Mary Manning Walsh Nursing Home Co Inc
November 30, 2018 Certification Survey

Standard Health Citations

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: November 30, 2018
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey the facility did not provide the resident or family representative with a written summary of the Baseline Care Plan. This was evident for 2 out of 21 residents reviewed. The facility policy on Baseline Care Plans dated 11/2017 documents: That the facility provides the Resident and the Representative, if applicable, with a written summary of the baseline care plan. 1) Resident #324 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. other abnormalities of gait and mobility, [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder 2) Resident #242 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/18 at 10:50 AM the Registered Nurse (RN) Manager for the 2nd and 3rd floors was interviewed and stated, I have been working here more than [AGE] years. Since the Baseline Care Plan was implemented here in (MONTH) or (MONTH) all residents admitted will have the Baseline Care Plan, it is an IDT Care Plan within 48 hours. It addresses risk factors diseases, conditions Activities for Daily Living , any resident at high risk for elopement, prevention against pressure ulcers. Family members are present at the care plan meetings. We have not routinely given copies of the care plan to them. I don't think we have been doing it house wide. I cover other units so I have not given a copy of the baseline care plan to family members after admission. We use a form called Care Plan Activity Report and it is use to document the resident and or family received a copy of the Baseline Care Plan and that they agreed with it. I don't have anything documented that Resident #242 received a copy of the baseline care plan. As for Resident #324, I don't have any documentation to show you that the resident or family member received a copy of the Baseline Care Plan within 48 hours of admission or thereafter. On 11/28/18 at 03:03 PM the Director of Nursing(DON) - Chief Nursing Officer was interviewed and stated, I am currently working as the DON of the facility. I started in this role in (MONTH) (YEAR). The regulation for the Baseline Care Plan was implemented in (MONTH) (YEAR). The IDT team assesses the resident within 48 hours of admission. The team creates a IDT Baseline Care Plan , We do a care plan meeting with the family, resident. We review the care plan. We do this prior to the 14 day time period. Sometimes we meet with the family within the first week. We review the care plan with the family. We print off the Baseline Care Plan and give it to the resident or a family member to sign that it was reviewed. If they request a copy, they can receive a copy. We offer a copy of the Baseline Care Plan to the resident or the family member. Over the year as we implemented the Baseline Care Plan process. we have had a process improvement plan. with auditing all new admissions with compliance. We had all high risk care plan initiated on admission. But we found some delay with the IDT team. The IDT team was struggling to meet the 48 hours timeframe to initiate the discipline specific care plan. Because of the amount of admissions that we receive. So we moved to an overall baseline care plan to be edited. It starts right on admission for the team to edit. For this resident the high risk care plan areas were initiated on the date of admission. We initiated the care plan on admission for this resident and this encompasses the baseline care plan. The daughter was not able to come so we had a conference on the phone. To my knowledge a copy of the baseline Care Plan was not sent by mail to the family member of Resident #324. I do not have any documentation to show you that the family member received a copy of the baseline care plan In (MONTH) we instituted a form and the Baseline Care Plan was put in place. before that they had the comprehensive care plan. We did not have a form for a resident or family to sign that they received a copy of the Baseline Care Plan in 11/2017. In (MONTH) (YEAR) we developed a form fro residents and family to sign that they received a copy of the Baseline. For Resident #242 there was no form for the daughter to sign when the resident was admitted in (MONTH) (YEAR).

Plan of Correction: ApprovedJanuary 28, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.
The facility expeditiously corrected and will continue to ensure measures are in place to maintain compliance as noted below.
F 655 ? Baseline Care Plan
483.21; 483.21(a) It is the policy of this facility to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident and meet professional standards of quality of care. The baseline is completed in 48 hours; includes healthcare information necessary to properly care for the resident including, but not limited to:
(A) Initial goals on admission orders [REDACTED]
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.
483.21 (a) (2) This facility developed a comprehensive care plan in place of the baseline care plan within 48 hours of the resident?s admission and provided to the resident and families on initial implementation of the requirements of participation in (MONTH) (YEAR). This process was monitored closely and evaluated through the Quality Assurance and Process Improvement (QAPI) process. In (MONTH) of (YEAR), through the facility QAPI process the baseline care plan is now triggered and completed within 48 hours of admission, in addition to the comprehensive care plan implemented above. Through further clarification that a signed document to prove resident/family were provided the comprehensive care plan/baseline care plan and physician orders [REDACTED].
All residents will continue to have a baseline care plan developed and implemented within 48 hours. All residents/families will be provided a copy of the baseline care plan and physician orders [REDACTED]. The signed receipt will be placed in the Medical Record.
The Chief Clinical Officer re-in serviced the Interdisciplinary Care Plan Team regarding ensuring that the resident/family sign for receiving the baseline care plan and the physician orders [REDACTED].
The Chief Clinical Officer/designee will conduct audits of 10 percent of the residents newly admitted with a 48 hour care plan to ensure signature of receipt is in the medical record. The results will be reported to the Quality Assurance Committee monthly times 3 months and then as determined by the QA Committee.

FF11 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDER

REGULATION: §483.30(b) Physician Visits The physician must- §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that the physician reviewed the resident's program of care and documented notes at each visit. Specifically, the Medical Doctor (MD) did not clarify and order for fingerstick blood sugar (FSBS) testing with insulin coverage after receiving a Medication Regimen Review from the Pharmacy Consultant. There is also no documented evidence that the MD reviewed the record of a resident who did not receive insulin coverage when the resident's FSBS readings were elevated. This was evident for 1 of 36 residents reviewed. (Resident #40) The findings are: Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documents that the resident has severe cognitive impairments and requires the extensive assistance of staff to complete the activities of daily living. On 11/30/18 at 9:49 AM, an observation was made that Resident #40 did not have any insulin vials labeled with her name on the medication cart or in the medication refrigerator on the unit. The physician's orders [REDACTED]. The protocol is for the nursing staff to inform the MD if the resident's blood sugar reading is below 70 or above 400. Regular Insulin Coverage is to be administered as follows: FSBS 0-200 = No Coverage; 201-250 = 2 Units; 251-300 = 4 Units; 301-35 = 6 Units; 351-400 = 8 Units. A Medication Regimen Review (MRR) dated 10/04/2018 documented that the resident has an order for [REDACTED]. The MD's documented response is that the alert is not useful. There were no documented changes to the resident's Physician order [REDACTED]. The resident's Medication Administration Record [REDACTED]=218), 11/21/18 (BS=281), and 11/22/18 (BS=287). The MAR for (MONTH) revealed no evidence that the resident was administered regular insulin and also documented that 0 units of Regular Insulin was administered to the resident at the time the elevated BS readings were documented. The Nursing Progress Notes and the Medical Progress Notes dated 11/20 - 11/22/2018 were reviewed. These documents do not reflect communication of the resident's elevated BS readings from the Nursing staff and/or the MD. An interview with the medication nurse on the unit, Licensed Practical Nurse (LPN) #3 was conducted on 11/29/18 at 2:49 PM. LPN #3 stated that Resident #40 does not have a vial of regular insulin ordered for her. LPN #3 is familiar with the resident and states that she has never had any insulin coverage ordered for her. The MD is only supposed to be contacted if FSBS reading is over 400. On 11/30/18 at 9:39 AM, an interview was conducted with the medication nurse, LPN #1. LPN #1 stated that she has been working on the resident's unit since 7/18 and that each time LPN #1 has tested the resident's BS, it has been within normal range. The resident should have a vial of regular insulin in the fridge to provide coverage if her FSBS is elevated. If the resident does not have a vial of insulin from the pharmacy, then the nurses do not provide her with insulin. The MD is to be contacted if the resident's FSBS reading is over 400. Since the resident has an order for [REDACTED]. A telephone interview was conducted with the Nursing Supervisor, RN #1, on 11/30/18 at 9:52 AM. RN #1 was the supervisor for the resident's unit on 11/20, 11/21, and 11/22/18 when the resident's FSBS readings were elevated. RN #1 does not recall being contacted by the nurse on the unit regarding any concerns with the resident's BS readings or with medication orders. If RN #1 was contacted regarding either of these issues, she would have written a progress note to document the issue and outcome. A telephone interview was conducted with the LPN #2 on 11/30/18 at 11:11 AM. LPN #2 is a floater nurse and was assigned to administer resident's medications on 11/20, 11/21, and 11/21/18. LPN #2 does not recall the resident as having elevated blood sugar. She can recall doing a FSBS testing for the resident; however, LPN #2 cannot recall the specific MD order and cannot recall whether the residents BS levels were elevated. LPN #2 would communicate with the Nursing Supervisor if the resident's FSBS was elevated and there was no vial of Regular Insulin available for her in the facility. LPN #2 cannot recall what her response was or what her intervention was on the 3 days that the resident's FSBS was elevated. On 11/30/18 at 11:44 AM, an interview was conducted with the Pharmacy Consultant. Once it was determined that there was an order from the MD for resident to have FSBS testing along with Regular Insulin coverage, a MRR was completed. If a MD orders FSBS testing with Regular Insulin coverage, then the MD must also write a separate order for Regular Insulin in order for a vial of insulin to be sent to the facility. Although the MD commented on the MRR, there was no clarification of the order for FSBS; therefore, the pharmacy did not send a vial of insulin for Resident #40. The pharmacy and the MD did not have any further communication regarding this issue for Resident #40. An interview was conducted with the MD on 11/30/18 at 11:59 AM. Resident #40 was transferred from another nursing home to the facility with a [DIAGNOSES REDACTED]. The MD always communicates with the nursing staff regarding the resident's condition since she tends to only eat food from the community. The resident does not usually eat the food that is provided to her in the facility and this can have an effect on her DM. Since the resident has a history of inconsistent nutrition, FSBS testing and [MEDICATION NAME] 5mg was ordered to ensure that the resident does not experience [DIAGNOSES REDACTED] from not eating. The resident's [DIAGNOSES REDACTED]. The MD is very familiar with the resident's condition and closely monitors her. The MD stated that due to the resident's current condition, he would rather that her FSBS readings were slightly elevated as opposed to abnormally low. The MD is on the resident's unit 2-3 times a week and inquires about her condition every time he is there. Upon receiving the MRR from the pharmacy on 10/4/18, the MD did not clarify the resident's orders by writing a separate order for Regular Insulin. The MD stated that he was concerned that if insulin was provided to the resident according to the current MD order for insulin coverage, then the resident would be at risk of her BS dropping to the point of becoming hypoglycemic. The MD decided not to order a vial of Regular Insulin for the resident because he wants the nursing staff to contact him if the resident's FSBS readings are abnormal. The MD believed that if the order was changed to just FSBS testing without any insulin coverage, then the nursing staff would just document the FSBS testing results without communicating them to the MD. This is considered a tailored approach just for this resident due to her complicated dementia and inability to communicate her symptoms of [DIAGNOSES REDACTED]. The MD stated that he did receive a call from the nurse on the unit on regarding the resident's elevated FSBS readings. The MD cannot recall who the nurse was and/or what date he was contacted. The nursing staff member who contacted the MD requested that he come to the facility to evaluate the resident. The MD ordered the staff member not to administer any insulin to the resident in accordance with the order for Regular Insulin coverage. The MD is unsure what documentation there may be in the resident's record regarding these communications between himself and the nursing staff. 415.15(b)(2)(iii)

Plan of Correction: ApprovedJanuary 28, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 711 - Physician Visits ? Review Care/Notes/Order.
It is the policy of this facility to ensure the
Physician reviews the resident's program of care and documents notes at each visit. The physician will continue to review Finger stick Blood Sugar monitoring orders and provide clarification of orders for finger stick blood sugar (FSBS) testing with insulin coverage as indicated. The physician will continue to address Medication Regimen Review from the Pharmacy Consultant. The MD will continue to document the review of the record FSBS monitoring to ensure protocol for MD notification or insulin coverage is followed.
Element # 1:
The physician order [REDACTED]. Resident #40 has not had an MD order for insulin since admission on 6/19/18, per the physician plan of care for this unique resident. Resident has been managed well on [MEDICATION NAME] since admission with an Hga1c of 6.2 on 10/1/18.
Element # 2:
The attending physicians covering residents that have FSBS (Fingerstick Blood Sugar) orders to monitor blood sugars will review the residents record monthly to ensure the protocol for MD notification or insulin coverage is followed, continues to be appropriate and clarifies the FSBS or insulin coverage order as indicated. The review will be documented in the monthly MD progress notes. The attending physician will address Medication Regimen Review from the Pharmacy Consultant regarding clarification of insulin orders as indicated. All residents that have FSBS (Finger stick Blood Sugar) have been reviewed. No other residents are affected.
Element # 3:
In-services will be conducted by the Medical Director for all attending physicians to ensure residents that have FSBS (Finger stick Blood Sugar) orders to monitor blood sugars are reviewed and documented in the resident?s record in the monthly MD progress note; Ensure the protocol for MD notification or insulin coverage is followed, continues to be appropriate and clarifies the FSBS or insulin coverage order as indicated; Address Medication Regimen Review from the Pharmacy Consultant regarding clarification of insulin orders as indicated.
Element # 4:
The Medical Director/designee will conduct audits of 10 percent of the residents receiving FSBS monitoring monthly to ensure the attending MD review is documented in the monthly MD progress notes and the Medication Regimen Review from the Pharmacy Consultant regarding clarification of insulin orders as indicated has been addressed. The results of the audit will be reported to the Quality Assurance Committee monthly times 3 months and then as determined by the QA Committee.

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview conducted during the recertification survey, the facility did not ensure that a resident received optimal quality of care. Specifically, the Nursing staff did not clarify a physician's orders [REDACTED]. (Resident #40) The findings are: A Diabetic Management Protocol Policy and Procedure dated 11/30/18 documents that the Licensed Nurse is responsible for checking the physician's orders [REDACTED]. Resident #40 was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident has severe cognitive impairments and requires the extensive assistance of staff to complete her activities of daily living. On 11/30/18 at 9:49 AM, an observation was made that Resident #40 did not have any insulin vials belonging to her in the medicine cart or in the refrigerator unit for medicine on her unit. The physician's orders [REDACTED]. The protocol is for the nursing staff to inform the MD if the resident's blood sugar reading is below 70 or above 400. Regular Insulin Coverage is to be administered as follows: FSBS 0-200 = No Coverage; 201-250 = 2 Units; 251-300 = 4 Units; 301-35 = 6 Units; 351-400 = 8 Units. A Medication Regimen Review (MRR) dated 10/04/2018 documents that the resident has an order for [REDACTED]. The MD's documented response is that the alert is not useful. There were no documented changes to the resident's Physician order [REDACTED]. The resident's Medication Administration Record [REDACTED]=218), 11/21/18 (BS=281), and 11/22/18 (BS=287). The MAR indicated [REDACTED]. The Nursing Progress Notes and the Medical Progress Notes dated 11/20 - 11/22/2018 were reviewed. These documents do not reflect communication of the resident's elevated BS readings from the Nursing staff and/or the MD. An interview with the medication nurse on the unit, Licensed Practical Nurse (LPN) #3 was conducted on 11/29/18 at 2:49 PM. LPN #3 stated that Resident #40 does not have a vial of regular insulin ordered for her. LPN #3 is familiar with the resident and states that she has never had any insulin coverage ordered for her. The MD is only supposed to be contacted if FSBS reading is over 400. On 11/30/18 at 9:39 AM, an interview was conducted with the medication nurse, LPN #1. LPN #1 stated that she has been working on the resident's unit since 7/18 and that each time LPN #1 has tested the resident's BS, it has been within normal range. The resident should have vial of regular insulin in the fridge to provide coverage if her FSBS is elevated. If the resident does not have a vial of insulin from the pharmacy, then the nurses do not provide her with insulin. The MD is to be contacted if the resident's FSBS reading is over 400. Since the resident has an order for [REDACTED]. A telephone interview was conducted with the Nursing Supervisor, RN #1, on 11/30/18 at 9:52 AM. RN #1 was the supervisor for the resident's unit on 11/20, 11/21, and 11/22/18 when the resident's FSBS readings were elevated. RN #1 does not recall being contacted by the nurse on the unit regarding any concerns with the resident's BS readings or with medication orders. If RN #1 was contacted regarding either of these issues, she would have written a progress note to document the issue and outcome. A telephone interview was conducted with the LPN #2 on 11/30/18 at 11:11 AM. LPN #2 is a floater nurse and was assigned to administer resident's medications on 11/20, 11/21, and 11/21/18. LPN #2 does not recall the resident as having elevated blood sugar. She can recall doing a FSBS testing for the resident; however, LPN #2 cannot recall the specific MD order and cannot recall whether the residents BS levels were elevated. LPN #2 would communicate with the Nursing Supervisor if the resident's FSBS was elevated and there was no vial of Regular Insulin available for her in the facility. LPN #2 cannot recall what her response was or what her intervention was on the 3 days that the resident's FSBS was elevated. On 11/30/18 at 11:44 AM, an interview was conducted with the Pharmacy Consultant. Once it was determined that there was an order from the MD for resident to have FSBS testing along with Regular Insulin coverage, a MRR was completed. If a MD orders FSBS testing with Regular Insulin coverage, then the MD must also write a separate order for Regular Insulin in order for a vial of insulin to be sent to the facility. Although the MD commented on the MRR, there was no clarification of the order for FSBS; therefore, the pharmacy did not send a vial of insulin for Resident #40. The pharmacy and the MD did not have any further communication regarding this issue for Resident #40. An interview was conducted with the MD on 11/30/18 at 11:59 AM. Resident #40 was transferred from another nursing home to the facility with a [DIAGNOSES REDACTED]. The resident does not usually eat the food that is provided to her in the facility and this can have an effect on her DM. Since the resident has a history of inconsistent nutrition, FSBS testing and [MEDICATION NAME] 5mg was ordered to ensure that the resident does not experience [DIAGNOSES REDACTED] from not eating. The resident's [DIAGNOSES REDACTED]. The MD is very familiar with the resident's condition and closely monitors her. The MD stated that due to the resident's current condition, he would rather that her FSBS readings were slightly elevated as opposed to abnormally low. The MD is on the resident's unit 2-3 times a week and inquires about her condition every time he is there. Upon receiving the MRR from the pharmacy on 10/4/18, the MD did not clarify the resident's orders by writing a separate order for Regular Insulin. The MD stated that he was concerned that if insulin was provided to the resident according to the current MD order for insulin coverage, then the resident would be at risk of her BS dropping to the point of becoming hypoglycemic. The MD decided not to order a vial of Regular Insulin for the resident because he wants the nursing staff to contact him if the resident's FSBS readings are abnormal. The MD believed that if the order was changed to just FSBS testing without any insulin coverage, then the nursing staff would just document the FSBS testing results without communicating them to the MD. This is considered a tailored approach just for this resident due to her complicated dementia and inability to communicate her symptoms of [DIAGNOSES REDACTED]. The MD stated that he did receive a call from the nurse on the unit on regarding the resident's elevated FSBS readings. The MD cannot recall who the nurse was and/or what date he was contacted. The nursing staff member who contacted the MD requested that he come to the facility to evaluate the resident. The MD ordered the staff member not to administer any insulin to the resident in accordance with the order for Regular Insulin coverage. The MD is unsure what documentation there may be in the resident's record regarding these communications between himself and the nursing staff. 415.12

Plan of Correction: ApprovedJanuary 28, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F684 - Quality of care
It is the policy of this facility to ensure optimal Quality of care § 483.25 is provided as a fundamental principle that is applied to all treatment and care provided to
our residents with professional standards of practice, the comprehensive person-centered
care plan, and the residents' choices.
Element # 1:
Resident #40 has received optimal Quality of Care tailored to the individual. The physician order [REDACTED]. Resident #40 has not had an MD order for insulin since admission on 6/19/18, per the physicians plan of care.
Element # 2:
All residents that have FSBS (Finger stick Blood Sugar) orders to monitor blood sugars have been checked by the Nurse Managers/designee to ensure that the protocol is accurate and if there is an insulin sliding scale present that the resident has a separate order for the insulin coverage to be documented. No other residents are affected.
Element # 3:
In-services will be conducted by the Staff Development Coordinator/Designee for all licensed nurses to clarify any FSBS orders that have a sliding scale for insulin coverage without a correlating insulin order to call the physician for a clarification order.
Element # 4:
The DON/designee will conduct audits of 10 percent of the residents receiving FSBS monitoring to ensure a correlating insulin order is in place for all sliding scale protocols. The results will be reported to the Quality Assurance Committee monthly times 3 months and then as determined by the QA Committee.

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview conducted during the recertification survey, the facility did not ensure that services provided met professional standards. Specifically, the Nursing staff did not clarify a physician's orders [REDACTED]. (Resident #40) The findings are: A Diabetic Management Protocol Policy and Procedure dated 11/30/18 documents that the Licensed Nurse is responsible for checking the physician's orders [REDACTED]. Resident #40 was admitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident has severe cognitive impairments and requires the extensive assistance of staff to complete her activities of daily living. On 11/30/18 at 9:49 AM, an observation was made that Resident #40 did not have any insulin vials belonging to her in the medicine cart or in the refrigerator unit for medicine on her unit. The physician's orders [REDACTED]. The protocol is for the nursing staff to inform the MD if the resident's blood sugar reading is below 70 or above 400. Regular Insulin Coverage is to be administered as follows: FSBS 0-200 = No Coverage; 201-250 = 2 Units; 251-300 = 4 Units; 301-35 = 6 Units; 351-400 = 8 Units. A Medication Regimen Review (MRR) dated 10/04/2018 documents that the resident has an order for [REDACTED]. The MD's documented response is that the alert is not useful. There were no documented changes to the resident's Physician order [REDACTED]. The resident's Medication Administration Record [REDACTED]=218), 11/21/18 (BS=281), and 11/22/18 (BS=287). The MAR indicated [REDACTED]. The Nursing Progress Notes and the Medical Progress Notes dated 11/20 - 11/22/2018 were reviewed. These documents do not reflect communication of the resident's elevated BS readings from the Nursing staff and/or the MD. An interview with the medication nurse on the unit, Licensed Practical Nurse (LPN) #3 was conducted on 11/29/18 at 2:49 PM. LPN #3 stated that Resident #40 does not have a vial of regular insulin ordered for her. LPN #3 is familiar with the resident and states that she has never had any insulin coverage ordered for her. The MD is only supposed to be contacted if FSBS reading is over 400. On 11/30/18 at 9:39 AM, an interview was conducted with the medication nurse, LPN #1. LPN #1 stated that she has been working on the resident's unit since 7/18 and that each time LPN #1 has tested the resident's BS, it has been within normal range. The resident should have vial of regular insulin in the fridge to provide coverage if her FSBS is elevated. If the resident does not have a vial of insulin from the pharmacy, then the nurses do not provide her with insulin. The MD is to be contacted if the resident's FSBS reading is over 400. Since the resident has an order for [REDACTED]. A telephone interview was conducted with the Nursing Supervisor, RN #1, on 11/30/18 at 9:52 AM. RN #1 was the supervisor for the resident's unit on 11/20, 11/21, and 11/22/18 when the resident's FSBS readings were elevated. RN #1 does not recall being contacted by the nurse on the unit regarding any concerns with the resident's BS readings or with medication orders. If RN #1 was contacted regarding either of these issues, she would have written a progress note to document the issue and outcome. A telephone interview was conducted with the LPN #2 on 11/30/18 at 11:11 AM. LPN #2 is a floater nurse and was assigned to administer resident's medications on 11/20, 11/21, and 11/21/18. LPN #2 does not recall the resident as having elevated blood sugar. She can recall doing a FSBS testing for the resident; however, LPN #2 cannot recall the specific MD order and cannot recall whether the residents BS levels were elevated. LPN #2 would communicate with the Nursing Supervisor if the resident's FSBS was elevated and there was no vial of Regular Insulin available for her in the facility. LPN #2 cannot recall what her response was or what her intervention was on the 3 days that the resident's FSBS was elevated. On 11/30/18 at 11:44 AM, an interview was conducted with the Pharmacy Consultant. Once it was determined that there was an order from the MD for resident to have FSBS testing along with Regular Insulin coverage, a MRR was completed. If a MD orders FSBS testing with Regular Insulin coverage, then the MD must also write a separate order for Regular Insulin in order for a vial of insulin to be sent to the facility. Although the MD commented on the MRR, there was no clarification of the order for FSBS; therefore, the pharmacy did not send a vial of insulin for Resident #40. The pharmacy and the MD did not have any further communication regarding this issue for Resident #40. An interview was conducted with the MD on 11/30/18 at 11:59 AM. Resident #40 was transferred from another nursing home to the facility with a [DIAGNOSES REDACTED]. The resident does not usually eat the food that is provided to her in the facility and this can have an effect on her DM. Since the resident has a history of inconsistent nutrition, FSBS testing and [MEDICATION NAME] 5mg was ordered to ensure that the resident does not experience [DIAGNOSES REDACTED] from not eating. The resident's [DIAGNOSES REDACTED]. The MD is very familiar with the resident's condition and closely monitors her. The MD stated that due to the resident's current condition, he would rather that her FSBS readings were slightly elevated as opposed to abnormally low. The MD is on the resident's unit 2-3 times a week and inquires about her condition every time he is there. Upon receiving the MRR from the pharmacy on 10/4/18, the MD did not clarify the resident's orders by writing a separate order for Regular Insulin. The MD stated that he was concerned that if insulin was provided to the resident according to the current MD order for insulin coverage, then the resident would be at risk of her BS dropping to the point of becoming hypoglycemic. The MD decided not to order a vial of Regular Insulin for the resident because he wants the nursing staff to contact him if the resident's FSBS readings are abnormal. The MD believed that if the order was changed to just FSBS testing without any insulin coverage, then the nursing staff would just document the FSBS testing results without communicating them to the MD. This is considered a tailored approach just for this resident due to her complicated dementia and inability to communicate her symptoms of [DIAGNOSES REDACTED]. The MD stated that he did receive a call from the nurse on the unit on regarding the resident's elevated FSBS readings. The MD cannot recall who the nurse was and/or what date he was contacted. The nursing staff member who contacted the MD requested that he come to the facility to evaluate the resident. The MD ordered the staff member not to administer any insulin to the resident in accordance with the order for Regular Insulin coverage. The MD is unsure what documentation there may be in the resident's record regarding these communications between himself and the nursing staff. 415.11(c)(3)(i)

Plan of Correction: ApprovedJanuary 28, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 658 - Professional Standards of Quality for Comprehensive Care Plans
It is the policy of this facility to ensure services are provided that meet
Professional Standards of Quality for Comprehensive Care Plans§483.21(b)(3). Physician order [REDACTED].
Element # 1:
The physician order [REDACTED]. Resident #40 has not had an MD order for insulin since admission on 6/19/18, per the physicians plan of care.
Element # 2:
All residents that have FSBS (Finger stick Blood Sugar) orders to monitor blood sugars have been checked by the Nurse Managers/designee to ensure a protocol is not present, as this would be a separate order if a sliding scale or insulin order was indicated. No other residents have been affected.
Element # 3:
In-services will be conducted by the Staff Development Coordinator/Designee for all licensed nurses to clarify any FSBS orders that have a sliding scale. A sliding scale insulin order would be separate if indicated.
Element # 4:
The DON/designee will conduct audits of 10 percent of the residents receiving FSBS monitoring to ensure if a sliding scale is warranted, this is a separate order. The results will be reported to the Quality Assurance Committee monthly times 3 months and then as determined by the QA Committee.

FF11 483.10(f)(10)(vi):SURETY BOND-SECURITY OF PERSONAL FUNDS

REGULATION: §483.10(f)(10)(vi) Assurance of financial security. The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 30, 2018

Citation Details

Based on Record Reviews and Interviews, the facility during the recertification survey did not ensure that a Surety Bond or similar protection with the amount equal to at least the current total amount of Resident's funds was obtained to protect the Residents Personal Funds Accounts. Specifically, there are 144 Residents with personal funds and a balance amounting to a total of $132,351.86 held by the Facility and no bond to assure residents against loss. This was evident for 144 residents who maintain personal funds accounts out of 319 residents residing in the facility. The findings are: The Parent Organization dated 7/18 and titled Resident Funds was reviewed. This policy documented the purpose of the Resident funds, the policy and procedure, how to establish a fund, restrictions on Use, maintaining the fund, Reimbursements of the Funds, Changes in Petty Cash Fund, Stolen Petty Cash, Protection of the Petty Cash Fund, Management of the Petty Cash Funds, Deposit/Withdrawal of Funds, Accounting and Records, and Conveyance of Funds upon Death/Discharge from Facility. The facility policy dated 12/2005 titled, Protection of Resident Funds documented that the Off-site Finance Department's tasks include; 1) Audits resident accounts for compliance and reviews and reports to the facility on a quarterly basis. 2) Maintains an insurance policy or other mechanism to comply with the intent of the above referenced code. On 11/29/18 at 02:52 PM Finance Liaison(Staff #1) was interviewed. When the SA asked Staff #1 if they knew what was a Surety Bond. The Staff #1 said that a surety bond is insurance you take out for each Resident. The Staff #1 could not describe the the purpose of the Surety Bond. Staff #1 confirmed that the Nursing Home is insured under the Parent Organization's name, from (MONTH) 12, (YEAR) to (MONTH) (YEAR). The Staff #1 further stated that Administration takes care of the Surety Bond. The Staff #1 provided a copy of the Executive Protection Portfolio with policy# 8221-4961 for Policy Period (MONTH) 16 (YEAR) to (MONTH) 16, (YEAR). The policy documented that the Parent Organization: as the insured. It further describes the following insurance coverage's: A. Insuring Clause 1 - Employee Theft Coverage, B. Insuring Clause 2 - Premises Coverage C. Insuring Clause 3 - In Transit Coverage D. Insuring Clause 4 - Forgery Coverage E. Insuring Clause 5 - Computer Fraud Coverage F. Insuring Clause 6 - Funds Transfer Fraud Coverage G. Insuring Clause 7 - Money Orders and Counterfeit Fraud Coverage H. Insuring Clause 8 - Credit Card Fraud Coverage I. Insuring Clause 9 - Client Coverage J. Insuring Clause 10 - Expense Coverage On 11/29/18 at 03:30 PM, the Administrator was interviewed. The Administrator was asked the question if the Facility has a surety bond or similar protection with the amount equal to at least the current total amount of resident funds. He could not answer the question. The Administrator was asked if he knew what is a surety bond, and he said that a Surety Bond basically guarantees the money for the Residents. The Administrator stated that he is not very familiar with Surety Bonds. The Administrator stated he would call the main office to obtain further information on the insurance protection for the Residents Personal Funds Account. The Administrator could not definitively state that the facility had a Surety Bond or otherwise provide assurance, to assure the security of all personal funds of residents deposited with the facility. On 11/30/18 at 09:03 AM, the Administrator provided a copy of the facility's insurance policy titled Executive Protection Portfolio (Crime Coverage Section) Insuring clauses-employee theft Insuring Clause 1: 1 which documents The Company shall pay the Parent Organization for direct loss of Money, Securities or Property sustained by an Insured resulting from Theft or Forgery committed by an Employee acting alone or in collusion with others. It was pointed out to the Administrator that this policy pays the Parent Organization for any loss rather than directly to the residents. The Administrator was asked if the facility had a Surety Bond or any other insurance coverage that would directly pay the residents. The Administrator stated, I will need to call the main office and inquire about any additional insurance coverage. On 11/30/18 at 11:59 AM, the Administrator was interviewed and stated We only have the current insurance policy that I previously showed you. I did read over the regulation and it does state that the Facility cannot be the insured. We do not have a Surety Bond in place to protect the Residents' funds. The main office's purchasing department will be following up on this issue and obtain a Surety Bond. 415.26(h)(5)(v)

Plan of Correction: ApprovedJanuary 28, 2019

Element # 1:
The facility's position is that the intent and purpose of the regulation was met at the time of the survey as there was an insurance policy in effect that protected the resident funds. To further ensure that resident's funds are protected, the facility has secured additional coverage via purchasing a surety bond, effective, 6/6/2018. The surety bond was obtained 12/10/2018 and retroactively covers 6 months, thus the facility coverage commenced 6/6/2018.
Element # 2:
All resident's having an account with deposited funds have the potential to be effected by this same practice.
Element # 3:
Administration will review and revise, as needed, it's policy and procedure for Protection of Resident Funds to ensure that the content and language is consistent with the regulation and the Parent Organization policy.
The Administrator will educate the Finance Liaison on the policy and procedure for Protection of Resident Funds. Such education will be included in the orientation of any new staff member assuming this position.
The Administrator/ designee will follow-up on all resident concerns related to their personal funds that are brought to Administration's attention.
Element # 4:
The Administrator/ designee will review the facility's surety bond on or around (MONTH) 1st and on or around (MONTH) 1st on an annual basis to ensure that the bond is in place to protect the resident funds. Findings of this review will be reported to the facility's QAPI Committee for discussion and follow-up.
The Finance Liaison/ designee will report any identified concerns related to the protection of resident funds on an as needed basis to the QAPI Committee for discussion and follow-up.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING REHABILITATION

REGULATION: Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 1, 2018

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that the areas of the building undergoing reconstruction were in compliance with requirements under NFPA 2012 Chapter 19 Exisitng Health Care Occupancies. Reference is made to the reconstruction area on the 10th floor that was not separated with a smoke resistive partition from the egress corridor. The findings include : On (MONTH) 27 and (MONTH) 28, (YEAR), at 10:00 AM to 3:00 PM, it was observed that the facility was reconstructing the nursing station area on the partially occupied 10th floor. The area undergoing reconstruction was not separated with a smoke resistive partition from the egress corridor leading to exit stair A, to provide safe exit for the floor occupants during fire or other emergecy. The reconstruction area was separated only by a clear plastic sheething for dust protection. On (MONTH) 28, (YEAR) at approximately 12: 30 PM, the facility's Corporate Director of Facilities Management stated that all areas undergoing reconstruction will be separated by a smoke resistant partition constructed of plaster boards.

Plan of Correction: ApprovedDecember 13, 2018

Element # 1 P(NAME) of Affected Area:
Upon notification on (MONTH) 28th, (YEAR) that the 10th floor nursing station construction area was not separated with a smoke resistive partition from egress corridor, the contractor was immediately instructed to stop all work. The clear plastic sheeting for dust protection was removed and a smoke resistant partition was installed to separate the construction area from the egress corridor. Work was completed (MONTH) 1st, (YEAR).
Element # 2 P(NAME) to Identify Other Areas Potentially Affected:
On (MONTH) 28th, the Director of Engineering conducted a building wide inspection of all construction areas to ensure that construction areas are separated from egress pathway by smoke resistive partition. No further cases were found.
Element # 3 P(NAME) for Facility Measure's to Prevent Re-occurrence:
Beginning (MONTH) 1st (YEAR), the Director of Engineering or designee as part of the environment of care rounds begin conducting audits to ensure:
? All areas undergoing reconstruction are separated by a smoke resistant partition.
Element # 4 P(NAME) for Monitoring Corrective Actions:
Beginning (MONTH) 1st, 2019 the Director of Engineering Designee will review monthly environment of care rounds for instances where,
? Areas undergoing reconstruction are not adequately separated by smoke resistant partition.
The Director of Engineering or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.

K307 NFPA 101:CORRIDOR - DOORS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 14, 2019

Citation Details

This requirement is not met as evidenced by : Based on observation and staff interview, it was determined that the facility did not ensure that all openings to rooms needing access for beds or stretchers were at least three feet eight inches side. Reference is made to the door openings to a number of resident rooms on the newly renovated 15th floor that were only three feet wide instead of the minimum of three feet eight inches, examples were : resident room #'s 1501, 1502, 1503, 1504, 1505 and 1518. The findings include : On (MONTH) 27 and (MONTH) 28, (YEAR),between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that door openings to newly renovated resident rooms were only three feet wide instead of the minimum of three feet eight inches wide, examples were : resident room #'s 1501, 1502, 1503, 1504, 1504 and 1518. On 11/28/18, at approximately 12:45 PM the facility's Corporate Director of Facilities Management stated that the facility will contact the architect company for the possible explanation and alterations for the narrow doors to certain resident rooms on the 15th floor.

Plan of Correction: ApprovedDecember 19, 2018

Element # 1 P(NAME) of Affected Areas:
The door opening to the following resident rooms on the 15th floor will be increased from three feet to a minimum of three feet 8 inches.
? 1501
? 1502
? 1503
? 1504
? 1505
? 1506
Work will be completed by (MONTH) 31st 2019. We are requesting a Time limited waiver (6 months).
Element # 2 P(NAME) to Identify Other Areas Potentially Affected:
On 11/29/18 -12/03/18 facility engineering staff conducted building wide inspection to ensure:
? All openings to rooms needing access for beds or stretchers are at least three feet eight inches.
Following inspection of the rooms, no additional doors outside of the 15th Floor were identified as not meeting the three feet eight inch requirement.
Element # 3 P(NAME) for Facility Measure's to Prevent Re-occurrence:
Beginning (MONTH) 1st, (YEAR), the Director of Engineering has added to the monthly Environmental of care rounds check list, the checking of all resident room openings to ensure the opening is at least three feet eight inches in width.
Element # 4 P(NAME) for Monitoring Corrective Actions:
Beginning (MONTH) 2nd, (YEAR), the Director of Engineering or Designee will review monthly environment of care rounds for any cases of non-compliance. The Director of Engineering or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
**Please Note- the facility is requesting a time limited waiver to provide an extension of the time period allowed to fully address this deficiency. The facility requires time for design, permitting (if applicable), material ordering and manufacture, installation and inspection (approval) of new door openings. We anticipate the time limited waiver will be in place by (MONTH) 14th, 2019.**

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: November 30, 2018
Corrected date: December 31, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 2012 NFPA 101 and NFPA 13. Reference is made to the lack of sprinklers as well as obstructed sprinklers in a number of areas in the building. The findings include : On 8/27/18 and 8/28/18, between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that automatic sprinklers were obstructed, or the sprinklers were lacking, in a number of areas of the building and did not provide coverage for the entire protected area. in accordance with NFPA 13. Examples include but are not limited to the following : (1) In room [ROOM NUMBER], the recessed alcove area containingn a lighting fixture and handwashing sink lacked sprinkler coverage. The existing sprinklers in the vicinity of the alcove were obstructed by the wall /partition and did not provide coverage for the entire protected area. (2) In the clean workroom, on the 10th floor, containing cartoned supplies, the existing sprinklers were installed approximately nine feet from the wall, instead of the maximum of six feet from the furthest wall. (3) In the toilet room/shower room, off resident room [ROOM NUMBER], sprinklers were obstructed by the turn of themwall/partition and did not provide coverage for the shower stall area. (4) In a number of centralized shower/toilet areas, the existing sprinklers were obstructed by solid curtains. In some cases the mesh installed on top of curtains did not provide an 18 inch clearance preventing coverage for the entire protected area. Examples were : shower area, in the vicinity of medical office, on the 15th floor, and the centralized shower area in the vicinity of the freight elevator, on the 15th floor. (5) In the ADL room off the physical therapy area on the 14th floor, one of the two shower stalls lacked sprinkler coverage. The existing sprinklers were obstructed by the turn of the wall/partition and did not provide coverage for the entire protected area On 11/28/18, at approximately 1:00 PM, the facility's Corporate Director of Facilities Management stated that the sprinkler company was being contacted to evaluated and provide sprinklers in all areas of the building in accordance with NFPA 13. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedDecember 13, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element # 1 P(NAME) of Affected Areas:
Upon notification by DOH on (MONTH) 28th (YEAR) of specific areas in the building not adequately protected by automatic sprinkler, W&M Sprinkler Company was contacted. In conjunction with Facility engineering staff, Sprinkler will be added or repositioned in the following locations. Work will be completed by (MONTH) 31st (YEAR).
1. In room [ROOM NUMBER]
2. Clean workroom on 10th floor
3. In toilet/shower room, off resident room [ROOM NUMBER]
4. Shower areas in the vicinity of medical office, on the 15th floor and centralized shower area in the vicinity of the freight elevator on the 15th floor.
5. In the ADL Bathing area in the physical therapy suite on the 14th floor.
Element # 2 P(NAME) to Identify Other Areas Potentially Affected:
On 12/05/18 W&M sprinkler company and the Director of Plant Engineering conducted a walk-through of the facility to identify any additional areas not protected by automatic sprinklers; sprinkler heads obstructed or missing. W&M in collaboration with facility engineering is in the process of installing and re-positioning sprinklers. All work will be completed by (MONTH) 31st (YEAR).
Element # 3 P(NAME) for Facility Measures to Prevent Re-occurrence:
Beginning (MONTH) 2nd, 2019 the Director of Engineering or Designee has added to the monthly Environment of care rounds inspections to ensure automatic sprinklers are not obstructed and adequate coverage is provided to the entire protected areas.
Element # 4 P(NAME) for Monitoring Corrective Actions:
Beginning (MONTH) 2nd, 2019 the Director of Engineering Designee will review monthly environment of care rounds for areas where sprinkler system was obstructed and those lacking sprinkler protection. The Director of Engineering will report the results of these audits to the Safety committee on a monthly basis, as well as corrective action plan if warranted.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 7, 2018

Citation Details

Section 7.1.8, 2012 NFPA 101, states that guards in accordance with 7.2.2.4 shall be provided at the open open side of the means of egress that exceed 30 inches (760 mm) above the floor of finished ground level below. This standard is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that guards provided at the open side of the exit stair landings were at least 42 inches high as per 7.2.2.4. Reference is made to the guards provided at the landing,on the top of the exit stair B that were approximately 36 inches above the landing floor instead of the minimum of 42 inches high from the stair landing floor. The findings include: On (MONTH) 27 and (MONTH) 28, (YEAR), between 10:00 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the facility had provided guards at the open side of the exit stair landings. The guards provided on the top landings of the exit stair B, measured approximately 36 inches high from the stair landing floor instead of the minimum of 42 inches high from the stair landing floor On (MONTH) 28, (YEAR) at approximately 10:30 AM, the facility's Corporate Director of Facilities Management stated that guardrails at the open side of all stair landings will be extended to the required height. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedDecember 13, 2018

Element # 1 P(NAME) for Affected Areas:
The guard rails measuring 36 inches at the open side of the top landing within exit stair ?B? was raised to 42 inches high from the stairs landing floor. Work was completed (MONTH) 7th (YEAR).
Element # 2 P(NAME) to Identify Other Areas Potentially Affected
On 11/28/18 through 11/29/18 the Facility Engineering staff inspected all guard rails at the open side of top landing on all stairs to ensure rails are installed at least 42 inches high from the stair landing floor. Non-compliance cases were corrected by (MONTH) 7th (YEAR).
Element # 3 P(NAME) for Facility Measures to Prevent Re-occurrence:
Beginning (MONTH) 1st, (YEAR) the Director of Engineering Designee added to the monthly Environment of care rounds inspection of guard rails at the top landing within Staircases to ensure they are no less than 42 inches high.
Element # 4 P(NAME) for Monitoring Corrective Actions:
Beginning (MONTH) 10th, 2019 the Director of Engineering or Designee will review monthly environment of care rounds for cases of non-compliant guardrails. The Director of Engineering or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: December 31, 2018

Citation Details

Physical Plant- State Only Violation NYCRR 713-2.21 (e)(2) (iii) Backflow preventers (vacuum breakers) shall be installed on hose bibbs, janitor's sinks, bed pan flushing attachments and on all other fixtures to which hoses or tubings can be attached. This requirement is not met as evidenced by : Based on observation and staff interview, it was determined that the facility did not ensure that all water fixtures to which tubing was attached were provided with backflow preventers (vacuum breakers). Reference is made to the water fixtures in the dental clinic with attached tubing tubing lacked backflow preventers (vacuum breakers ). The findings include : On (MONTH) 27 and (MONTH) 28, (YEAR), between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that the facility had attached an equipment tubing attached to a water fixture in the dental clinic on the 14th floor. The water fixtures lacked a vacuum breakers (backflow preventers). On 11/28/18, at approximately 11:00 AM the facility's Corporate Director of Facilities Management stated that backflow preventers will be installed at all water fixtures to which tubing is attached.

Plan of Correction: ApprovedDecember 13, 2018

Element # 1 P(NAME) of Affected Area:
The water fixture in the dental clinic on the 14th floor to which equipment tubing is attached will be protected by vacuum breaker (backflow preventer). Work will be completed by (MONTH) 31st (YEAR).
Element # 2 P(NAME) to Identify Other Areas Potentially Affected:
On 11/29/18 thru 12/05/18 the facilities engineering staff checked the entire facility to ensure:
? Backflow preventers (vacuum breakers) are installed to all water fixtures to which tubing is attached.
All additional cases of non-compliance will be corrected by (MONTH) 31st (YEAR).
Element # 3 P(NAME) for Facility Measure's to Prevent Re-occurrence:
Beginning (MONTH) 2nd, 2019 the Director of Engineering or Designee as part of the Environment of Care rounds will conduct inspections to ensure:
? Backflow preventers (vacuum breakers) are installed to all water fixtures to which tubing is attached.

Element # 4 P(NAME) for Monitoring Corrective Actions:
Beginning (MONTH) 1st, 2019 the Director of Engineering or Designee will review monthly environment of care rounds for cases of non-compliance.
The Director of Engineering or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 30, 2018
Corrected date: January 15, 2019

Citation Details

Based on observation, it was determined that the facility did not ensure that the smoke barrier doors were constructed to resist the passage of smoke and /or were provided with astragals at the meeting edges of the doors. Reference is made to the lack of astragal at the meeting edges of the new smoke barrier door on the 15 floor and the excessive gap between the meeting edges of the smoke barrier door on the 10th floor. The findings include : On (MONTH) 27 and (MONTH) 28, (YEAR), at 10:00 AM to 3:00 PM, during the recertification survey of the facility, the following was observed : (1) The pair of smoke barrier doors on the newly renovated floor were swinging in opposite direction to each other. An astragal was lacking at the meeting edges of the doors. (2) The smoke barrier door on the 10th floor was installed as free swinging pair of doors. The smoke resistance rating of the smoke barrier door was compromised by the presence of an excessive gap (approximately 1/4 - 1/2 inch ) between the meeting edges of the doors. On 11/28/18, at approximately 12:00 PM, the faciltiy's Corporate Director of Facilities Management stated that astragals will be installed at the meeting edges of all smoke barrier doors so as to maintain their smoke resistance rating. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedDecember 13, 2018

Element # 1 P(NAME) of Affected Areas:
Astragals will be installed at the meeting edges of the following doors:
1. The pair of smoke barrier doors on the newly renovated floor
2. The smoke barrier door on the 10th floor
Work will be completed by (MONTH) 31st (YEAR).
Element # 2 P(NAME) to Identify Other Areas Potentially Affected:
On 11/29/18 thru 12/05/18 the facilities engineering staff checked the entire facility to ensure:
? That smoke barrier doors were constructed to resist the passage of smoke and /or were provided with astragals at the meeting edges.
All additional cases of non-compliant doors will be corrected by (MONTH) 31st (YEAR).
Element # 3 P(NAME) for Facility Measures to Prevent Re-occurrence:
Plan of Correction for system measures to prevent reoccurrence
Beginning (MONTH) 2nd, 2019 the Director of Engineering or Designee as part of the Environment of Care rounds will conduct inspections to identify the following:
? Smoke barrier doors are constructed to resist the passage of smoke and /or are provided with astragals at the meeting edges.
Element # 4 P(NAME) for Monitoring Corrective Actions:
Beginning (MONTH) 1st, 2019 the Director of Engineering or Designee will review monthly environment of care rounds for cases of non-compliant smoke barrier doors.
The Director of Engineering or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.