up to have specimen collected.
5. Educational counseling on file for validation.
II. Identification of Other Resident:
1. Facility respectfully states that all residents with orders for Urinalysis were potentially affected by deficient practice. The DNS will make a list of urinalysis ordered for past 60 days and DNS/Designee will evaluate that each urinalysis was collected timely by staff and BDL laboratories picked up timely. The facility respectfully states that upon completion of review all identified issues will be corrected.
III. Systemic Changes made so the deficiency will not reoccur:
1. Administration/DNS/BDL Representative met on 4/10/2018. F770 Tag, systems and current Policy and Procedure were reviewed. P&P was revised and will be in-serviced to all BDL Lab Technicians and licensed nursing staff. The lesson plan will focus on:
2. Lab technician will print up a ?Finished Visit Report? for all lab data that was collected and not collected for all assigned lab tests and specimen pick-ups. Lab Technician will hand this report to the RN Supervisor. Supervisor will sign off at the bottom of the sheet and place report in the laboratory binder.
3. The facility will maintain a copy of the ?Finished Visit Report? in the laboratory binder located in the Nursing Office.
4. All uncollected specimens will be documented on the 24 hour report sheet and reviewed at AM report.
5. RN Supervisor is responsible to review ?Finished Visit Report? for all uncollected laboratory tests and specimens and ensure that laboratory tests are completed and specimens collected.
6. RN Supervisor will notify Primary Medical Doctor of residents whose labs have not been completed or refuse laboratory tests for further instructions.
7. The unit RNS Supervisor will be responsible for following-up all uncollected specimens from the report.
8. The DNS/Designee will review the Finished Visit Report at QA meeting daily and ensure that all uncollected labs has been reconciled.
9. Education on file for validation
IV. Monitoring of the Corrective Action/Quality Assurance:
1. The DNS will developed an audit tool to monitor orders for Urinalysis.
2. The audits will be completed by the assigned DNS/Designee.
3. Four audits per week x one month, four audits per month x 3 months and quarterly thereafter. Any negative findings will be corrected immediately.
4. All findings will be presented reported to the QA Committee quarterly for input, evaluation and follow-up as needed.
V. Responsibility: Director of Nursing

FF11 483.55(b)(1)-(5):ROUTINE/EMERGENCY DENTAL SRVCS IN NFS

REGULATION: §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility- §483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: May 21, 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 residents with lost or damaged dentures were promptly referred for dental services for 1 of 2 residents reviewed for the Dental investigative area. Specifically, a dentist identified Resident #137 as having upper and lower partial dentures in a (YEAR) dental consult. However, the (YEAR) dental consult did not identify the dentures, and there was no documented evidence addressing the missing dentures. The finding is: The facility's policy and procedure titled Dental Services, dated 10/2017, states that it is the policy of the facility to ensure that the dental needs of each resident are met by providing and/or obtaining the necessary dental services. The policy further states that the unit nurse/Registered Nurse supervisor will be responsible for contacting the dental office and making a referral within three days of the report of/identification of the dentures being lost or damaged. Resident #137 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/19/2018 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. There were no swallowing or dental issues identified in the MDS. A Comprehensive Care Plan titled Dental Care, dated 11/4/2016 and last updated 11/21/2017, did not identify the resident as having dentures or that the resident's dentures were missing. Resident #137 was interviewed on 3/19/2018 at 11:51 AM. She stated that her top denture was broken and missing and the bottom denture was missing. She stated they have been missing for a long time and she could not remember if she told the nurse. She stated she has not had any problems chewing her food but that sometimes her gums get sore. A dental consult dated 6/12/2016 identified the resident as having partial upper and partial lower dentures and that the dentures were functional. All findings were within normal limits and the follow-up was to treat symptomatically. A dental consult dated 6/8/2017 did not identify the partial upper and lower dentures. The consult documented that the annual exam was unchanged and the resident was functioning well as is. The 6/8/2017 dental report does not reflect the missing partial upper and partial lower dentures which were identified on the (YEAR) dental consult. The resident's Certified Nursing Assistant (CNA) was interviewed on 3/22/2018 at 11:46 AM. She stated the resident did not have dentures and she was not aware of missing dentures. Review of the (MONTH) (YEAR) CNA Accountability Record (CNAAR) revealed no documentation regarding dentures. The dentist was interviewed on 3/22/2018 at 12:20 PM. He stated that he should have been made aware when a resident's dentures are missing or broken. He stated that he does not routinely check the prior year's dental consult when he does his annual exam. The Registered Nurse (RN) unit supervisor was interviewed on 3/22/2018 at 1:06 PM. She stated that she did not know if the resident had dentures. A nursing note dated 3/22/2018 at 1:28 PM documented the resident's daughter was called and the daughter stated that the dentures were lost and that the resident wanted her partial dentures. The Medical Director was interviewed on 3/26/2018 at 9:20 AM and stated the dentist should review past consults when making the annual visits. 415.17 (a-d)

Plan of Correction: ApprovedApril 19, 2018

F791 Routine /Emergency Dental Srvcs in NFs
I. Immediate Corrective Action for Resident affected:
Resident #137
1. The Dentist completed an examination of resident for upper and lower dentures. He determined that resident will be processed for transitional upper and transitional lower dentures. Molds initiated for dentures.
2. Medical Director will provide educational counseling to the dentist to ensure that the dental needs of each resident is met and document findings for all visits. Counseling will also be provided for dentist to review and follow up previous consultation findings such as annual follow up and change in condition according to current P&P for dental services.
3. RN supervisor completed a care plan regarding oral care and missing dentures.
4. RN supervisor who failed to complete care plan accurately received an Educational Counseling on Care Plan Accuracy.
5. Education on file for validation
II. Identification of Other Resident:
1. Facility respectfully states that all residents with dentures were potentially affected by deficient practice. The DNS will make a list of all dental consults for past 60 days and Dentist will reevaluate each resident to ensure that the dental needs of each residents are being met and document findings. RN Supervisor will check that dental care plans are accurate. The facility respectfully states that any identified issues have been corrected.
III. Systemic Changes made so the deficiency will not reoccur:
1. The Administration/DNS/Medical Director/Dentserv Staff met on 4/12/2018 and reviewed Policy and Procedure on Dental Services and found same to be compliant. P&P will be in-serviced to all licensed nursing staff. The lesson plan will focus on:
2. It is the policy of this facility to ensure that the dental needs of each resident are met by providing and/or obtaining the necessary dental services.
3. Routine dental services- an annual examination of the oral cavity to identify and/or diagnose dental disease which includes as needed dental radiographs, dental cleaning, fillings(new or repairs), minor partial/full denture adjustments, smoothing of broken teeth and taking impressions for dentures/fitting dentures
4. Emergency dental services- services needed to treat acute pain in the teeth, gums or palate; broken or damaged teeth or any other oral cavity symptom which requires the immediate attention of a dentist.
5. Promptly- means within 3 business days or less from the time the loss or damage to dentures is identified.
6. Residents' that have lost or broken dentures will be listed on the 24 hour report sheet and the nurse will enter a progress note indicating the problem and intervention.
7. The nurse will document in the residents chart that a dental consult has been made and inform the resident and/or resident representative.
8. The resident diet will be reviewed to ensure that it is appropriate diet consistency in lieu of missing dentures.
9. Dental Care plan will be updated.
10. Education on file for validation.
IV. Monitoring of the Corrective Action/Quality Assurance:
1. The DNS will developed an audit tool to monitor routine and emergency dental services.
2. The audits will be completed by the assigned DNS/Designee. Four audits per week x one month, four audits per month x 3 months and quarterly thereafter.
3. Any negative findings will be corrected immediately.
4. All findings will be presented monthly to the QA committee x3 months then quarterly thereafter for input, evaluation and follow-up as needed.
V. Responsibility: Director of Nursing

Standard Life Safety Code Citations

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 11, 2018
Corrected date: June 4, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the Emergency Preparedness (EP) communication plan complies with Federal, State and local laws. Specifically, the facility did not complete the task of assigning and including contact information within the Health Provider Network (HPN) Communications Directory. This occurred while reviewing the facility's EP plan. The finding is: On 4/11/2018 between the hours of 8:30am and 2:45pm during the recertification survey, the following was noted: Upon review of the facility's EP documentation, it was revealed that the facility did not assign a point of contact for the task of 24 by 7 Contact, Emergency Medical Supplies Receiving Office and Office of Administrator. This is required by 10NYCRR 400.10 and must be designated by each facility in the Health Provider Network (HPN) Communications Directory. In an interview on 4/11/2018 at approximately 12:30pm with the Assistant Administrator, she stated that she used the coordinator's update tool and has the facility 24 hour contact information in the system but it is not under the Role Look Up Tool. In an interview on 4/11/2018 at approximately 12:35pm with the Administrator, he stated he is the facility 24 hour contact and receives the information sent from the Department of Health. He also stated he uses the coordinator's update tool to update information in the Health Commerce System (HCS). He further stated he tried to assign the tasks but was unable to and would contact the HCS. 10NYCRR 400.10

Plan of Correction: ApprovedMay 9, 2018

Part I. Immediate Corrective Action for Resident affected:
The Administrator completed the designation and assignment of the point of contact in the Health Provider Network (HPN) Communications Directory for the:
1. Task of 24 by 7 contact,
2. Emergency Medical Supplies Receiving Office,
3. Office of Administrator
Part II. Identification of other Resident:
1. The facility respectfully submits that other residents could have potentially be affected by this deficient practice.
2. All other point of contact for the emergency preparedness role have been assigned to HPN Communications Directory.
Part III. Systemic Changes made so the deficiency will not reoccur:
1. The administrator or designee will ensure that the point of contact for the task of 24 by 7 contact, emergency medical supplies receiving office, and office of administrator role is designated and that the assignment is updated in the HPN
2. In-service will be provided to assigned/designated staff regarding their role and to ensure that the emergency preparedness roles are assigned and updated.
3. In-service lesson plan and attendance records will be kept on file for validation.

Part IV. Monitoring of the Corrective Action/Quality Assurance:
The Administrator developed a log and will review the HPN monthly to ensure that the task of 24 by 7 contact, emergency medical supplies receiving office, and office of administrator roles continue to be assigned to a designated staff member.
1. The Administrator will address and correct any negative findings immediately.
2. All findings will be reported to Quality Assurance quarterly for follow-up and recommendation as necessary.
Part V. Responsibility/Discipline:
Administrator.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 11, 2018
Corrected date: June 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19.3.2 Protection from Hazards 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic closing. 19.3.2.1.5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 (9.3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 (4.6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. Based on observation and staff interview, the facility failed to ensure that doors protecting hazardous areas were self-closing or automatic closing. This occurred on 1 of 4 floors of the facility. The finding is: On 4/10/2018 and 4/11/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was observed: Rooms containing large amounts of stored combustible material were noted to be lacking self- closing or automatic closing doors. Locations include, but are not limited to: 1) Storage Room adjacent to the Finance Office on the 1st Floor, Unit A 2) room [ROOM NUMBER]/Room144 on the 1st Floor, Unit A 3) Nursing Supply Office on the 1st Floor, Unit A 4) Wheelchair Storage Room on the 1st Floor, Unit D In an interview on 4/11/2018 with the Director of Engineering, he stated he can add a self-closing device to the doors. 2012 NFPA 101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMay 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I. Immediate Corrective Action for Resident affected:
Self-closing door devices were immediately installed on the following doors:
1. Storage Room adjacent to the Finance Office on the 1st Floor, Unit A
2. room [ROOM NUMBER]/Room144 on the 1st Floor, Unit A
3. Nursing Supply Office on the 1st Floor, Unit A
4. Wheelchair Storage Room on the 1st Floor, Unit D
Part II. Identification of other Resident:
1. The facility respectfully submits that other residents could have potentially be affected by this deficient practice.
2. All other doors to rooms containing large amounts of stored combustible material were checked throughout the building and self-closing devices were installed where required.
Part III. Systemic Changes made so the deficiency will not reoccur:
1. The director of maintenance or designee will ensure that rooms containing large amounts of stored combustible material will have self-closing or automatic closing devices.
2. In-service will be provided to maintenance staff regarding the self-closing device requirements of rooms containing large amounts of stored combustible material.
3. In-service lesson plan and attendance records will be kept on file for validation.
Part IV. Monitoring of the Corrective Action/Quality Assurance:
1. The Director of Maintenance or designee will check on a monthly basis all doors leading into rooms containing large amounts of stored combustible material to verify that self-closing devices are installed and operational.
2. The Director of Maintenance will develop a log to track the doors requiring self-closure. The Director of maintenance will address and correct any negative findings immediately.
3. All findings will be reported to Quality Assurance quarterly for follow-up and recommendation as necessary.
Part V. Responsibility/Discipline:
Director of Maintenance.

K307 NFPA 101:NUMBER OF EXITS - CORRIDORS

REGULATION: Number of Exits - Corridors Every corridor shall provide access to not less than two approved exits in accordance with Sections 7.4 and 7.5 without passing through any intervening rooms or spaces other than corridors or lobbies. 18.2.5.4, 19.2.5.4

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: April 11, 2018
Corrected date: June 4, 2018

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. K-252 S/S=B At least two acceptable exits are not provided form the 4416 square foot basement general store room. One of the two required exits is an emergency escape hatch, which is not in accordance with 7.5. 483.70(a), 711.2(a)(1), 10NYCRR 415.29, 2012NFPA 101: 7.5, 19.2.4.1, 19.2.4

Plan of Correction: ApprovedMay 9, 2018

Facility respectfully requests a continuation of waiver.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 11, 2018
Corrected date: June 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2011 NFPA 25: 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance. Test Frequency Reference Sprinklers At [AGE] years and every [AGE] years thereafter 5.3.1.1.1 5.3 Testing. 5.3.1* Sprinklers. 5.3.1.1* Where required by this section, sample sprinklers shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. 5.3.1.1.1 Where sprinklers have been in service for [AGE] years, they shall be replaced or representative samples from one or more sample areas shall be tested . 5.3.1.1.1.1 Test procedures shall be repeated at 10-year intervals. Based on observation, documentation review and staff interview, the facility failed to ensure that sprinklers installed over [AGE] years ago were tested , or replaced in accordance with NFPA 25, 2011 edition. This occurred on 4 of 4 floors of the facility, including the basement. The finding is: On 4/10/2018 and 4/11/2018 between the hours of 8:30 am and 2:45pm during the recertification survey, the following was observed: In the Boiler Room located in the Basement of the facility, the sprinklers were observed to be of an older style sprinkler. Documentation review revealed that the sprinklers were older than [AGE] years. Specifically, a document dated 10/21/2016 from the sprinkler vendor stated, The end of (YEAR), will be older than [AGE] years. Additionally, subsequent inspections performed by the sprinkler vendor company and corresponding documentation, indicated a yes under the column System [AGE] years or Older. In an interview with the Administrator on 4/10/2018 at approximately 10:45am, he stated the facility has a vendor who is scheduled to install the new sprinklers. Review of the facility submitted document titled Sprinkler Head Replacement Project revealed the sprinklers are scheduled to be replaced by (MONTH) 16th, (YEAR). This is beyond the [AGE] years allowed by NFPA 25, 2011 edition.

Plan of Correction: ApprovedMay 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I. Immediate Corrective Action for Resident affected:
All sprinkler heads throughout the building have been replaced. This includes the four floors of the facility as well as the basement by a sprinkler vendor company.
Part II. Identification of other Resident:
1. The facility respectfully submits that all residents could have potentially be affected by this deficient practice.
2. All sprinklers throughout the building were visually inspected to verify that they were replaced.
Part III. Systemic Changes made so the deficiency will not reoccur:
1. The director of maintenance has been in-serviced as to the requirement that sprinkler heads in service for [AGE] years shall be replaced or representative samples from one or more sample areas be tested .
2. In-service lesson plan and attendance records will be kept on file for validation.
Part IV. Monitoring of the Corrective Action/Quality Assurance:
1. The Director of Maintenance or designee will check on a monthly basis the monthly inspection report after inspection by the sprinkler vendor to verify that there are no outstanding sprinkler issues.
2. The Director of Maintenance will develop a log to track any outstanding sprinkler issues. The Director of maintenance will address and correct any negative findings immediately.
3. All findings will be reported to Quality Assurance quarterly for follow-up and recommendation as necessary.
Part V. Responsibility/Discipline:
Director of Maintenance.