Aurelia Osborn Fox Memorial Hospital
May 4, 2018 Certification 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: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility did not ensure development of comprehensive person-centered care plans to address residents assessed needs, for three (Resident #'s 89, 75, and 127) of thirty-three residents reviewed for comprehensive care plans (CCP). Specifically: For Resident #75, a CCP was not developed for the [DIAGNOSES REDACTED].#89, a CCP was not developed to address skin tears, and; For Resident #127, a CCP was not developed to address the resident's pain treated with daily and as needed (prn) opioid pain medications. This was evidenced by: The Nursing Service policy and procedure for Minimum Data Set/Care Area Assessments (MDS/CAAs) Care Plans dated (MONTH) (YEAR), documented assessments and care plans are pertinent to each resident's state of physical, emotional, and social functioning and that each discipline is responsible for completing the care plan for their assigned care area. Resident #75: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident understands others, is able to make herself understood and cognitively is moderately impaired. A physician's orders [REDACTED]. During interview on 5/3/18 at 11:06 am, the Director of Social Services (DSS) stated that if a resident flags/triggers on the MDS or has symptoms of depression then either social work or nursing are responsible to initiate the care plan. During an interview on 5/4/18 at 10:48 am, the Registered Nurse Manager (RNM) #4 stated that a resident with a [DIAGNOSES REDACTED]. Resident #89: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 3/15/18, assessed the resident sometimes understands, was sometimes understood and had moderately impaired cognitive ability. The MDS of 12/17/17, documented the resident had a skin tear. Nurses notes on 12/17/17 documented the resident had a skin tear from a fall. During an observation on 5/02/18 at 8:44 am, a large scab was noted on the middle of the resident's left forearm. During interview on 5/2/18 at 3:33 pm, Registered Nurse Manager (RNM) stated it was from a skin tear that happened on 3/20/18. An Accident and Incident Report was provided for the skin tear. During interview on 5/02/18 at 4:30 pm, the RNM stated the only CCP for skin was for skin breakdown. A CCP should have been developed for skin tears. This must have been an over sight. We do use the MDSs to do CCPs. Resident #127: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident could understand, usually be understood, had moderately impaired cognitive skills, and received opioid pain medication daily. physician's orders [REDACTED]. There was no CCP addressing the resident's pain management needs or the use of pain medication. During an interview on 5/4/18, RN #4 reported that any resident receiving routine and/or PRN pain medication should have a CCP for pain management. She was not sure why there was not one for this resident. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedJune 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents affected by deficient practice:
-Care Plans have been developed for Res # 89 - skin tears, # 75 - Depression. Res # 127 was adm. 3/9 with Care Plan due day 21 (3/29) The opiod was discontinued on 3/23 and the resident discharged ,[DATE].
Other residents potentially affected by the deficient practice:
-All residents prone to skin tears and/or with psychoactive medications will be reviewed to assure res. centered care plans are in place. All residents receiving pain medications were reviewed to assure a Comprehensive Care Plan was in place.
Systemic Changes:
The Comprehensive Care Plan policy has been reviewed and revised as appropriate.
-A mandatory education program regarding need for development of resident centered care plans for individuals prone to skin tears and psychoactive medications and pain medication, including PRN pain medication use, will be completed by Licensed Nursing staff.
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with maintaining resident centered Care Plans for individuals prone to skin tears, receiving anti-psychotics and/or receiving [MEDICATION NAME] medications. The monitor will be conducted on a resident sample from each unit and shift weekly for 90 days, then monthly. The results will be reported to the Quality Review/ QAPI Committee.
-Responsibility: Director Nursing Services

FF11 483.45(d)(1)-(6):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility did not ensure that each resident's drug regimen was free from unnecessary drugs, which is any drug used in excessive dose, for excessive duration without adequate monitoring, without adequate indications for its use, or in the presence of adverse consequences for 2 (# 98 and #127) of 4 residents reviewed for pain management. Specifically, for Residents #'s 98 and 127, there were no before and after pain scales documented for monitor the effectiveness of pain medications administered as needed (PRN). This is evidenced by: The facility Policy & Procedure titled Pain Management Policy and dated (MONTH) (YEAR) documented that each resident is entitled to have their pain assessed and managed to a level the individual feels is tolerable. Administration of as needed (PRN) medications will be recorded on the Medication Administration Review (MAR). Resident #98: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had no cognitive impairment. The Medication Administration Record (MAR) dated (MONTH) (YEAR) documented; [MEDICATION NAME]-[MEDICATION NAME] 5 milligrams (mg)/325 mg tablet, give 1 tablet every 6 hours as needed. The ordered pain medication was administered on 16 occasions. On 4/13/18, pain assessments were not documented before and after receiving the medication. On 4/14/18, 4/19/18, 4/20/18, 4/21/18, and 4/23/18 there was no documented pain assessment prior to receiving the medication. During an interview on 05/04/18 at 9:18 am, Licensed Practical Nurse (LPN) #5 stated she looks at the residents and if they look like they're in pain or they say they're in pain she will try to reposition them or do something to make them more comfortable. I document what I saw of the resident or the number they tell me when I give them pain medication, and I will check on the resident after the same. During an interview on 05/04/18 09:35 am, LPN #9 stated she documented the prn pain medication in the progress notes. There are four different pain scales to choose from, should use the same scale before and after. During an interview on 05/04/18 at 2:24 pm, the Director of Nursing (DON) stated the nurses document with the number scale or the non-verbal scale before and after administering the pain medication. She did not know the same pain scale had to be used before and after the medication administration. Resident #127: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident could understand, was usually understood, had moderately impaired cognitive skills, and received opioid pain medication daily. A physician's orders [REDACTED]. The Medication Administration Record for (MONTH) (YEAR), documented the PRN [MEDICATION NAME] was administered 5 times and each time the monitoring section was blank. During an interview on 5/4/18, Registered Nurse #4 reported that pain scales should be documented on the MAR before and 30 minutes after any PRN pain medication is given. The order must have been entered without monitoring attached, if it was entered properly the nurses would have to enter a pain scale before the system would allow them to continue. 10NYCRR4154.12(l)(1)

Plan of Correction: ApprovedMay 29, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents affected by deficient practice:
-Res #98 and #127 have been discharged and no correction possible
Other residents potentially affected by the deficient practice:
-All prn [MEDICATION NAME] orders have been reviewed to assure pain monitor is attached and an actual or potential pain care plan is in place.
Systemic Changes:
-Policy M-41 PRN Medications identifies need for monitoring of pain at time of PRN [MEDICATION NAME] administration and 60 minute follow-up. It has been revised to include use of consistent pain scale.
-All licensed Nursing staff will receive mandatory education regarding Policy M-41.
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with monitoring pain with PRN [MEDICATION NAME] administration. The monitor will be conducted for all new PRN [MEDICATION NAME] orders weekly for 90 days, then monthly. The results will be reported to the Quality Review/ QAPI Committee.
-Responsibility: Director Nursing Services

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: During an interview on 05/03/18 at 4:21 pm, the Director of Nursing (DON) reported the facility does not have an MRR policy, only the pharmacy policy, which does not address time frames. 10NYCRR415.18 (c)(2)

Plan of Correction: ApprovedMay 29, 2018

-Policy P-22 Pharmacist Consultant Recommendations Actions was developed and put in place 11/27/17. This policy defines time frames for the different steps in the process. A copy was faxed to NYSDOH following survey team exit.
-The policy has been applied to all NH residents since it's implementation last November.
-A QI monitor will be developed to assess and assure facility compliance with the monthly medication regime policy. The monitor will be conducted on a resident sample from each unit and shift weekly for 90 days, then monthly. The results will be reported to the Quality Review QAPI Committee.
-Responsibility: Director: Pharmacy

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification survey it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, until ready for final preparation before service, be maintained at 41 degrees Fahrenheit (F) or less and that automatic dishwashing machines operate in accordance with manufacturer specifications. Specifically, TCS foods were being held greater then 41F, and the automatic dish washing machine was not rinsing at the specified water pressure. On 1 of 3 units, the Dietary Server was not serving food in accordance with professional standards for food service safety. This is evidenced as follows. Observations on 05/01/2018 revealed that at 9:44 am, cooked and cooled roasted beef found in the walk-in refrigerator was 51F, and the automatic dishwashing machine final rinse was 13 pounds per square inch (psi). Record review of the automatic dishwashing machine information data plate on 05/01/2018 revealed that the final rinse water pressure is to be 20 psi 5 psi (15 psi to 25 psi). The Director of Food and Nutrition Service (Director) stated in an interview conducted on 05/01/2018 at 9:44 am, that the roast beef was sliced today for service tomorrow (05/02/2018), and that due to the food temperature being elevated it will be discarded. Additionally, the Director stated that she will contact the maintenance department to have the dishwashing machine water pressure adjusted. Finding Unit 3 During Dining Observation on Unit 3 on 5/02/18 at 8:24 am, the Dietary Server (DS) put waffles in the toaster with gloved hands, pushed the lever down, then took the cooked waffles out of the toaster with the same gloved hands. She did not change gloves before cooking another set of waffles. The DS grabbed the outside of the waffle bag, put more waffles in the toaster and took the cooked waffles out of the toaster. Gloves were not changed when the gloves were contaminated. The DS continued to make waffles in the toaster, opened the hot box with the handle twice and continued to make waffles. At no time did the DS change her gloves. When the DS was getting plates she would put her thumbs onto plate, and did not keep thumbs on the edge of the plate. During interview on 5/03/18 at 5:29 pm, Patient Services Food Company Supervisor #10 stated the DS should have changed gloves when she touched the toaster lever and the hot box handle. The preferable method of handling the cooked waffles would be to use tongs. He stated thumbs should be placed on the exterior of the plate not in the plate. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(a), 14-1.113

Plan of Correction: ApprovedJune 1, 2018

Residents identified to be affected by deficient practice: None noted
Other Residents potentially affected by the deficient practice: All residents have potential to be affected, systemic changes in practice will eliminate the deficiency.
Systemic Changes:
All Food Production staff will attend a mandatory education using the ServSafe National Restaurant training program, led by the Director of Food and Nutrition and the Executive Chef.
In addition, all production staff will be re-educated on Department Policy, B007, Food Handling Guidelines: Production, Purchasing and Storage, HACCP guidelines per FDA Guidelines.
Food production staff will review at the Daily Production Meetings the On Track with Food Safety Training, rotating the 24 training topics in the series.
The dish machine rinse pressure will be maintained within the manufacturers guideline of 15- 25 PSI. The pressure was correct on survey. The gauge will indicate the rinse pressure when the rinse cycle is activated. No adjustments to the machine were necessary. A monitor to record the rinse pressure will be conducted 3 times per day; morning, mid-day and evening. The staff will be educated on the proper procedure to implement should the pressure not be within the acceptable range. The dish machine log was revised to include the recording of the pressure 3 times per day, morning, mid-day and evening. The desired range is indicated on the form. Should the pressure be out of range, the staff will immediately shut down the machine, and notify the Supervisor. The machine will be taken out of service until the repair is made, and the machine is in proper working conditions.
Dining Room Service staff will attend mandatory training on safe food handling. Contamination precautions will be addressed per Department Policy, B007, Food handling guidelines. Education will include techniques that include the use of tongs, snack wrap, and single use disposable glove.
Monitoring:
The Executive Chef will complete a monitor to ensure that all production staff are following safe food handling requirements, including cooling procedures, proper food handling, preparation, and temperature requirements.
The Kitchen Supervisor, along with the Food Service Dishwasher will complete a monitor 3 times per day, morning, mid-day and evening to ensure the dishmachine is maintaining the rinse pressure at an appropriate level.
A monitor will be conducted through direct observation of the Dining Room Servers to ensure that all staff are following proper food handling practices. This monitor will be completed by the Director: Nutrition Services, or a Food and Nutrition Manager or supervisor.
All monitors will be conducted weekly, and will randomly include all staff being observed for compliance. The results of the monitors will be presented to the NH Quality Assurance/QAPI committee on a monthly basis.
Responsibility: Director: Food and Nutrition Services

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a recertification survey, the facility did not ensure the environment remained as free of accident hazards as possible for 3 of 3 units. Specifically: For Unit 2, an on demand hot beverage machine was left unlocked in a dining area that residents could readily access; For Unit 3, cleaning supplies were left unsupervised near Resident #89 and; For Unit 1, a gallon sized plastic jug labeled bleach, was found on the floor of an unlocked laundry room. This is evidenced by: A Coffee Pot Safety Policy dated 4/6/16, last revised 9/23/16 documented the following: 1. Purpose: Maintain resident safety and prevent the potential [MEDICAL CONDITION] hot beverages via the on demand hot beverage machine. 2. Policy: Each coffee pot will be locked, internally and externally, whenever there is not a staff member within the immediate area to supervise the coffee machine. 3. Immediately after meal service the coffee machine must be locked. 4. To confirm the coffee machine is locked, a symbol display confirms the machine is locked and can not draw hot beverages. 5. It is the responsibility of Nutrition Services Department to monitor that the coffee machine is locked at the end of meals as well as between meals. 6. If Nursing or Activities unlocks the machine to get a hot beverage for a resident it is their responsibility to make sure the machine is locked before leaving the area. The operating manual for Folgers commercial brewing system documented the dispenser has three product outlets, left for coffee or tea, center for hot water, right for coffee or tea. The Drink delivery warning documented that liquids dispensed are hot! To avoid scalding, keep hands and other body parts away from the dispenser. Door lock (mechanical door lock with key) is provided to prevent unauthorized access. When the icon lock is displayed as closed, delivery of the drink is blocked. Locking and unlocking the dispenser as follows: 1. Open the dispenser door 2. Press Lock/clear -error switch (inside of door) to block the drink delivery. 3. Lock icon appears on the display. 4. To unlock insert key, unlock door dispenser, open door, press Lock/clear- Error switch again to enable drink delivery. Finding #1: The facility did not ensure that an on demand hot beverage machine was not left unlocked in a dining area that residents could readily access During observation on 5/3/18 at 10:05 am, the on demand hot beverage machine was unlocked and unattended in the main dining area on Unit 2. Several residents were observed ambulating in and out of the room and staff was not present to monitor the machine. During observation on 5/3/18 at 10:45 AM, a Licensed Practical Nurse (LPN) #1 entered the main dining room, and obtained a cup of hot water. During interview on 05/03/18 11:15 AM, Food Service Worker (FSW) #6, stated he is responsible for the area where the on demand hot beverage machine is located. He stated he was responsible for locking the machine when he leaves the unit after breakfast and lunch, but often returns to find it unlocked. Nurses can access the key that is stored in the cabinet above the machine and sometimes leave it unlocked. He reported the water temperature is routinely checked and runs around 180 degrees. He poured a cup of water, and checked the temperature of the water. The water temperature was over 150 degrees. Two surveyors placed a finger into the cup of hot water, and pulled them out because the water was too hot. During an interview on 5/3/18 at 11:50 AM, LPN #1 stated she did not unlock the machine because it was already unlocked. She realized this when the lock icon on the hot beverage machine showed the lock was open. She stated the coffee machine was supposed to be locked when dining staff left the area. She stated someone must have forgotten to lock it after using it. She didn't know who, but said it happens sometimes. During interview on 5/3/18 at 12:00 PM, FSW #6 stated he checks the on demand hot beverage machine before he leaves the main dining room, after breakfast and lunch. If it is unlocked he locks it to prevent residents that wander in and out of the room from getting burned. The button to dispense the coffee and hot water is accessible to residents who can stand. There is a log used to demonstrate things have been checked after meals, but a key is up in the cupboard and anyone can unlock it after he leaves. Everyone is responsible to immediately lock it after using it . During interview on 5/3/18 at 3:15 PM, Registered Nurse Unit Manager #1 (RNUM) stated the coffee dispenser is supposed to be locked by staff before leaving the dining room because there are residents that ambulate freely in and out of the room all day and evening. The residents access the refrigerator which is in the same area when staff are not in the room. There is a key to unlock the coffee dispenser and sometimes people do forget to relock it after using it. Everyone is aware it cannot be left unlocked for the safety of wandering residents, because there are no closed doors to prevent access to the room. During interview on 5/4/18 at 9:48 AM, the Director of Nursing stated the coffee dispenser was designed to lock when not in use by staff. It should never be left unlocked if staff are not in the dinning room. That is a policy of the facility and everyone has been inserviced on this. Finding #2: Resident #89: The facility did not ensure that cleaning supplies were not left unsupervised near the resident. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 5/02/18 at 10:28 AM, housekeeper # 8 was in the residents room cleaning the bed frame at the head of the bed. She had the mattress on her shoulder and her head down under the mattress looking at the frame. The cleaning cart was in the doorway. The resident was in her wheelchair near the bathroom side of the bed. There was a bottle of CREW Non-Acid Bowl and Bathroom Disinfectant Cleaner on the floor, within three feet of the resident. The CREW Cleaner, had a Caution label for skin corrosion/irritation and serious eye damage/irritation, keep out of reach of children. Housekeeper # 8 finished the bed cleaning and came around to the resident. She was asked what the CREW was and said bathroom cleaner. She stated she left it there because she still needed to clean the bathroom. She then picked it up and went into bathroom. During interview on 5/02/18 at 10:46 AM, Housekeeper # 8 said she left the cleaner on the floor because they were recently told not to make many trips into the rooms, they should have everything with them. She stated she used to leave it locked in the cart before that. During interview on 5/02/18 at 4:48 PM, RNUM # 2 stated if the housekeeper was watching the resident, it would not be a concern, if the housekeeper could not see the resident, it would be more of a concern. During interview on 5/03/18 at 8:47 AM, Housekeeper #12 stated she normally doesn't take the CREW cleaner in the room until the last thing. She said it was not normal procedure or a safe thing to leave the cleaner in the room near a resident. During interview on 5/04/18 at 1:13 PM, the Director of Housekeeping said the housekeeper should have left the cleaner in the cart and gone back to get it. Staff is trained to leave everything in the cart until needed and they are ready to use it. Finding #3: The facility did not ensure that a gallon sized plastic jug labeled bleach, was not found on the floor of an unlocked laundry room. A document provided by the facility addressing ways laundry can be handled in the Nursing home, revised 2/2018, did not address securing cleaning supplies left in the unlocked laundry room. During observation on 5/1/18 at 1:02 PM, a gallon sized almost half full plastic jug tabled bleach was found in an unlocked laundry room on the unit. During interview on 5/1/18 at 1:15 PM, RNUM #4 stated she was unsure if the laundry should be locked but the bottle of bleach should not be on the floor in the room. During interview on 5/4/18 at 10:21 AM, Housekeeper #8 stated she cleans the laundry, but does not supply or replace laundry supplies. She was not sure if the bleach should be left in the unlocked laundry room. During interview on 5/4/18 at 1:13 PM, the Director of Housekeeping stated her department is not responsible for laundry rooms used by residents. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedMay 30, 2018

Resident affected by the deficient practice:
Resident 89 did not come in contact with the CREW Bowl and Bathroom cleaner.
Other residents potentially affected by the deficient practices:
No other residents were affected by the deficient practices.
During survey, the keys to the coffee machines were removed from access for all nursing home staff. Only Nutritional Services staff had access to the key, and they unlocked the machine prior to the meal, and locked the machine immediately after the meal.
The Chlorine bleach that was believed to have been brought in by a family member for a resident that washes their own clothing was removed and discarded.
All Environmental Services staff were educated on the proper use and storage of cleaning supplies.
Systemic Changes:
The facility policy on the use of the coffee makers has been updated. The key to the coffee machine will be in the sole possession of the Nutritional Services staff. they are responsible to ensure the machine is un-locked during meal time, and then locked post meal service. In order to have fresh coffee available to the residents at all times, and in between meals, the key ring that is issued to the Charge Nurse on the unit will have a key for the coffee machine. It will be the Charge Nurses responsibility to unlock the machine, retrieve the beverage, and then immediately re-lock the machine.
An informational instruction flyer on the use of the washing machine will be provided to any resident or family that wish to utilize the unit washing machines. The instructions will describe that the only detergent that can be used in the machine must be from the auto-dispenser attached to the washing machine. No products will be allowed to be brought into the facility.
All Environmental Services Staff attended an educational session on the safe use, handling, and storage of cleaning products.
Monitoring:
A monitor has been developed to ensure that the coffee maker is locked when unattended. This monitor will be completed by the Nutritional Services Supervisor Staff at random times throughout the day.
The Environmental Rounds monitor has been updated to include monitoring of the laundry rooms for unacceptable products.
The Environmental Services Audit will be conducted to ensure the safe handling of cleaning products.
The monitors will be completed weekly. With continued compliance after 90 days, the monitors might be completed on a less frequent basis, but no less than monthly. The results of the monitors will be reported to the NH Quality Assurance/ QAPI Committee.
Coffee Machine Safety - Responsibility of the Director of Food and Nutrition
EVS Cleaning Product Safety and Laundry Room Monitor - Responsibility of the Director of Environmental Services

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on employee health record review, staff interview, and Infection Control policy review during the recertification survey, the facility did not maintain a comprehensive Infection Control Program to help prevent the development and transmission of disease. Specifically, within the past year, the facility did not provide education on the risks and benefits for the pneumococcal vaccine for 1 of 10 employees reviewed. This is evidenced by the following. Record review of the employee health records for Desktop Support Technician II #1 on 05/01/2018 revealed that he did not receive education on the risks and benefits of the pneumococcal vaccine (pneumococcal vaccine education) within the past year. The Director of Education and Employee Wellness stated in an interview conducted 05/01/2018 at 3:55 pm, that Support Technician #1 is a contracted employee, she did not know he worked in the nursing home, and he did not receive pneumococcal vaccine education from either this facility or his company. The policy Pre-placement Assessment Requirements and Scheduling of Assessment, Lab Work, Xray, Physical Therapy Evaluation and Physical Examination (if deemed necessary) was reviewed on 05/02/2018. This policy states that all employees working in the Nursing Home are to be educated on the risks and benefits of the pneumococcal vaccine but is silent on contracted employees. 10 NYCRR 483.65

Plan of Correction: ApprovedMay 30, 2018

Systemic Changes:
The Information Technology Staff are employees of the Bassett Medical Center, and are assigned to work at(NAME)Hospital and Nursing Home as part of their network assignment in the Bassett Health Network. Immediately following the survey, The Information Technology employees assigned to A. O.(NAME)have received education on the risks and benefits of the pneumococcal vaccine.
A policy has been developed outlining that contracted employees assigned to A. O.(NAME)must have pneumococcal vaccine education conducted through the Employee Health Department. As part of the initial orientation to(NAME) the employee must report to the Employee Health Office for education.
Several departments utilize contract employees. An audit was conducted to assure that all contracted employees had received pneumococcal vaccine education. No other employee outside of the IT staff were found out of compliance with this requirement.
A master list of contracted employees was not available prior to survey. A master list of contracted employees, by department, is being developed and will be maintained and updated as changes occur.
Monitoring:
A survey of a random sample of contracted employees will be conducted to ensure education has been provided. On a monthly basis, the results of the survey will be presented to the NH Quality Assurance/ QAPI Committee.
Responsibility of the Director: Education and Employee Wellness

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection for all residents and staff on 2 of 3. Specifically, the facility did not ensure: Personal care items found in bathing areas were labeled with resident specific names; Residents performed handwashing prior to accessing the refrigerator and freezer; A Certified Nursing Assistant (CNA) washed their hands after caring for a resident and prior to accessing the coffee machine and refrigerator in the Main dining area; A CNA washed their hands after caring for one resident before providing care to another resident. This is evidenced by. Finding 1: Unit 3 During observation on 5/1/18 at 9:45 AM, unlabeled personal products (body wash, [MEDICATION NAME] ointment, body lotion, [MEDICATION NAME] skin cleanser, and 2- small shave creams) were found in the shower room. Unlabeled personal products (Two -[MEDICATION NAME] skin cleaner and one [MEDICATION NAME] skin ointment) were also found in the tub room. During observation on 5/02/18 at 5:16 PM, unlabeled personal products (1 [MEDICATION NAME] body wash, one (NAME)son's baby powder and one body lotion) were found in the shower room. Unlabeled personal products (2 [MEDICATION NAME] perineal/ skin cleaner, 2 small shave creams and 1 Remedy body lotion) were found in the tub room. During observation on 5/3/18 at 5:25 PM, unlabeled personal products (1 [MEDICATION NAME] body wash, one (NAME)son's baby powder and one body lotion) were found in the shower room. Unlabeled personal products (2 [MEDICATION NAME] perineal/ skin cleaner, 2 small shave creams and 1 Remedy body lotion) were found in the tub room the same as 5/2/18 was still observed. During interview on 5/4/18 at 10:00 AM, the Infection Control Nurse (ICRN) stated all personal care items should be labeled, and should not be left in the shower room after use. Nursing should make sure all items are marked with resident names. Finding #2: Unit 2 During an observation on 5/3/18 at 10:50 AM, a male resident entered the main dining area on Unit 2 opened the freezer and removed ice cream from the freezer, then opened the refrigerator and moved food items around the refrigerator to access a box of milk. The resident had been observed sitting in the activity area of the unit and was scratching himself and was wearing soiled wet pants prior to going to the kitchen and going into the refrigerator. During interview on 5/3/18 at 11:05 the Registered Nurse Unit Manager (RNUM) stated the resident was soiled and will be brought him to his room to be cleaned. The RNUM was not aware the resident had opened the refrigerator and handled refrigerated items with soiled hands. He frequently accesses the refrigerator to remove items without assistance. The RNUM was not sure how frequently the handles on the refrigerator were cleaned. Finding #3: During an observation on 5/3/18 at 11:00 AM, CNA #3 wheeled a resident to the activity room, entered the kitchen, opened the cupboard above the coffee machine, unlocked the coffee maker, got cup of coffee, put the key back up in the cupboard, opened the refrigerator, removed milk, poured it in the coffee, and replaced the milk in the refrigerator. CNA #3 did not wash her hands. The refrigerator handle was visibly soiled. RNUM #1 told CNA #3 to stop and wash her hands. During interview on 5/3/18 at 11:10 AM, RNUM #1, who had observed CNA #3 accessing the cupboards and refrigerator without handwashing, stated CNA #3 should have washed her hands between care and accessing items in the dining room. Staff should be washing their hands before getting anything out of the refrigerator. All staff are taught about proper handwashing to prevent the spread of infection. During interview on 5/3/18 at 12:28 PM, CNA #3 stated she should have washed her hands immediately after care of the resident and before going into the kitchen to remove food from the refrigerator. Finding #4: During observation on 05/03/18 04:17 PM, CNA #4 exited a resident's room, removed her gloves in the activity room, rolled her gloves into her left hand and approached another resident. The CNA pushed the resident's wheelchair to the medicine cart and disposed the gloves into a waste basket. CNA #4 did not wash hands after removing gloves. During interview on 5/3/18 at 4:35 PM, CNA #4 stated she was giving a resident care in the room before coming out into the hall. I should have removed my gloves and washed my hands before leaving the room, but I was rushing. During interview on 5/3/18 at 5:00 PM, Licensed Practical Nurse (LPN) #4, stated the CNA's have to perform handwashing before and after giving care to the resident's. Gloves should be disposed of in the room and handwashing done immediately. During interview on 5/4/18 at 10:00 AM, the Infection Control Nurse (ICN) stated handwashing audits are done monthly. The two ICN's walk the units regularly and observe for handwashing problems. The residents should not be touching the items in the refrigerator and other food items with dirty hands. Their care plans should reinforce hygiene. Handwashing should be done regularly by all staff, and staff should be holding each other accountable for infection control. 10NYCRR415.19(a)(1-3)

Plan of Correction: ApprovedJune 4, 2018

Residents affected by deficient practice:
-The male resident is ambulatory with dementia - Increased staff monitoring in place
-CNA #3 and #4 were educated re. hand hygiene immediately following the observation 5/3/18
Other residents affected by deficient practice:
-All personal items have been removed from the shower rooms and unlabeled items were discarded 5/3/18
Systemic changes:
-All staff will be re-educated on hand hygiene.
-A policy/protocol will be developed re. hand hygiene for residents.
-Refrigerator handles will be cleansed by Nutrition Services staff before and after each meal service. This requirement has been added to the opening and closing procedure for Nutritional Services staff, and is audited on the dining room observation audit performed by the Nutrition Services Supervisor.
-All nursing staff will receive mandatory education re. systemic changes involving resident hand hygiene, proper storage and labeling of personal care products, and infection control practices.
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with infection control policies/practices including shower/bathing areas for unlabeled personal care products, observation of care and hand washing, and cleaning of refrigerator handles. The monitor will be conducted on a resident sample from each unit and both day and evening shifts weekly for 90 days, then monthly. The results will be reported to the Quality Review Committee.
-Responsibility: Infection Control Nurse

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure all drugs were stored in locked compartments. Specifically, during observation of a medication pass, the medication cart was left unlocked and unattended and a bottle of calcium was left unattended on top of the medication cart. This is evidenced by: Finding #1: During observation of a medication pass on 5/03/18 at 7:45 am, Licensed Practical Nurse (LPN) #3 walked over to Resident #72, who was sitting in a chair in the common area, approximately 10 feet away from the medication cart. The cart was left unlocked and unattended with the front of the cart facing away from LPN #3. Finding #2: During observation of a medication pass on 5/03/18 at 7:50 am, LPN #3 was observed walking into Resident #38's room to give her medication. The medication cart was left unlocked and unattended next to the resident's room. The drawers to the cart were facing outward into the hallway. Finding #3: During observation of a medication pass on 5/03/18 at 8:28 am, LPN #3 was observed walking into Resident #28's room to give her medication. A bottle of calcium 500 mg tablets was left unattended on top of the medication cart. The medication cart was left next to the resident's room. During an interview on 5/03/18 at 8:10 am, LPN #3 stated she usually puts the medications back into the cart. She also stated she usually locks the medication cart if it is not in her field of vision. When the cart was in the common area, she stated she did not think she had to lock it. During an interview on 5/04/18 at 9:30 am, Registered Nurse (RN) Nurse Manager (NM) #2 stated medication carts should always be locked when not within eyesight of the nurse and the bottle of calcium should not have been left on top of the cart. 10NYCRR415.18(e)(1-4)

Plan of Correction: ApprovedMay 29, 2018

Residents affected by the deficient practice:
- LPN #3 educated 5/3/18 regarding need to lock med cart when not in direct line of sight as well as need to secure all medications within the cart before walking away.
-Unable to correct occurrences related to Res #72, #38, #28 of 5/3/18.
Other residents potentially affected by the deficient practice:
- Spot checks have been done of medication carts all units and shifts to assure carts are secure and without unsecured medications.
Systemic changes:
-Policy M-4 Medication Administration has been revised to clarify when carts are to locked and that no medications are to be left on unattended med carts.
-All licensed Nursing staff will be re-educated regarding Policy M-4.
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with storage of drugs and locking of med carts. The monitor will be conducted on a random sample from all shifts and units weekly for 90 days, then monthly. The results will be reported to the Quality Review Committee.
-Responsibility: Director Nursing Services

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 (Resident #85) of 5 residents reviewed for nutrition. Specifically, for Resident #85, the facility did not ensure weight changes were verified with a reweigh to identify and address weight loss. This was determined by: The Policy & Procedure titled Nutrition/Hydration Protocol 6/16/2016, documented all residents will be monitored and evaluated for changes in weight and hydration status. The Diet Technician or Dietician reviews monthly weights and requests nursing verification of significant weight changes as needed (per policy-plus or minus five pounds). The Diet Technician or Dietitian will identify residents with significant weight loss and report this at the morning meeting. Resident #85: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident's weight record documented: 3/7/18=126.06 lbs., 4/4/18=108.46 lbs., 4/17/18=117 lbs., 5/2/18=105.1 lbs. The Dietary assessment dated [DATE], documented; Weight 126.1 lbs., supplement 8 oz (ounce) low fat chocolate milk, ice cream, pudding. Weight status (loss or gain) moderate-4.8% gain x 1 month, 4 % gain x 3 months, 1.5% loss x 6 months. Weights are without significant changes x 1, 2, and 3 months. Continue plan of care as is. Dietary progress notes dated 4/9/18 documented the (MONTH) weight of 108.5 lbs., shows 17.6 lb. loss x 1 month. reweigh requested to confirm/deny. Follow-up once reweigh available and if necessary. A physician order [REDACTED]. The Physician Annual assessment dated [DATE], documented a weight of 117 lbs.; a significant weight change. The Comprehensive Care Plan titled Nutritional Status documented the resident was at increased risk for inadequate food, fluid intake, and weight loss. Interventions documented to alert the MD (physician) of significant weight changes. The Note section documented the annual assessment dated [DATE] referred to the weight of 126 lbs. with no significant changes x 1,3, and 6 months. During an interview on 05/02/18 at 2:18 pm, LPN #8 stated resident weights are done on the first shower day of the month. If the weight is 5 lb. different than the previous weight a reweigh should be done the next day in the morning. A gain or loss of 5 lbs. or more should be written in the MD communication book. During an interview on 05/03/18 at 02:49 pm, the Registered Nurse Manager (RNM) #4 stated the night shift nurses place the scheduled weights on the certified nursing assistants (CNA) assignment sheets. The CNAs weigh the residents, document the weight in the computer and communicate the weight to the unit nurse. She was new in her role, and did not know the protocol for weight changes. RNM would want a reweigh to be done and a change in weight to be communicated to the Registered Dietician (RD) and MD. During interview on 05/03/18 at 2:51 pm, the Director of Nursing (DON) stated a 5 lb. or more weight should have a reweigh done. The CNA weighs the resident and documents the weight in the computer. The CNA tells the nurse what the weight was. The licensed staff member should be looking at the old and new weight and then determines the reweight. The RD can run a weight report of 5 % weight changes. Resident #85 should have been reweighed with the 5 lb. or more weight change. During an interview on 05/04/18 at 9:10 am, CNA #8 stated residents are weighed the first week of the month, the CNA weighs the resident and documents in the computer. We do not see the previous weight; The nurses are supposed to look at the weights and tell the CNAs if a reweight is needed. During an interview on 05/04/18 at 9:35 am, LPN #9 stated that residents are weighed in the morning. A weight change of 5 lb. the resident should be reweighed the same day. The weight change should be written in the MD book. 10NYCRR415.12(i)(1)

Plan of Correction: ApprovedMay 29, 2018

Residents affected by the deficient practice:
- Resident # 85 was reweighed on 5/3 with wt. of 118 lb which is a 1 lb change from previous month (105 lb obtained 5/2 is an erroneous wt.)
Other residents potentially affected by the deficient practice:
-All residents weights over the past quarter have been reviewed and reweighs obtained where indicated.
Systemic Changes:
-All residents have had a lic. treatment ordered (Done 5/3/18) to compare the current monthly weight to the previous wt. and schedule a reweigh if 5 lb change or more.This has been added to our policy for weight monitoring (W-1).
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with weighing/reweighing residents. The monitor will be conducted on a resident sample from each unit and shift weekly for 90 days, then monthly. The results will be reported to the Quality Review/ QAPI Committee.
-Responsibility: Director Nursing Services

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide protection to prevent potential of contamination of the potable water supply. Backflow prevention (vacuum breakers) is required on all fixtures to which hoses or tubing can be attached. Specifically, the beautician's sink hose fixture was not protected with a vacuum breaker. This is evidenced as follows. The beautician's sink was inspected on 05/04/2018 at 11:30 am. The potable water line servicing the attach hose was not plumbed with a vacuum breaker. Maintenance Mechanic #2 stated in an interview conducted on 05/04/2018 at 12:05 pm, that he will install a vacuum breaker on the beautician's sink hose. 10 NYCRR 415.29(b), 713-2.21(e)(iii)

Plan of Correction: ApprovedMay 29, 2018

Maintenance Work Order #2656-3875 issued to install a vacuum breaker on the beauty shop sink. The vacuum breaker has been installed and the work order is complete and closed.
All Maintenance staff will be educated on the Survey findings, the deficient practice, and the Code requirement.
The Director of Plant Operations will have all sinks with hose and/or tube attachments inspected for appropriate back-flow prevention.

The monthly Environmental Rounds checklist will be revised to include back flow prevention on sinks with hoses and/or tub attachments.
The results of the Environmental Rounds will be presented to the NH Quality Assurance/ QAPI committee monthly.
Responsibility of the Director of Plant Operations.

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during a recertification survey, the facility did not ensure residents' rights were maintained for one (1) (Resident #117) of twenty-eight (28) residents reviewed. Also, staff were observed not knocking on residents' doors prior to entering their rooms. This is evidenced by: Resident #117: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition, was usually understood by others and sometimes understood. During an observation on 5/03/18 at 9:05 am, Certified Nursing Assistant (CNA) #2 was heard asking Resident #117, Why didn't you tell me before I put you in the chair that you needed a shave? During an interview on 5/03/10 at 10:15 am, CNA #2 stated she was joking with the resident, she was picking on her. The CNA stated she realizes she has a problem with the tone in her voice and that it is not intentional. She realizes she has to work on it. During an interview on 5/04/18 at 8:00 am, Registered Nurse (RN) Nurse Manager (NM) #2 stated when she hears CNA #2 being gruff, she indicates for her to stop. She has spoken to the CNA in the past about the manner in which she speaks to the residents. RN NM #2 stated, the CNA should not be speaking to the residents in this manner. During an interview on 5/01/18 at 10:54 AM, Resident #61's wife stated that CNA #2 is a hard worker but is gruff in the way she speaks to the residents. She stated approximately two weeks ago the CNA had a resident in a maxi sling which bumped into the wall. The resident yelled and the CNA told him if he sat still that would not happen. Resident #61's wife stated the CNA has to watch her mouth and attitude. She had previously complained to RN NM #2 and that CNA #2 calms down for awhile after she is spoken to by the NM. Finding #1: During an interview on 05/01/18 at 10:53 AM, a family member stated when her husband's door is closed staff will knock before entering. If the door is open, staff do not knock. During Medication Administration observation on 5/03/18 at 7:50 AM, Licensed Practical Nurse (LPN) #3 did not knock when entering Resident #38's room. During Medication Administration observation on 5/03/18 at 8:28 am, LPN #3 did not knock before entering Resident #28's room. During an interview on 5/03/18 at 8:10 am, LPN #3 stated she usually does not knock if the residents see her coming. She does not want to startle the residents by knocking. She stated she usually knocks, but if she makes eye contact she does not. During an interview on 5/04/18 at 8:00 AM, RN NM #2 stated the staff do not have to knock on the door if the resident sees them coming or if they are waving for the nurse to come in. The residents are used to the staff coming into their rooms, they are like family. She stated the staff should knock with the new residents or staff should knock before entering if they are not known to the residents. 10NYCRR415.3(c)(1)(i)

Plan of Correction: ApprovedMay 29, 2018

Residents affected by deficient practice:
-Residents #117 and #61 have dementia and are without recall of the situations identified.
Other Residents potentially affected by deficient practice:
All Nurse Managers and Charge Nurses will be educated on the deficient practice and will observe for breaches throughout their assigned shift, and immediately take corrective action.
-CNA #2 Has been issued a formal Educational Opportunity identifying her communication issues and the CMS/facility expectations.
-LPN #3 was re-educated during survey re. the need to always knock on resident doors prior to entering.
-All nursing staff will complete a mandatory education program on Resident Rights & Staff Responsibilities.
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with maintaining resident rights. The monitor will be conducted on a resident sample from each unit and shift weekly for 90 days, then monthly. The results will be reported to the Quality Review/ QAPI Committee.
-Responsibility: Director Nursing Services

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences for one (Resident # 11) of two resident's reviewed for respiratory care. Specifically: For Resident #11, the medical record did not include documentation regarding the reason for and the use of as needed (PRN), a Comprehensive Care Plan was not developed for the use of oxygen, the physician was not informed of the frequent or continual use of oxygen and the failure to try to wean the resident off the oxygen. This is evidenced by: Resident #11: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 4/19/18, assessed the resident understands, was usually understood, and had moderate cognitive impairment. It documented the resident received respiratory treatments of oxygen therapy. The MDS of 1/19/18 documented the resident received respiratory treatments of oxygen therapy. The resident was observed with oxygen running via nasal cannula on: 5/01/18 at 3:00 PM; on 5/02/18 at 8:54 AM while eating; on 5/02/18 at 5:14 PM while sitting in the recliner in his room; on 5/03/18 at 8:37 AM sitting at edge of bed eating, no oxygen , res breathing a little heavily when went to talk then fine, but at 9:07 AM the resident was wearing the oxygen. There was a Comprehensive Care Plan (CCP) dated 5/20/15, for the use of a [MEDICAL CONDITION] machine, but no CCP for the use of oxygen therapy. Physician orders [REDACTED]. The Treatment Administration Records (TAR) for Dec-2017; (MONTH) (YEAR); (MONTH) (YEAR); (MONTH) (YEAR); (MONTH) (YEAR) and (MONTH) (YEAR) documented the use of the as needed (prn) oxygen one time on 2/16/18. Nursing Notes documented use of oxygen on 2/3/18, 2/4/18, 2/5/18, 2/14/18, 2/16/18 , 2/17/18, 2/18/18, 2/19/18, 2/20/18, 2/21/18, 4/17/18, 4/18/18, 4/19/18, 4/20/18. Nurses notes documented: 4/17/18 at 6:46 am- wore C-Pap and oxygen during night. Oxygen was taken off resident for ten minutes this morning so oxygen saturation could be checked on room air. Oxygen saturation was 93% on room air at 4:03 am. 4/17/18 at 10:19 am- room air saturation done was 85%. Placed on 2 liters via nasal canula, oxygen up to 95%. 4/17/18 at 2:27 pm- pulse oxygen done on room air. Placed back on oxygen due to 85% and 88%. 4/18/18 at 5:37 am- wore C-Pap and oxygen during the night. Oxygen was taken off for 18 minutes this morning so oxygen could be checked on room air, was 94% at 5:09 am. 4/19/18 at 4:04 am resident wore C-pap and oxygen during the night. Oxygen off for ten minutes to check oxygen. 92% on room air at 3:55 pm. 4/19/18 at 2:37 pm room air oxygen saturation was 87% at 2:04 pm, placed back on oxygen. 4/19/18 at 9:02 pm continues on oxygen. Oxygen saturation 85% on room air. 4/20/18 at 10:47 am- monitored resident oxygen level to clarify need. Resident desaturated to 85%-89% confirming need of oxygen at all times. (this note was signed by a Licensed Practical Nurse.) A Physician Bi-Monthly Progress Note on 4/19/18, documented nasal oxygen in use, breathing non labored, good air entry. The resident was doing well, no concerns. During interview on 5/03/18 at 10:40 am, the Registered Nurse Manager (RNM) said the doctor's order does not say Oxygen at all times, it is a prn. She looked at Oxygen saturations in the computer and said that is why he needed the oxygen at all times. She stated she would leave the oxygen prn and do trials of saturations when off oxygen to determine need. She was asked why there was no CCP for the use of oxygen. She said the resident was not on it before he had pneumonia ( (MONTH) (YEAR)). She wanted to see now if he really needs the oxygen continuously. An oxygen CCP would be dependent on that. During interview on 5/03/18 at 10:50 am, LPN #7 said the resident has been using oxygen continuously since he was sick with pneumonia. They trialed him without it and he did not do well so remained on it continuously. On 5/04/18 at 7:21 am, the resident was sitting in the recliner in his room using oxygen via nasal canula and concentrator. He said he needs the oxygen, he wears it all the time. During interview on 5/04/18 at 7:30 am the Director of Nurses (DON) said the oxygen order is a standing order that all residents receive on admission. If it is needed all the time there should be a doctor's order for it. She stated if the nurses are giving the prn oxygen they should be documenting they are giving it. She looked at the TAR and stated staff are not documenting it on the TAR, they should be if they are using it. During interview on 5/04/18 at 8:16 Certified Nurse Aide (CNA) #6, stated he has been wearing the oxygen since sick. He wears it all the time during the day/evening till he goes to bed then he is on the C-pap machine. During interview on 5/04/18 at 8:45 am, LPN # 2 said she cares for the resident. She has seen the resident use oxygen via concentrator continuously. It started when was sick. Around the 20 th of last month she wondered if we should try him without oxygen. She stated he was not ok without it. She did not communicate with the Medical Doctor directly that the resident was on oxygen continuously or they tried him without oxygen and he failed. She made the RN aware. She put in the order to do pulse oxygen's. The MD did not sign off on this order, apparently not aware. She said the order for the resident's oxygen is a prn order, did not need an order to use oxygen continuously. For a prn order they have to document why they are giving it. She could not find consistent documentation of why the oxygen was being used. During interview on 5/04/18 at 10:36 AM the MDS Coordinator said the MDS Section O identified oxygen used in last 14 days. She saw it was in use during the time frame for the 4/19/18 MDS. The previous MDS's identified oxygen use also. The Annual MDS in (MONTH) (YEAR) did identify oxygen use. If he was still needing oxygen we should have a care plan for it. During interview on 5/04/18 at 10:50 am the RNM said the MD was aware the resident was using oxygen. The MD saw the resident and would have seen oxygen so would have been aware. She said she thought she was with the MD on his visit. They talked about the flu and pneumonia the resident had. She told the MD the resident was using oxygen more. During telephone interview on 5/04/18 at 1:37 pm, the resident's MD stated he was not aware the resident was using oxygen as much as he is. If frequent or continuous they should have let me know so I could assess the resident, possibly change his orders. They should have let me know of the weaning attempt and failure so I could assess the resident. 10NYCRR415.12(k)(6)

Plan of Correction: ApprovedJune 4, 2018

Residents affected by the deficient practice:
-Res. #11 had a respiratory Care Plan added 5/4/18. Oxygen titrated and discontinued. Physician evaluation completed.
Other Residents potentially affected by deficient practice:
-All residents using O2 have been identified and orders checked to evaluate need for Medical eval/routine order placement, as well as res. specific Care Plans in place.
Systemic Changes:
-A policy is being developed with Medical and Respiratory Therapy staff to establish perimeters with prn oxygen use, and respiratory protocol. Per policy, the physician will be notified of the outcome of failed oxygen weaning attempts. Any adjustments to oxygen use orders will be amended at that time. Mandatory education will be provided to licensed staff regarding the associated systemic changes.
Monitoring:
-A QI monitor will be developed to assess and assure facility compliance with oxygen administration and care plan initiation. All residents that utilize oxygen will be part of the monitor sample. The monitor will assess oxygen use, blood saturation levels, continued need for oxygen, tritration attempts, and appropriate care plan in place. The monitor will be conducted on a resident sample from each unit and shift weekly for 90 days, then monthly. The results will be reported to the Quality Review Committee.
-Responsibility: Director Nursing Services

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment in resident care areas. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall when used to energize appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, such as for communications equipment. Specifically, power strips were not secured to the wall and non-compliant power strips were used in the resident care areas. This is evidenced as follows. Observations on 05/04/2018 at 9:30 am, found power strips dangling loosely mid-air in the physical therapy room, the MDS Coordinator Office, and Laboratory. A non-compliant power strip use to power computer equipment was found in the Physical Therapy treatment area. Maintenance Mechanic #2 stated in an interview conducted on 05/04/2018 at 12:05 pm, that all power strips should be secured to walls and not dangling, and the Physical Therapy Department will bring in power strips unbeknownst to maintenance personnel. 42 CFR 483.70 (a) (1); 2011 NFPA 70 400.8, 400.7, 368.56(B); 2012 NFPA 99 10.2.3.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 70; 1999 NFPA 99 3-3

Plan of Correction: ApprovedMay 31, 2018

A written survey will be completed by all departments identifying use of power strips within their department. This will aid the Environmental Rounds team in a complete walk through survey of the entire facility to determine if power strips are in use.
Following the survey, all needed power strips will be replaced with appropriate UL rated devices, and mounted by the Maintenance Department. This includes the power strips that were identified during survey in the Physical Therapy Department, MDS Office and the Laboratory.
To ensure that only approved UL rated power strips are installed, the Plant Operations will maintain an inventory of acceptable power strips.
Materials Management has blocked the electronic ordering of power strips by individual departments or staff.
All staff and Department leaders will be educated to place a work order into the Physical Plant work order system if they believe they are in need of additional power outlets. The Maintenance Department will determine if a permanent hard-wired solution is able to be accomplished. If a power strip is determined to be necessary, only an approved UL power strip will be installed, and mounted for use once approved by the Director of Plant Operations. Staff will be educated to the reason behind this requirement, and instructed not to supply their own power strips in any circumstance.
The Information Technology staff will be educated on the need to request Department Leaders to submit work orders if they determine their is not sufficient power for computer installations.
The Environmental Rounds team will be educated on the regulations surrounding power strips. The Environmental Rounds monitor will address the need to observe for inappropriate use of power strips.
Monitoring:
The Environmental Rounds Committee will monitor for compliance. The results of the monitor will be reported to the NH Quality Assurance/ QAPI Committee on a monthly basis.
Responsibility: Director: Plant Operations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee interview and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities maintain PCREE with consideration of the owner's manual. Specifically, 2 of 3 PCREE observed was not maintained as prescribed in the owner's manual. This is evidenced as follows. Observations on 05/03/2018 at 1:30 pm revealed the following: (1) electric inhalation-treatment nebulizer # 6790 assigned to a resident in room [ROOM NUMBER] was not in use and plugged into an electrical outlet, and (2) electric bed #4668 was assigned to a resident in room [ROOM NUMBER]. Licensed Practical Nurse #2 stated in an interview conducted on 05/03/2018 at 2:30 pm that nursing staff administer nebulizer treatments and that she received no instruction to unplug the units after each use. Review of the owner's manual for nebulizer # 6790 on 05/03/2018 revealed that to reduce the risk for electrocution, the unit is to be unplugged immediately after use. The Nursing Home Education Manager stated in an interview conducted on 05/04/2018 at 8:30 am that she is responsible for training staff on the safe use of patient care equipment but did not know nebulizers should be unplugged after each use. The Director of Plant Operations stated in an interview conducted on 05/03/2018 at 2:30 pm that including electric bed #4668 assigned to a resident in room [ROOM NUMBER], his department is responsible for checking the electrical cords on electric beds but does no further inspections. Review of the Operation, Parts & Maintenance Manual for electric bed #4668 was reviewed on 05/03/2018. This review revealed that preventative maintenance for items such as motor operation, normal operation over full range, and caster locking is to be completed every 6 months. The Director of Plant Operations stated in an interview conducted on 05/03/2018 at 2:30 pm that including electric bed #4668 assigned to a resident in room [ROOM NUMBER], his department is responsible for checking the electrical cords on electric beds but does no further inspections. The facility maintenance policies for PCREE were reviewed on 05/03/2018. This policy states that the preventative maintenance for PCREE will be consistent with the manufacturer recommendations. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedMay 31, 2018

All nursing staff have been instructed to unplug the portable nebulizers in between treatments. The nursing staff was informed of the risk associated in the owner's manual.
A preventive maintenance schedule has been developed for all nursing home beds in association with the manufacturer's recommendations. A complete and through PM is underway and is being completed by the Physical Plant department.
The facility is compiling the owner's manuals for all PCREE to ensure that all pieces of equipment are being maintained in accordance with manufacturer's recommendations. Staff will be educated on any changes in current practice that needs to be modified.
The Environmental Rounds Monitor will be updated to include checking for compliance of the deficient practices.
Monitoring:
The Environmental Rounds team will complete their monitoring rounds monthly.
In addition, a monitor specific to unplugging the nebulizer in between treatments will be conducted weekly on a random basis to ensure compliance with this requirement.
The results of the monitors will be reported to the NH Quality Assurance/ QAPI committee on a monthly basis.
Responsibility of the Director: Plant Operations

K307 NFPA 101:FIRE DRILLS

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the staff were not familiar with the basic response to fire. NFPA 101 Life Safety Code 2012 edition section 19.7.1 requires that fire drills (drills) shall be scheduled under varied conditions. Section 19.7.2 states that employees shall be trained in the basic response to fire including but limited to the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire) and closing doors to confine the effects of fire. Specifically, fire drills were not scheduled at various times, and 7 of 10 employees interviewed were not familiar with the basic response to fire. This is evidenced as follows. The facility policy Code Red - Fire Plan was reviewed on 05/01/2018. This policy states as part of the initial response to fire, that persons upon discovery of fire are to call out Code Red and to close the door to the room after removing persons in danger. Registered Nurse #1 stated in an interview conducted on 05/01/2018 at 1:30 pm, that she would yell fire upon discovery of fire. Licensed Practical Nurse #1 stated in an interview conducted on 05/01/2018 at 1:35 pm, that she would yell fire upon discovery of fire. Maintenance Mechanic #1 stated in an interview conducted on 05/01/2018 at 1:50 pm, that he would yell fire upon discovery of fire. In an interview conducted on 05/01/2018 at 1:25 pm, Certified Nursing Assistant #1 did not state that she would yell Code Red upon discovery of fire. In an interview conducted on 05/01/2018 at 1:25 pm, Desk Support Technician II #1 did not state that he would yell Code Red upon discovery of fire. In an interview conducted on 05/01/2018 at 1:10 pm, Environmental Service Aide #1 did not state that he would close the door after removing persons endangered with fire. In an interview conducted on 05/01/2018 at 1:15 pm, Laboratory Clerical Assistant #1 did not state that she would close the door after removing persons endangered with fire. The fire drill evaluations were reviewed 05/03/2018. These documents reveal that 6 of the last 7 Day Shift drills were conducted within the same 47-minute period, 4 of the last 7 Evening Shift drills were conducted within the same 32-minute period, and 4 of the last 7 Night Shift drills were conducted within the same 28-minute period. The Administrator stated in an interview conducted on 05/03/2018 at 9:10 am, that he was aware that the Day Shift drills had been conducted near the same time. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.1, 19.7.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7

Plan of Correction: ApprovedMay 30, 2018

Mandatory Staff Training regarding ARACE has been modified to reinforce using the Code name, not fire, to announce a fire/smoke/ situation. In addition, Confining the fire, by closing the resident door will be reinforced.
Staff identified during survey as inappropriately replying to the ARACE procedure will be educated and re-tested on the ARACE Procedure.
All Department Leaders will review the ARACE procedure with their staff.
ARACE procedures will continue to be part of the mandatory education for all staff, as will monthly fire drills.
The Administrator and the Manager: Education and Quality have developed an annual fire drill schedule with varying times to meet NFPA requirements.
Monitoring:
A monitor will be developed to assure staff understand and can verbalize the ARACE procedure. A sample of employees from each department will be interviewed. Staff education will be provided to any employee that fails the monitor. The monitor will be completed weekly for 12 weeks. With continued compliance the monitor will be conducted monthly thereafter.
A monitor will be conducted to assure that varying times are conducted for the fire drills. If a drill is conducted that does not meet requirements, it will be repeated for the month.
Responsibility of the Manager: NH Education

K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did protect pressurized oxygen cylinders (cylinders) from damage in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Section 11.5.2.1 requires that personnel who handle medical gases and the cylinders that contain medical gases be trained and receive continuing education on the risks associated with their handling and use. Section 11.6.2.2 requires that oxygen cylinder shall not be draped with any materials. Section 11.6.2.3 requires that freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. Section 11.6.5.3 requires that empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Specifically, empty cylinders were not marked, all personnel handling cylinders were not trained in the risks, cylinders were draped with clothing, and freestanding cylinders were not properly chained. This is evidenced as follows. The Unit 1 and Unit 2 oxygen storage rooms were inspected on 05/04/2018 at 9:30 am. One cylinder was freestanding and not chained, several cylinders were draped with clothing, and empty cylinders were not marked. The Emergency Preparedness Coordinator Registered Nurse stated in an interview conducted on 05/04/2018 at 12:00 pm, that all cylinders should be stored in the racks provided, not should have anything placed on them, and the empty cylinders will be placed in a marked area. The Nursing Home Education Manager stated in an interview conducted on 05/04/2018 at 8:30 am, that clinical staff that handle oxygen cylinders receive annual training in the hazards and that she does not provide hazard training to the maintenance staff that deliver the cylinders onto the nursing units. The Director of Plant Operations stated in an interview conducted on 05/04/2018 at 9:00 am, that his staff deliver oxygen cylinders onto the nursing units, but receive no training on the hazards. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1, 11.6.2, 11.6.5; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-3

Plan of Correction: ApprovedMay 31, 2018

All Nursing and Physical Plant Staff will be educated on the proper safe handling and storage of oxygen cylinders. In addition, education will include the need to label empty cylinders to reduce the potential of confusion in an emergent situation.
New storage racks are being obtained to ensure that all tanks are properly secured.
AirGas, the facility oxygen tank supplier was contacted. They will provide tear of tags that will be utilized to indicate an empty versus full tank. Staff will be educated on this method to label the tanks.
The Environmental Rounds team will be educated on the requirements of proper storage, and labeling of oxygen cylinders. The Environment Rounds monitor will be modified to included checking for compliance.

Monitoring:
A monitor will be developed to ensure that tank are appropriately stored, secured, and labeled. This monitor will be completed weekly for 12 weeks, with continued compliance the monitor will be completed monthly thereafter.
In addition, The Environmental Rounds team will monitor for compliance during the monthly rounds.
The results of the monitors will be reported to the NH Quality Assurance / QAPI Committee on a monthly basis.
Responsibility: Director of Plant Operations

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID 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.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC 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 annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation, interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include sharing emergency preparedness policies and procedures with residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 02/05/2018, revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with family members and resident representatives. The Administrator stated in an interview conducted on 02/05/2018 at 12:00 pm, that the Emergency Plan has not been communicated to residents or their families. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedMay 28, 2018

As discussed with the surveyor, the Administrator shared the relevant portions of the emergency preparedness plan with the residents and families that attend Resident Council and the Family Council.
To ensure that all residents, and families/representatives are informed of the relevant portions of the Emergency Preparedness plan, the Administrator will create a document outlining key elements of our plan. The document will be mailed to all families and representatives. A copy of that same document will be distributed to all current residents of the facility.
To ensure that all future residents and their families/representatives are informed of our Emergency Preparedness plan, the document will become part of the Admissions Packet. The residents, families/representatives will receive the document during the admissions conference.
Responsibility of the Administrator

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.3.1 requires that door assemblies in exit enclosures be tested not less than annually in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition (NFPA 80). NFPA 80 section 5.1.5 requires that repairs shall be made, and defects that could interfere with operation shall be corrected without delay. The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group S&C 17-38-LSC requires that full compliance with the annual fire door assembly inspection and testing in accordance with 2010 NFPA 80 is required by 01/01/2018. Specifically, fire door assemblies were not inspected by 01/01/2018 as required. Fire door assemblies were inspected on 01/30/2018, and corrections were not made when defects were found. This is evidenced as follows. The fire rated door inspection reports were reviewed on 05/02/2018. A visual check of the fire rated doors was conducted on 05/02/2018 at 4:00 pm. This visual check and record review revealed that the 20-minute fire rated smoke barrier doors were not inspected and corrections to the fire rated doors, such as the installation of latching hardware and gaps between doors and door frames, were not made. The Regional Director of Plant Operations and the Director of Plant Operations stated in an interview conducted on 05/02/2018 at 4:45 pm, that due to clerical errors and confusion with the adoption of a new computerized preventive maintenance system, the door inspections and corrections were not conducted as required. 42 CFR 483.70 (a)(1); 2012 NFPA 101 8.3.3.1; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedJune 1, 2018

As noted in the Statement of Deficiencies, the annual inspection of door assemblies at A. O.(NAME)NH was completed by (MONTH) 31, (YEAR), delinquent by 1 month.
Corrections to deficiencies noted during annual inspection of fire rated door assemblies is in progress. A Door, and hardware were ordered and arrived onsite on 5/31/18. All repairs will be completed by 6/8/18.
Fire Door Solutions of Stillwell, Kansas, a certified fire/smoke door company, has been contracted to evaluate all doors for proper rating,labeling and code compliance. Any deficiency will be corrected immediately.

The computerized preventive maintenance system will automatically issue the work order for the annual testing of fire and smoke rated doors. The work order for the inspection that must be completed by (MONTH) 1, 2019 will be issued on (MONTH) 1, (YEAR). The inspection will be completed on time, and any corrections will be made in a timely fashion.
Monitoring:
On a monthly basis a random sample of door assemblies will be inspected for proper compliance. Results and corrective actions will be presented to the NH Quality Assurance/ QAPI Committee.
Responsibility of the Director: Plant Operations



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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.5.6 states that the clearance between the sprinkler deflector and the top of storage shall be 18 in. (457 mm) or greater. Section 8.6.4.1.1.1 states that the distance between the deflector of a pendent sprinkler head and the ceiling shall be a minimum of 1 inch (25.4 mm) and a maximum of 12 inches (305 mm) throughout the area of coverage of the sprinkler. Section 8.6.5.1.2 permits certain limitations on obstructions to the sprinkler system discharge pattern. Specifically, the top of storage was within 18 in. of the automatic sprinkler system deflectors, the deflectors of several pendent sprinkler heads were less than 1 inch from the ceiling, and the automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. A spot check of the sprinkler system was conducted on 05/03/2018 at 3:00 pm, and again on 05/04/2018 at 9:30 am. Light fixtures obstructed the automatic sprinkler spray area in the Unit 3 floor-tech janitor closet, Archives Hallway, and the Microbiology Lab. Storage within18-inches of the sprinkler deflector was found in the Speech Therapy Office storeroom, Archive Rooms,(NAME)Room storeroom, and IT storeroom. Two pendant sprinkler head deflectors were within 1-inch of the ceiling in the Unit 2 corridor and resident lounge, and 7 pendant sprinkler deflectors were within 1-inch of the ceiling in the Archives Rooms. The Director of Plant Operations stated in an interview on 05/03/2018 at 5:00 pm, that the entire sprinkler system will be re-assessed for obstructions and correct installation. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-13.3.2

Plan of Correction: ApprovedMay 31, 2018

Maintenance Work Order #2656-3865 issued to replace or relocate light fixtures in the tech-janitors closet and microbiology lab. This work is complete.
Improper storage within 18 inches of a sprinkler deflector will be removed. Items stored within 18-inches of sprinkler deflectors in Speech Therapy Office Storeroom,(NAME)Storeroom, and IT storeroom have been removed.
Storage within 18 inches of sprinklers is monitored on monthly environmental rounds. This monitor will continue.
Fyr Fyter,our fire protection system service vendor, will correct the sprinkler pendants in the Unit 2 corridor, resident lounge and Archives to assure these devises meet NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition, section 8.6.4.1.1.1
The Director of Plant Operations will conduct a thorough evaluation of the nursing home to assure there are no other light fixtures, storage or any other devices obstructing sprinkler pendants. In addition, an evaluation of all sprinkler heads to ensure that the deflectors are at the appropriate distance from the ceiling will be conducted. Any deficiencies identified will be corrected in a timely manner.
Maintenance staff and the Environmental Rounds team members will be educated on the regulations related to obstruction of sprinklers.
All staff will be educated on the requirement not to store items or boxes within 18 inches of a sprinkler head.
Monitoring:
Monthly, the Environmental Rounds Team will observe for deficiencies in the sprinkler installation, and improper storage with 18 inches of the sprinkler deflector. Results of the Monitor will be presented to the NH Quality Assurance/ QAPI committee on a monthly basis.
Responsibility of the Director of Plant Operations.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 19.3.7.3 and 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Section 8.3.5.6.3 restricts the installation of non-fire protected metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Specifically, 2 of 2 smoke barriers observed were not continuous, and metal electrical boxes were not fire protected. This is evidenced as follows. The Unit 2 south smoke barrier wall (wall) was inspected on 05/03/2018 at 9:30 am. In the corridor, one 6-inch by 4-inch hole, two 3-inch holes, and one ½-inch hole were found. In the employee lounge, an unprotected 10-inch by 5.25-inch metal electrical box was found. The Unit 3 F/G wall was inspected on 05/03/2018 at 4:00 pm. Unprotected metal boxes for the exit signs were found directly opposite each other. The Director of Plant Operations stated in an interview conducted on 05/03/2018 at 9:30 am, that he did not know why the holes found were not sealed and the electrical boxes were not protected. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.6, 8.3.5.6.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedMay 31, 2018

Maintenance Work Order #2656-3866 issued to seal holes in the Unit 2 smoke barrier wall.
Maintenance Work Order #2656-3867 issued to seal the unprotected electrical box in the employee lounge. work order completed.

Maintenance Work Order #2656-3868 issued to seal holes in the Unit 3 smoke barrier wall on either side of the exit sign. Work order completed.
An inspection of all fire and/or smoke rated walls within the nursing home will be completed. Any deficiencies found will be corrected immediately.
All Maintenance staff will attend a mandatory education regarding on the Code Requirements surrounding this deficiency.
Monitoring:
Following the complete inspection of smoke/fire walls, a Monthly inspections of smoke barrier walls will be conducted. Each unit and floor will be done on a rotating basis, to ensure each smoke and fire barrier is inspected semi-annually.
Results will be reported to the Nursing Home Quality Assurance/QAPI Committee.
Responsibility of the Director of Plant Operations.

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification, the facility did not maintain electrical wiring and equipment in accordance with the adopted regulations. NFPA 70 National Electrical Code 2011 edition Article 210.8 requires that Ground Fault Circuit Interrupter protection (GFCI) be provided on electrical outlets within six-feet of a sink rim or water source. Specifically, electrical outlet GFCI protection was not provided near all sinks. This is evidenced as follows. Observations of the Information Technology breakroom on 05/04/2018 at 9:30 am, revealed that the electrical outlets directly next to the sink did not have GFCI protection. The Maintenance Mechanic #2 stated in an interview conducted on 05/04/2018 at 12:05 pm that the outlets by the Information technology sink require GFCI protection. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.2; 2011 NFPA 70 Article 210.8; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 70 Article 210.8

Plan of Correction: ApprovedMay 30, 2018

Maintenance Work Order #2656-3869 was issued to install GFCI outlets in the I.T. breakroom adjacent to the sink. This work order is complete and closed.

The Director of Plant Operations will conduct a survey of all sink and water source locations to assure that any electrical outlet within six feet of sinks and other water sources is GFCI. Any deficiencies found will be corrected immediately.
All Maintenance Employees will be required to attend mandatory education surrounding proper code requirements regarding this deficiency.
The monthly Environmental Rounds checklist will be revised to include ?Electrical outlets within six feet of a sink or water source are GFCI.?
The results of the Environmental Rounds Monitor will be reported to the NH Quality Assurance/ QAPI Committee on a Monthly basis.
Responsibility of the Director: Plant Operations

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 4, 2018
Corrected date: July 3, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be continuous. Specifically, rated ceilings were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations on 05/03/2018 at 2:10 pm, and again on 05/04/2018 at 9:30 am, revealed 3 unsealed holes for utility piping in the floor/ceiling rated assembly in the Activities Office and 6 unsealed holes in the floor/ceiling assembly in the air handler mechanical room. The Director of Plant Operations stated in an interview conducted on 05/03/2018 at 2:10 pm, that he will seal the holes found in the ceilings. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3

Plan of Correction: ApprovedJune 1, 2018

Maintenance Work Order #2656-3863 issued to seal holes for utility piping on the floor/ceiling rated assembly in the Activities Office. Work order completed in accordance with a UL-Approved fire stopping system.
Maintenance Work Order #2656-3864 issued to seal 6 holes in the floor/ceiling assembly in the air handler mechanical room. Work order completed in accordance with a UL-Approved fire stopping system.
An audit of the entire floor-ceiling assembly to check for penetrations will be conducted. Any penetration discovered will be sealed immediately in accordance with a UL-Approved fire stopping system.

Maintenance Department Policy PEN-1 Penetration of Walls and Above Ceiling Work will be reviewed with all maintenance staff.
Additional education will include proper products and procedures for sealing penetrations in smoke/fire walls and floor/ceiling assemblies in accordance with a UL-Approved fire stopping system.
Monitoring:
The Director of Plant Operations will conduct periodic random sampling surveys of floor/ceiling rated assemblies. Any unsealed penetrations will be properly sealed with an approved fire seal product.
Results of surveys will be reported to the Nursing Home Quality Assurance/ QAPI Committee.
Responsibility of the Director of Plant Operations.