The Diamond Nursing and Rehabilitation Center
May 17, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(e)(1)(2):COORDINATION OF PASARR AND ASSESSMENTS

REGULATION: §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey the facility did not refer a resident with newly evident or possible serious mental illness for level II review for (1) one Resident (#57) of one (1) residents reviewed for PASRR (Pre Admission screening and Resident Review). Specifically: Resident #57 experienced an increase in negative symptoms related to the [DIAGNOSES REDACTED]. This is evidenced by: Resident #57: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 2/3/18 assessed the resident could understand, and was understood. The quarterly MDS dated [DATE] documented [DIAGNOSES REDACTED]. The Screen Form for the Level 1 Review for Possible Mental Illness dated 7/17/14 documented that the resident did not have a serious mental illness. The MDS dated [DATE], documented there was no psychiatric disorder or [MEDICAL CONDITION] medication use. There were no other PAS[DIAGNOSES REDACTED] in the medical record other that the initial PASSAR of 7/17/14 done prior to admission. A nursing progress note dated 3/6/18, documented the resident was sent to the hospital for increased psychotic symptoms with hallucinations. A Psychologist report dated 5/2/18, documented the resident had a medical history of [REDACTED]. The resident had been seen after returning from the hospital on [DATE] for increased hallucinations. Antipsychotic medications were to be continued. During observation on 5/15/18 at 9:44 AM, Resident #57 was observed in bed in his room. The resident demonstrated significant cognitive impairment. The resident could not articulate his needs, could not understand and could not be understood. During interview on 5/15/18 at 11:05 AM, the Registered Nurse Unit Manager (RNUM) #1 stated the resident had been in decline both medically and physically since (MONTH) (YEAR) and had been sent to the hospital on [DATE] for significant changes. The resident returned to the facility on [DATE], with little improvement. RNUM #1 stated a PASSAR had not been completed prior to his return from the hospitalization of 3/6/18. During interview on 5/16/18 at 11:14 AM, the MDS Registered Nurse (RN) stated the resident's MDS dated [DATE] included the [DIAGNOSES REDACTED]. A significant change MDS should have been completed at that time and this may have triggered the need for an updated PASSAR level 1 screen. During interview on 5/16/18 at 1:46 PM, the Director of Nursing (DON) stated the resident had a significant change related to the [DIAGNOSES REDACTED]. The symptoms he was having required hospitalization . A significant change MDS should have been completed after return from the hospital. She thought that was the reason the referral for a Level 1 repeat screen may have been missed. 10NYCRR415.11(e)

Plan of Correction: ApprovedJune 28, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will insure coordination of PASSAR and Assessments.
The facility will insure that any resident(s) sent to the hospital for a change in condition will be reviewed at morning clinical meeting and any resident identified to have a significant change in physical or mental condition who has a [DIAGNOSES REDACTED].
The facility will educate all RN?s, Admissions Director, Social Work and Admissions Liaison on the policy and requirement for when a PASSAR level 1 screen and evaluation of a level 2 screen is to be completed.
The facility will ensure that any resident with a newly diagnosed Mental Illness/Mental [MEDICAL CONDITION] or Developmental Disability will have a new PASSAR level 1 screen and evaluation of a Level 2 screen and or referral completed within 14 days.
The facility will review all resident charts to ensure that any resident with a [DIAGNOSES REDACTED].
The facility reviewed chart of resident #57 and completed a new PASSAR level 1 screen and level 2 evaluation. Resident #57 did not require a level 2 screen.
Social worker or designee will conduct 10 audits per month for 3 months to insure any resident with [DIAGNOSES REDACTED].
Social Worker or designee will conduct audits on all residents newly diagnosed with [REDACTED].

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not ensure development of policies and procedures for the monthly drug regimen review 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 action to protect the resident. This is evidenced by: On 5/15/18, the facility Medication Regimen Review, revised on 9/14/17 and implemented on 9/22/17, documented bullet point #7- upon completion of the MRR, the facility designee and/or physician will respond to the recommendations in a timely manner and documented bullet point #8 that if the pharmacist should identify an irregularity and communicates to the facility that it requires urgent action to protect a resident, it will be acted upon immediately. There were no specific timeframes for when the Nurse Manager and Physician would review the Pharmacist's recommendations or steps the pharmacist would take when he or she identified an irregularity that required urgent action to protect the resident. During interview on 5/16/18 at 4:00 PM. The Director of Nurses (DON) stated she assumed timely manner was enough. She said timely can mean different things to the Medical Doctor versus her. Timely is what the doctors agreed to. She stated that immediately was a time frame. 10NYCRR415.18(c)(2)

Plan of Correction: ApprovedJune 28, 2018

The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will maintain policies and procedures for monthly drug regimen review that include time frames for the different steps in the process the pharmacist must take when he or she identifies and irregularity that requires urgent action to the protect the resident.
The facility policy for Medication Regimen Review has been revised to include specific time frames for Nurse Manager/Supervisor/Designee and Physician to review pharmacist recommendations and the steps the pharmacist would take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the policy reads in part:
7. Upon completion of the MRR, the facility designee and/or physician, will respond to the recommendations in 30-45 days
8. If the pharmacist should identify an irregularity and communicates to the facility that it requires urgent action to protect a resident, it will be acted upon immediately within 2 hours by the nurse manager/supervisor or designee and communicated to the primary physician for action
The Pharmacy Consultant, Physician and PA will be educated on the revised MRR policy
The revised policy for Medication Regimen Review will be reviewed at QAPI committee

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

Based on staff interview and the Legionella Water Sampling and Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.4(a)(2) requires that Legionella sampling be conducted at periods not exceeding 90 days after the adoption of the WMP. Section 4-2.4(a)(3) and Appendix 4-B requires that the WMP include the development of responsive actions based on certain Legionella culture results (responsive actions). Specifically, the facility did not test for Legionella as required by New York State regulation and the WMP did not include responsive actions. This is evidenced by the following. The WMP was reviewed on 05/14/2018. This review documented that the WMP was adopted on 09/2016 and revised on 05/25/2018. Quarterly water sampling was not and has not yet been conducted since the adoption of the plan and the plan does not include responsive actions. The Administrator, Director of Maintenance, and Infection Control Preventionist stated in an interview conducted on 05/14/2018 at 9:00 am, that the Legionella testing will be conducted as required and the WMP will be revised and updated to meet current state regulations. 415.19(a)

Plan of Correction: ApprovedJune 6, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Specifically, the Legionella Water Sampling and Management Plan (WMP) will be reviewed to include the development of responsive actions based on certain Legionella culture results and Part 4 Protection Against Legionella.
The facility will test for Legionella as required by New York State Regulation and the WMP will include responsive actions.
The Facility has developed a Flow Chart and a detailed description of the water systems using text and flow diagrams.
The Facility has also employed the services of Certified National Analytics (CNA) Environmental, LLC., a NYSDOH / NELAP accredited water testing laboratory to assist the facility develop a comprehensive water management policy that addresses both short and long-term risk associated with legionella. Legionella testing will be conducted quarterly (6/18, 9/18, 12/18, and 3/19) for a year and annually thereafter by (CNA) Environmental.
Short-term control measures or temporary interventions will include, but are not limited to, heating and flushing the water system, hyperchlorination, or the temporary installation of treatment such as [MEDICATION NAME] silver ionization (CSI). Long-term control measure will include inspection, cleaning and disinfection of equipment?s to the standard required to control Legionella bacteria within the facility.
The Director of Maintenance will ensure records of servicing and maintenance of equipment are retained, along with a log detailing flushing regime.
The ICP and Director of Maintenance will train staff on the Legionella Management Plan, the potential sources of infection and both short and long term responsive actions based on any positive Legionella culture results.
The ICP will be responsible for continued compliance. WMP reports will be reviewed quarterly by the Inter Disciplinary Team and any issues reported to the Administrator and Quality Assurance and Performance Improvement QAPI.

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review 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 2 of 2 Units. Specifically: The facility did not develop a Legionella Water Management Plan (WMP) in accordance with adopted regulations; did not ensure oxygen tubing that had rested on the floor was not given to a resident for use and that urinary catheter tubing was kept off the floor and; that staff that had not received the flu vaccine wore face masks appropriately. This is evidenced as follows. Finding #1: The facility did not develop a Legionella Water Management Plan (WMP) in accordance with adopted regulations The WMP was reviewed on 5/14/2018. The WMP did not include a description of the potable water system with a flow chart and written description. The Administrator, Director of Maintenance, and the Infection Control Preventionist stated in an interview conducted on 05/14/2018 at 9:00 am that the WMP will be modified to include a written and flow chart description of the potable water system. Finding 2: The facility did not ensure oxygen tubing that had rested on the floor was not given to a resident for use and that urinary catheter tubing was kept off the floor On 5/16/18 at 10:25 AM, Resident #507's nasal cannula connected to the oxygen concentrator was resting on the floor. A Speech Therapist (ST) picked the nasal cannula off the floor and gave it to the resident who put it on. Resident #63: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 2/3/18, assessed the resident had moderately impaired cognitive ability and urinary catheter. Physician orders [REDACTED]. On 5/09/18 at 3:12 PM, the resident was in the elevator. The resident's foley catheter tubing was resting on the on the floor. The resident was wheeled into the far end of the main dining room. The catheter tubing dragged across the floor. On 5/10/18 at 9:29 AM, the resident wheeled down the Unit hallway into his room. The urinary catheter tubing was dragging across the floor. At 12:15 PM, the resident was in the small green dining room. The catheter tubing was laying on the floor. At 3:18 PM, the resident was in the hallway. The catheter tubing was laying on the floor. During interview on 5/15/18 at 9:22 AM, the Registered Nurse Manager (RNM) stated catheter tubing should not drag on the floor. It is an infection control concern as well as a dignity and comfort concern. The resident's chair is low which made it difficult to position the tubing off floor. She thought someone did not adjust straps on the catheter bag diagonally, which was needed to keep the tubing off the floor. The RNM was asked if the care card (tells staff how to care for the resident) documented the need to adjust the straps diagonally. The RNM looked and responded that it did not. Finding #3: During observation on 5/9/18 at 9:21 AM, Certified Nursing Assistant #1 (CNA) was feeding a resident, with her mask below her nose. The CNA did not adjust the mask during the 45 minute time period that the CNA assisted the residents. During observation on 5/9/18 at 12:30 PM, CNA #1 entered the main kitchen area with her mask below her nose. After exiting the kitchen, CNA #1's mask was still below her nose. During observation on 5/10/18 at 11:22 AM, CNA #1 was entering and exiting residents rooms answering lights and giving direct resident care to several residents with her mask below her nose. Two LPN's and the Registered Nurse Unit Manger #2 (RNUM) were in the hallway. The CNA was not given direction for the appropriate use of the face mask. During interview on 5/10/18 at 12:38 PM, CNA #1 stated that she had not been vaccinated for the flu. The mask fits poorly and even though she pinches it, it does not stay in place. She had not asked anyone for a better fitting mask. The CNA was aware that the mask should cover her mouth and nose in order to protect the residents. During interview on 5/10/18 at 11:45 AM, RNUM #2, stated CNA #1 was wearing a mask because she had not been immunized for the flu. RNUM #2 had a list of employees that need to wear masks. All staff including herself should be monitoring to ensure all staff are compliant with the use of masks and proper use of personal protective equipment to protect the residents. During interview on 5/16/18 at 2:42 PM, the Infection Control Registered Nurse stated that staff members who have not received the flu vaccine are required to wear a mask. The mask needs to be above the nose at all times to be effective and in compliance with New York State Center for Disease Control regulations. If a mask does not fit properly the CNA or person having a problem should ask for a different type of mask. All the nurses on the unit should be monitoring to see the mask is above the nose. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f)

Plan of Correction: ApprovedJune 28, 2018

The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will ensure and maintain an Infection Prevention and Control program designed to provide safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Legionella:
The facility will maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Specifically, the Legionella Water Sampling and Management Plan (WMP) will be reviewed to include the development of responsive actions based on certain Legionella culture results and Part 4 Protection Against Legionella.
The facility will test for Legionella as required by New York State Regulation and the WMP will include responsive actions.
The Facility has developed a Flow Chart and a detailed description of the water systems using text and flow diagrams.
The Infection Control Preventionist will be responsible for continued compliance. WMP reports will be reviewed quarterly by the Inter Disciplinary Team and any issues reported to the Administrator and Quality Assurance and Performance Improvement (QAPI) team.
O2 tubing, Flu Masks and Foley bags:
The Infection Prevention and Control Policy was reviewed and revised to include: during flu season the Infection Control Preventionist will ensure any Staff or volunteers who decline or are unable to take the flu vaccination will be educated on masking requirement, use and fit of masks and sign an acknowledgement of education and expectation.
Staff will be educated on infection control practices for O2 tubing and Foley bags and tubing, and proper masking. Education has already been initiated for Licensed staff, Rehab staff and RN?s
The facility insured that resident #507 had her oxygen nasal cannula replaced.
Nursing staff will be educated on use of Foley leg bags
Residents with a Foley Catheter will be assessed, and care planned if a Foley leg bag is deemed appropriate for use during awake hours.
The Nurse Manager or designee will conduct weekly audits x4 weeks then monthly for 2 months any resident deemed not appropriate for a leg bag to insure the Foley tubing is secured to wheelchair and not dragging on the floor when out of bed.
Nurse Manager/Supervisor of designee will conduct audits of 20 residents weekly, for 4 weeks, then monthly for 3 months to insure residents with O2 tubing is properly placed on residents or stored in proper bags.
The DON will review weekly and monthly audits respectively
Audits will be reviewed by the DON weekly and monthly respectively
The DON will report on the audits to QAPI committee

FF11 483.20(k)(1)-(3):PASARR SCREENING FOR MD & ID

REGULATION: §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, conducted during the recertification survey, the facility did not ensure that a New York SCREEN Form DOH (Department of Health)- 695 Preadmission Screen and Resident Review (PASARR) was completed for one (Resident #46) of twenty-three residents reviewed. This is evidenced by: Resident #46: The resident was admitted to facility on 8/8/17, with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident is able to make himself understood and is able to understand others, and has minimal cognitive impairment. On 5/10/18 at 3:30 pm, the resident's medical record did not include a New York SCREEN Forms DOH (Department of Health)- 695 Preadmission Screen and Resident Review (PASARR). During an interview on 5/17/18 at 10:02 am, the Director of Social Services (DSS) #3 confirmed that the New York State PASARR screen had not been completed for this resident. The DSS reported that she recently became aware that the screen was required to be completed prior to a resident's admission. 10 NYCRR415.11(e)

Plan of Correction: ApprovedJune 6, 2018

The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
A New York State PASARR Screen has been completed for resident #46
The facility will insure that all residents newly admitted to the facility will have a signed New York State PASARR Screening prior to admission.
The policy for admission/Transfers and Discharges has been reviewed and revised to include ?all new admission will require a signed New York State PASARR prior to admission into the building?.
The Admission Liaison, Director of Admissions, Social Workers and RN?s will be educated on the facility Admissions Requirement including the completed and signed New York State PASARR Screen.
The Director of Social Work or designee will conduct weekly audits for 4 weeks then monthly audits for 3 months to insure all new admissions have a completed and signed PASARR Screen on file in the Medical Record.
The DON or designee will review audits weekly and monthly respectively.
The Social Worker or designee will report audits and findings to QAPI Committee

FF11 483.20(c):QRTLY ASSESSMENT AT LEAST EVERY 3 MONTHS

REGULATION: §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a recertification survey the facility did not assess the resident using the quarterly review instrument as specified by the State and approved by CMS not less frequently than once every three months for twelve (12) (Resident's # 3, 4, 5, 6, 7, 8, 9, 11, 12,13,14, and #48) of twelve (12) residents reviewed for quarterly resident assessments. Specifically, for Resident #'s 5, 6, 8, and 9, the quarterly Minimum Data Set (MDS - a resident assessment tool) assessment was not completed and submitted, and for Resident #'s 3, 4, 7, 12, 13, 14, 16, and #48, MDS's were not completed and submitted timely as required. This is evidenced by: Finding #1: The facility did not ensure that the quarterly Minimum Data Set (MDS) (resident assessment tool) assessment was completed and submitted. Resident #6: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], documented the resident was understood and could usually understand. Review of the MDS Summary on 5/16/2018, revealed the quarterly MDS due 4/23/18 was not completed and submitted . Resident #9: The resident was admitted to the facility 2/1/13 and readmitted on [DATE], with the [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], documented the resident was understood and could usually understand. Review of the MDS Summary on 5/16/2018, revealed the quarterly MDS due 4/25/18 was not completed and submitted Finding #2: The facility did not ensure that MDSs were completed and submitted timely. Resident #14: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], documented the resident was understood and could usually understand. Review of the MDS Summary revealed the quarterly MDS due 3/23/18 was not completed or submitted by 3/23/18. According to record review the quarterly MDS was completed on 5/3/18 and submitted on 5/7/18. Interviews: During an interview on 05/16/18 at 10:45 AM, the Registered Nurse/ MDS coordinator stated she knew she was behind on completing MDS assessments. She stated she was completing as many as she could as fast as she could to catch up since her return to work on 4/24/18 post medical leave. During an interview on 5/16/18 at 11:30 AM, the Administrator stated the MDS's were incomplete and the submissions were late because the MDS coordinator had been out on medical leave. He had a back up person to help her, but that person had been injured and there was no one else in the facility to complete them. They were addressing this issue and trying to develop a plan to prevent this from happening again. During an interview on 5/17/18 at 8:59 AM, the Director of Nursing (DON) stated the facility does not have a specific policy for the completion and submission of MDS's. The facility's policy is to follow the MDS manual. She acknowledged many of the MDS's were overdue and submitted late due to a facility staff problem. The MDS coordinator had been out on a medical leave. They are trying to catch up and get the ones that are late submitted to be in compliance. NY10CRR 415.11(a)(4)

Plan of Correction: ApprovedJune 6, 2018

The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will ensure that Quarterly Review Assessments are completed and submitted for all residents not less than once every 3 months.
The facility ensured that for Resident #5,6,8,9 the quarterly MDS assessments were completed and submitted.
The facility reviewed the MDS assessment for residents # 3,4,7,12,13,14,16 that were not completed and submitted timely, no decline identified and care plans accurately reflected resident?s care needs. There was no adverse effect to the residents.
The facility has reviewed and revised the current policy for Resident Assessments. MDS Assessments will be completed and submitted for all residents according to the revised policies.
The Governing Board have hired an MDS Consultant who will assist in coverage for any future absences of MDS personnel. In addition, the facility has hired a part time MDS nurse to assist in completion of MDS?s.
The Inter Disciplinary Team (IDT) will now review in daily clinical meeting resident assessment dates and completion expectations. The MDS Coordinator will work closely with IDT to ensure timely completion of Resident Assessments. Any issues identified will be brought to the attention of the Administrator and QAPI.
The MDS Consultant will perform weekly audits for the timeliness and completion of resident?s assessments and any issues identified will be brought to the attention of the Administrator.
The MDS Coordinator will report on the completion rates at QAPI.

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: May 17, 2018
Corrected date: July 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure residents received treatment and care based on professional standards and practice, the comprehensive person-centered care plan, and the residents' choices for one (1) (Resident #30) of two (2) residents reviewed. Specifically, Resident #30 was not provided adequate care for a history of constipation when the resident did not have a bowel movement from 5/8 - 5/12/18. Facility staff did not adequately monitor the resident's BMs, did not follow the care plan for constipation and did not notify the resident's physician after three days without a BM. This is evidenced by: Resident #30: The resident was admitted on [DATE], and readmitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, was able to understand others and was able to be understood. The resident is a hospice patient. The facility's policy on Bowel Movement Monitoring with a revision date of 1/21/13, documented it will be the responsibility of the 7-3 Charge Nurse/Supervisor to review the Bowel Movement (BM) Records for the previous 24 hours and if no BM is documented in a 72 hour period (and/or 3 days), the physician is contacted for further instructions if they are warranted. The Comprehensive Care Plan (CCP) for At Risk for Gastrointestinal Dysfunction secondary [MEDICAL CONDITION](heartburn) and constipation, with an effective date of 11/17/17, documented an intervention for the resident to have a BM every 2 to 3 days. A physician's orders [REDACTED]. A physician's orders [REDACTED]. If no BM in 3 days, call the physician. A BM log documented the resident did not have a BM on 5/08, 5/09, 5/10, 5/11, and 5/12/18. The resident had a medium sized BM on 5/13, no BM on 5/14 and an extra large BM on 5/15. During an interview on 05/09/18 at 02:50 PM, the resident stated that she is constipated and the medication she gets is not enough because she remains constipated. During an interview on 05/15/18 at 09:27 AM, Licensed Practical Nurse (LPN) #1 reviewed the BM log and stated there were no BM's indicated for the resident on 5/08, 09, 10, 11, 12, and 5/13/18. The physician should have been notified. The night shift usually reports if a resident does not have a BM over 3 days. Nurses at the end of their shift review the BM book. The resident does not have an as needed (PRN) medication for constipation. During an interview on 05/15/18 at 09:39 AM, LPN #2 stated he would call the physician if the resident had no BM in 3 days. He would call the physician, get orders, and follow up the next day with the nurse. He would chart the resident's BM's in the electronic Medical Record and in progress notes. During an interview on 05/15/18 at 09:42 AM, Registered Nurse Manager (RNM) #1, stated the physician should have been called. Hospice should also have been called for a recommendation for a medication and the physician would be called for the medication order. After 5 days the resident should have had a large BM. 10NYCRR415.12

Plan of Correction: ApprovedJune 28, 2018

The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will ensure that all residents in the facility receive Quality Care, based on a comprehensive assessment of each resident and insure treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident?s choices.
The facility will ensure that resident #30 has a bowel movement every 3 day or the MD will be notified
The Facility will ensure that any resident who has not had a BM in 3 days the MD is notified, and treatment has been ordered.
A complete audit was performed on all resident to ensure that any resident without BM in last 3-days MD was notified and treated ordered.
The facility has reviewed and revised the current Bowel Monitoring Policy.
Nursing Staff will be educated on the revised Bowel Monitoring Policy
The Nurse Manager/Supervisor or designee will audit 20 residents daily on each unit for 4 weeks, then weekly for 1 month and monthly for 2 months
The DON will review audits daily, weekly and monthly respectively
The DON will report on the audits and findings to QAPI committee
Date of Compliance 6/30/18

FF11 483.10(e)(2):RESPECT, DIGNITY/RIGHT TO HAVE PRSNL PROPERTY

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

Based on observation and interview the facility did not ensure residents were treated with respect and dignity on 1 of 2 units during the recertification survey. Specifically, female residents were observed to have long facial hair and a resident was observed undergoing treatment by the dentist with the door open. This is evidenced by: Finding 1: Unit 2 Resident #76 had long facial hair on 5/10/18 at 11:30 AM. On 5/15/18 at 2:30 PM, the resident was in an ice cream social with long facial hair. At 3:08 PM, the resident went into another activity still having long facial hair. Resident #21 had long facial hair on 5/10/18 at 12:20 PM, while in the dining room. On 5/14/18 at 1:25 PM, and again on 5/15/18 at 10:27 AM, the resident still had long facial hair. Resident #29 had long facial hair on 5/10/18 at 11:30 AM. On 05/14/18 at 1:22 PM and on 5/15/18 at 10:28 AM the resident still had long facial hair. During interview on 5/16/18 at 10:21 AM, Certified Nurse Aide #3 said she does not care for any of the ladies noted with facial hair, but all female residents with facial hair should be shaved, it is a dignity issue. During interview on 5/16/18 at 2:37 PM, the RNM said staff should go to the charge nurse if unable to shave a female resident. If still unable they should come to me or my assistant. The medication nurses should be seeing long facial hair and addressing it. During interview on 5/16/18 at 3:00 PM, Licensed Practical Nurse (LPN) #5 stated she has seen female residents with long facial hair. The CNAs usually take care of it. She could not remember asking a resident if she wanted it shaved. She has never told the RNM someone needed a shave. Finding 2: Unit 2 On 5/10/18 at 2:15 PM, the Dentist was in the dental room working on Resident #401. The dental room door was wide open. During interview on 5/16/18 at 2:37 PM, the Registered Nurse Manager (RNM) stated the Dentist should not have had the door open while treating a resident. 10NYCRR415.5(a)

Plan of Correction: ApprovedJune 6, 2018

This Plan of Correction is submitted as required under Federal and State regulation and statues applicable to long term care providers. This Plan of Correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of the plan does not constitute an agreement by the facility that the surveyors? findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of the deficiencies cited are correctly applied.
The Facility respectfully states that all residents residing in the facility could be potentially affected by this deficient practice.
The facility will ensure that all residents in the facility are treated with respect and dignity.
The facility ensured that resident 76, 21 and 29 were shaved of facial hair before survey exit.
The facility will ensure that resident 401 and all other residents that use dental services are treated with respect and dignity.
Nursing staff will be educated on importance of ADL care in support of dignity, respect and quality of care.
Nursing staff will be educated on policy and procedure for ADL?s including shaving residents.
Nurse Manager/ Supervisor will audit 20 residents weekly on each unit for 4 weeks then monthly for 3 months to insure ADL care was done including shaving. Any resident care issues will be addressed and corrected immediately the same day.
The dentist and his assistant will be educated on the facility policy for dignity and respect of all residents.
The ADON or designee will audit the dental clinic weekly x 4 weeks then monthly for 3 months to insure residents are given privacy during treatment.
Audits will be reviewed by the DON or designee weekly then monthly respectively.
The DON and or designee will report audits and findings to the QAPI Committee.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: July 13, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean and walls were not in good repair on 2 of 2 resident units. This is evidenced as follows. The floors and walls were spot checked on 05/16/2018 at 3:00 pm. The corridor, common area, and resident room floors next to walls were soiled with dirt or a black build-up on residential unit 1 and residential unit 2. On residential unit 1, the walls had holes, peeling wall paper, or scrapes in resident rooms 169, 171, 183, 191, 220. On residential unit 2, the walls had holes, peeling wall paper, or scrapes in resident rooms 316, 318, 324, 336, 412, 414, 416, 418, and 442. The Director of Housekeeping stated in an interview conducted on 05/16/2018 at 3:50 pm, that the soiled floors will be cleaned. The Director of Maintenance stated in an interview conducted on 05/16/2018 at 3:50 pm, that wall repairs are targeted by unit, but new wall maintenance issues develop daily. 483.10(i)(2)

Plan of Correction: ApprovedJune 28, 2018

The facility maintains a contract with Housekeeping Services Group (HSG) LLC., to provide management services to the Housekeeping and Laundry department and will provide a safe, clean, comfortable, and homelike environment for all residents, including but not limited to receiving and support for daily living safely.
On residential unit 1, the walls had holes, peeling wall paper, or scrapes in resident rooms 169, 171, 183, 191, 220. On residential unit 2, the walls had holes, peeling wall paper, or scrapes in resident rooms 316, 318, 324, 336, 412, 414, 416, 418, and 442. Specifically, floors and walls that were identified not in good repair on 2 of 2 resident units will be corrected and fixed. Resident room floors next to walls that were soiled and the black build-up on residential unit 1 and residential unit 2 will be cleaned. In addition, the Maintenance Department will perform a facility-wide structural audit to identify other areas affected by this deficient practice and correct.
The Director of Housekeeping Services (DHS) or HSG and will perform 5 Quality Control Inspections (QCI) a week in resident?s rooms for the next 3 months and then to 3 QCI a week for 3 months. Additionally, The DHS or HSG will perform 3 QCI a week on the floor-tech X 3 months and then to 3 QCI a week for 3 months to ensure that floors are clean and without spills in corridors, common areas, nurses station etc.
HSG will provide in-service and training for all Housekeeping, Laundry, Porters and Floor Techs on the need to provide a safe, clean, comfortable, and homelike environment for residents.
The Director of Maintenance will institute a daily work order system to address peeling wall paper and holes in walls.
The Administrator will perform weekly environmental rounds with the Director of Maintenance and Director of Housekeeping to address issues identified in deficiency which includes: walls which have holes, peeling wall paper, resident room floors, etc.
The Director for Housekeeping or designee and Director of Maintenance or designee will be responsible for continued compliance.

Standard Life Safety Code Citations

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: June 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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. Section 10.5 requires that testing and maintenance logs include a unique identification of the equipment tested . Specifically, PCREE was not maintained as prescribed in the owner's manual, and maintenance logs did not include a unique identification of the equipment. This is evidenced as follows. Observations of oxygen concentrator #4 were conducted on 05/16/2018 at 10:00 am. The concentrator was found in resident room [ROOM NUMBER]. No persons were found in the room. The concentrator was running producing an oxygen-rich atmosphere and was less than 1-foot from both the wall and privacy curtain. Review of the patient manual for oxygen concentrator #4 on 05/16/2018, revealed that the unit is to be placed 1-foot or more from the wall or curtains and be turned off when not in use. Observations on 05/16/2018 at 10:00 am, and again at 3:00 pm, revealed the following: (1) the suction machine assigned to the 1st floor north nurse station was not assigned a unique identifier for testing and maintenance; (2) nebulizers in resident rooms [ROOM NUMBERS] were not in use, but were plugged into the electrical outlet. Review of the nebulizer owner's manual on 05/16/2018, revealed that due to the risk of electric shock, the power cord is to be unplugged from the electric outlet after using the device. Further, the owner's manual requires that the air filter is to be replaced every 60 days. Record review of the facility PCREE test logs and nebulizer audit logs on 05/16/2018, revealed that tracking as to when the nebulizer filters require replacement is not documented and suction machines are not uniquely identified. The facility maintenance policy for PCREE was reviewed on 05/16/2018. This policy states that all PCREE is to be individually numbered and maintained in accordance with the owner/maintenance manuals. The Director of Maintenance stated in an interview conducted on 05/16/2018 at 11:15 am, that he has not yet completed numbering all PCREE including the suction machines, and the oxygen concentrator both should not have been located near the wall and curtain and should have been turned off after the last use. The Education Specialist stated in an interview conducted on 05/17/2018 at 9:35 am, that she is responsible for training staff on the safe use of PCREE and was not aware that nebulizers should be unplugged after each use. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedJune 11, 2018

The Facility will ensure that all fixed and portable patient-care related electrical equipment (PCREE) used in patient care rooms are in accordance with NFPA 99.
The Director of Maintenance will be responsible for testing PCREE and ensuring that it is: maintained in accordance with information from the PCREE owner?s/maintenance manual(s) accessible to staff; in good repair, no frayed wires, etc.; individually and uniquely identified; and in accordance with regulations before being put into service for the first time and after any repair or modification that might have compromised electrical safety.
Personnel involved in the daily use of PCREE (such as RNs, LPNs, CNAs) will be educated on the safe use of this equipment as described in the owner's manual.
Director of Maintenance or Designee will conduct audits of Two (2) PCREE weekly X (4 weeks), monthly x (3 months) and monthly X (6 months) for compliance. Any issues identified will be reported to Education Coordinator and Administrator immediately.
The Director of Maintenance will be the responsible person(s) for monitoring continued compliance.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: June 30, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide emergency power as required by adopted regulations. NFPA 99 Health Care Facilities Code 2012 edition section 6.4.1.1.17 requires that the emergency power source (emergency generator) is to include a remote annunciator that is storage battery powered and shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. Specifically, the emergency generator is not equipped with a remote annunciator. This is evidenced as follows. Observations on 05/14/2018 at 11:10 am, revealed that a remote annunciator for the emergency generator could not be found. The Director of Maintenance stated in an interview conducted on 05/14/2018 at 11:10 am, that the emergency generator is not serviced by a remote annunciator. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1.1.15

Plan of Correction: ApprovedJune 11, 2018

The Facility has installed an emergency remote annunciator in accordance with NFPA 99. This is storage battery powered and located in the Nursing Station on Downstairs (1N). The emergency remote annunciator is also hard-wired to indicate alarm conditions and this location is readily observed and accessible to all operating personnel 24/7.
Operating personnel at this regular work station will be educated on what to look for and to report all alarms immediately to Maintenance staff.
The Director of Maintenance or designee will routinely inspect and service the remote annunciator and report any failures to the Generator Servicing Vendor and Administrator immediately.

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: June 30, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide continuing education on the risks associated with the handling medical oxygen cylinders. This is evidenced as follows. The Education Specialist stated in an interview conducted on 05/15/2018 at 2:30 pm, that Registered Nurses, Licensed Practical Nurses, and maintenance staff handle oxygen cylinders and training on the risks associated with the handling of oxygen cylinders was not included in their periodic oxygen cylinder training. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedJune 6, 2018

The Facility will provide training to personnel (Registered Nurses, Licensed Practical Nurses, Physical and Occupational Therapist, and Maintenance staff) concerned with the application, maintenance and handling of medical gases and cylinders. This training will include the risks associated with handling of medical gases and cylinders in accordance with adopted regulations.
The Administrator will perform random audit to verify weekly x 4, monthly x 3 months and quarterly for a year the status (risk training) of personnel concerned with the application, maintenance and handling of medical gases and cylinders. Issues identified will be reported immediately to the Education Coordinator.
The Education Coordinator will be the responsible person(s) for monitoring continued compliance

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 17, 2018
Corrected date: June 30, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include sharing emergency preparedness policies and procedures with all residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 05/10/2018, revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with all resident families and/or resident representatives. The Administrator and the Director of Maintenance stated in an interview conducted on 05/10/2018 at 1:45 pm, that the facility has not yet comprehensively informed all residents' families on pertinent sections of the Emergency Preparedness Plan. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedJune 11, 2018

The facility will revise its emergency plan and policies to include how it will notify resident?s families or resident representatives regarding the pertinent sections of the overall emergency preparedness plan.
The facility will develop a brochure summarizing the pertinent sections of the overall emergency preparedness plan and distribute this to resident?s families or resident representatives.

The brochure will be included in the Admission Packet and also provided to resident?s families or resident representatives during care plan meetings. Copies of the brochure will be available to resident?s families or resident representatives at the front lobby.
The Receptionist, Social Workers will inform resident?s families or resident representatives about the availability of the brochure.
The Director for Maintenance will be responsible for continued compliance.

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 17, 2018
Corrected date: June 30, 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. Specifically, the fire rated doors were not inspected within the past year. This is evidenced as follows. The Director of Maintenance stated in an interview conducted on 05/ 8 at 11:25 am, that the annual door inspections have not been completed but will be. 42 CFR 483.70 (a)(1); 2012 NFPA 101 19.2.1, 7.2.1.15; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedJune 18, 2018

The facility will maintain the means of egress in accordance with adopted regulations. Also, the facility will inspect all fire rated doors in accordance with NFPA 80.
The facility has signed an agreement with Life Safety Services (LSS) to inspect, test and maintain on an annual basis:
a. all door assemblies in exit enclosures in accordance with NFPA 80
b. identify ?compliant? and ?non-compliant? doors, and repair to NFPA Code.
At a minimum the following will be verified: No open holes or breaks exist in surfaces of either the door or frame; The door, frame, hinges, hardware, and noncombustible thresholds are secured, aligned, and in working order with no visible signs of damage; Placement of identification stickers on each door; and etc.
The Director of Maintenance will keep written record of the annual inspections and be responsible for continued compliance.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: June 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include provisions for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 05/10/2018, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator and the Director of Maintenance stated in an interview conducted on 04/10/2018 at 9:15 am, that the Emergency Plan does not currently have provisions for care at alternate site. It will be revised to include provisions for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedJune 6, 2018

The Facility respectfully states that all deficiencies identified during annual re-certification survey could have potentially affected residents. However, No Harm was identified.
The facility Emergency Plan will be revised to include provisions for care at alternative site and also under an 1135 waiver. This deficient practice will be corrected by revising the appropriate sections of the Emergency Plan and developing Policies and Procedures on how we will provide care at an alternate site as well as how to communicate to family, visitors and community about the alternative site.
The facility will identify and sign an agreement with three transportation providers that will have the capability of transporting wheelchairs, stretchers, blankets, linen, electronic beds and other emergency lifesaving equipment?s to an alternative site during evacuation.
In advance of the need for evacuation: Transportation providers shall be trained on the needs of the chronic, cognitively impaired, and frail population, as well as knowledgeable of methods to minimize transfer trauma. Also, methods of communication, including alternate methods, between the facility and the transportation provider will be documented.
Additionally, the facility will provide transportation providers information regarding facility relocation sites and the notification process.
For the protection of residents; their proper nutrition and hydration; adequate staffing before, during, and after an event; and maintenance of essential communications with both families? government officials including the transportation of life safety equipment?s and beds;
The Facility will implement a three-deep philosophy, entering into contracts with multiple vendors for the provision of food, water, emergency power, transportation, and emergency destinations in the event conditions warrant swift relocation.
The Administrator and Director of Maintenance will be responsible for revising the facility Emergency Plan and developing Policies and Procedures to include provisions for care at alternative site. The updates and revision to the Emergency plan will be communicated to the Quality Assurance and Performance Improvement Committee for review.
Director of Maintenance or designee will be responsible for educating staff on the Emergency Preparedness plan.
The Administrator will be responsible for continued compliance.

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 17, 2018
Corrected date: June 30, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed and maintained in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition 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. Specifically, the top of storage was within 18 inches of the automatic sprinkler system deflectors. This is evidenced as follows. Observations of the sprinkler system 05/15/2018 at 1:30 pm, revealed storage was within eighteen (18) inches of the bottom of sprinkler deflectors in the Laundry storage room, diaper storage room, and Two-East Unit medical supply room. The Director of Maintenance stated in an interview on 05/15/2018 at 2:45 pm, that Storage should not have been within 18-inches of sprinkler heads. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.7.5; 2010 NFPA 13: 8.6.4.1.1.1; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 9.7.5; 1999 NFPA 13: 5-6.4.1.1

Plan of Correction: ApprovedJune 11, 2018

An 18-inch perimeter line (reflector line) has been drawn on the walls in the Laundry storage room, Diaper storage room, and Two-East Unit medical supply room. The perimeter line is to ensure that staff are not storing within 18-inches of sprinkler deflectors.
All current and new employees including managers will be educated about this storage requirement and to keep storage areas within 18-inches of sprinkler heads.
The Director of Housekeeping will perform daily checks X (2 weeks), weekly X (3 months) and monthly X 6 months) to ensure staff are not storing within 18-inches of sprinkler deflectors.
The Director of Housekeeping will be responsible for continued compliance.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: June 30, 2018

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Section 5.3.3.1 requires that alarming devices servicing sprinkler systems shall be tested quarterly. Specifically, sprinkler heads were found with a coating of dust, and alarming devices were not tested quarterly. This is evidenced as follows. Observations of the sprinkler system on 05/14/2018 at 1:30 pm, revealed sprinkler heads had a coating of dust in the following areas: walk-in refrigerator, 1st floor mechanical room, Laundry (4 sprinkler heads), Men's Room storage room, Unit One medication room and soiled linen room, One-South corridor by the exit, Staff Coordinator Office, Green Room, and Two-North Unit medical records room. The sprinkler system inspection records were reviewed on 05/15/2018. The records showed that the flow alarm devices were not tested during the second quarter of (YEAR). The Director of Maintenance stated in interviews conducted on 05/14/2018 at 2:45 pm, and again on 05/15/2018 at 9:30 am, that the sprinkler heads should have been dust-free and that due to a postponement with the testing company, the sprinkler flow alarm was not tested during the second quarter of (YEAR). 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1, 5.3.3.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-3.3

Plan of Correction: ApprovedJune 6, 2018

The automatic sprinkler and standpipe systems will be inspected, tested , and maintained in accordance with NFPA 25 and Records of system design, maintenance, inspection and testing will be maintained in a secure location and readily available including the:
a) Date sprinkler system last checked
b) Who provided system test
c) Water system supply source
All sprinkler head locations in the facility will be identified and documented. A schedule will be developed for continued inspection of the sprinkler heads to ensure that it is free of foreign materials, such as dust. Also, all alarming devices servicing sprinkler systems will be tested quarterly by(NAME)Court Company (Sprinkler Head Servicer). In this respect, the facility has developed an annual schedule and signed an agreement with(NAME)Court to perform quarterly testing of our automatic sprinkler system and provide records to be filed accordingly. The Schedule and Agreement will be approved by the Administrator and renewed annually.
In the meantime, the sprinkler heads in the following areas: walk-in refrigerator, 1st floor mechanical room, Laundry (4 sprinkler heads), Men's Room storage room, Unit One medication room and soiled linen room, One-South corridor by the exit, Staff Coordinator Office, Green Room, and Two-North Unit medical records room have all been cleaned and are free of dust.
The Director of Maintenance will perform audits monthly of sprinkler systems in the facility and bring to the attention of the Administrator any issues identified.
The responsible person for continued compliance is the Director of Maintenance or designee and will be verified by Administrator upon completion.

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 17, 2018
Corrected date: September 13, 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 section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Section 8.5.6 requires that penetrations and miscellaneous openings in smoke barrier walls be sealed with materials capable of maintaining the smoke rating of the smoke barrier wall. Specifically, metal electrical boxes in 1 of 1 smoke barriers observed were not fire-protected as required, and penetrations were not sealed. This is evidenced as follows. The One-North Unit smoke barrier wall (wall) was inspected on 05/15/2018 at 1:30 pm. This wall includes resident room 175, 177, 216, and 218. Four 24-inch by 18-inch metal electrical boxes housing disconnected heating units were not fire separated with any listed materials. Twelve unsealed 2-inch holes for sink piping and twelve unsealed -inch bore holes were found. The Director of Maintenance stated in an interview conducted on 05/15/2018 at 2:10 pm, that he will seal the penetrations and remove the wall heaters and install gypsum board. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedJune 6, 2018

The facility will maintain smoke barriers in accordance with NFPA 101 Life Safety Code 2012 and penetrations and miscellaneous openings in smoke barrier walls will be sealed with
materials capable of maintaining the smoke rating of the smoke barrier wall.
Specifically, the Four 24-inch by 18-inch metal electrical boxes housing disconnected heating units in the smoke barrier wall on One-North Unit (resident room 175, 177, 216, and 218) have all been removed. The wiring in these locations were also removed. Breakers will be removed for the wiring in the unit and will install gypsum boards. Meanwhile smoke and fire rooms will be separated and sealed with a 2-hour fire sealant.
The Twelve unsealed 2-inch holes for sink piping and twelve unsealed -inch bore holes that were identified will be corrected.
The Director of Maintenance will conduct a facility-wide room inspection to verify if other smoke barriers are in accordance with NFPA 101 Life Safety Code 2012 and penetrations and miscellaneous openings in smoke barrier walls are sealed. All deficient areas will be corrected.
The Director of Maintenance or designee will be responsible for this project. The Administrator will verify work upon completion.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 17, 2018
Corrected date: June 30, 2018

Citation Details

Based on observation, staff interview, and record review during the recertification survey, it was determined that the facility did not maintain the elevator machine room in accordance with adopted regulations. NFPA 70 National Electrical Code 2011 edition Article 408.38 requires that panelboard enclosures be dead front, without live parts exposed. Article 408.4 requires that all circuits in panel boards be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Article 620-71 requires that elevator driving machines, motor-generator sets, motor controllers, and disconnecting means, unless enclosed with doors or removable panels, are to be installed in a room or enclosure set aside for that purpose. Specifically, electrical panelboards had exposed live parts, panelboard circuits were not identified, and the elevator machine room was used for storage and not set aside as an installation for the elevator operating equipment. This is evidenced as follows. The elevator machine room was inspected on 05/14/2018 at 2:10 pm. The elevator electrical motor controller relays were not enclosed with doors or removable panels that are capable of being locked in the closed position. Two 5-gallon plastic containers of hydraulic fluid, two plastic wash basins, a plastic caution cone, and a cloth rag were stored in this room. Observations of electrical panelboard LP20A on 05/14/2018 at 2:30 pm, revealed the 4 circuits were not identified and 2 unused openings were not dead-front exposing live parts. The Director of Maintenance stated in an interview conducted on 05/14/2018 at 2:45 pm, that nothing should have been stored in the elevator machine room, and he will identify all panelboard circuits and enclose all unused openings. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.1.2; 2011 NFPA 70 Article 408.38, Article 408.4, Article 620-71; 10 NYCRR 713-1.1, 711.2 (19); 2000 NFPA 101 9.1.2; 1999 NFPA 70

Plan of Correction: ApprovedJune 19, 2018

The facility will ensure that all electrical wiring and equipment complies with NFPA 70. In this respect, the facility will ensure that panelboard enclosure in the elevator machine room and Physical Therapy room will have circuits identified; directory of each part as to its specific purpose or use; and no exposed live parts. The two (2) Spacers missing on the electrical panelboard (Panelboard LP20A) located in the physical therapy room will be replaced.
Additionally, the elevator machine room will not be used for storage but set aside as an installation for the elevator operating equipment in accordance with NFPA 54. All non-operating equipment stored in this location will be removed and absolutely no storage in this location. The room will always be kept locked.
The Director of Maintenance or designee will audit all electrical panelboards, directories, circuit identification, and exposed live parts in the facility for compliance. Additionally, the Director of Maintenance or designee will inspect the elevator room weekly for continued compliance.

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 17, 2018
Corrected date: September 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, the rated ceiling between the first and second floor residential units was not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations on 05/15/2018 at 1:30 pm, revealed a 12-inch by 6-inch through penetration hole between the first and second floor residential units found in resident room [ROOM NUMBER]. The Director of Maintenance stated in an interview conducted on 05/15/2018 at 2:10 pm, that he was not aware of the hole in the floor-ceiling assembly in room [ROOM NUMBER]. 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 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will maintain vertical openings in accordance with adopted regulation by installing two layers of 2-hour fire wall and sealed it with fire proof sealer. Thus, the interstitial space between the duct and he floor/ceiling assembly will be sealed and no longer create an opening between the first and second floor.
Specifically, the 12-inch by 6-inch through penetration hole between the first and second floor residential units found in resident room [ROOM NUMBER] has been sealed with sealed with a UL-Approved fire-stopping system.
The Director of Maintenance will conduct a facility-wide structural inspection and audit all floor-ceiling assemblies any and all penetrations/holes identified will be sealed with a UL-Approved fire-stopping system.
The Director for Maintenance or Designee will conduct weekly Environmental Rounds and any penetrations/holes identified will be sealed with a UL-Approved fire-stopping system and reported to the Administrator and QA Committee for review.
The Director of Maintenance will be the responsible for continued compliance.