Pine Haven Home
July 25, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.70:ADMINISTRATION

REGULATION: §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not provide operative oversight to ensure that an effective system was in place to communicate malfunction of equipment essential to maintain health, safety and the highest practicable well-being of residents. Staff did not report to the Administrator when electrical beds were in disrepair and when electrical receptacles were dislodged from the metal receptacle wall boxes. This is evidenced as follows. Observations on 07/24/2018 at 11:15 AM, revealed that the electrical receptacle wall outlet behind the bed in resident room S-8 was pulled away and hanging from the resident room wall; the bed was located approximately 5-inches from the wall and the bed wheel castors were locked precluding resident access. The metal bed-bumper attached to the bed was loose and damaged. No nursing or housekeeping staff or residents were present during survey observations. The maintenance department work order logs for the (MONTH) (YEAR) and (MONTH) (YEAR), were reviewed on 07/25/2018. No work order regarding the loose electrical receptacle outlet and damage to the resident bed were available for survey review. The Director of Building Services stated in an interview conducted on 07/24/2018 at 12:15 PM, that his department too often does not receive necessary repair work orders, and a work order for the outlet and bed repair should have been submitted. Review of the work order policy on 07/25/2018 revealed that work orders are to be submitted when repairs to the facility or facility equipment are needed. 483.70

Plan of Correction: ApprovedAugust 17, 2018

I Immediate Corrective Actions
The receptacle in room S8 and the metal bed casters on the bed were immediately repaired.
II Identification of Other
All receptacles and metal bed casters were checked immediately.
III System Changes
To ensure this deficient practice does not reoccur, maintenance staff, nursing staff and housekeeping staff will be inserviced on the work order policy to ensure it is reported when repairs to the facility or facility equipment are needed.
IV Quality Assurance
To ensure the deficient practice does not reoccur, the facility has developed a room audit tool to be completed weekly by the Director of Maintenance or designee. The results of the audits will be compared to the work order requests to ensure the work order policy is being followed. The results of this review will be reported to the QA committee
V Responsible for Compliance.
The Director of Maintenance will be responsible for future compliance.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 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 the development and implementation of comprehensive person-centered care plans (CCPs), that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs for 4 (Resident #'s 20, 66, 71, and #361) of 24 residents reviewed. Specifically, the facility did not ensure that CCPs were developed to address the use of a psychoactive medication to treat Resident #71's [MEDICAL CONDITION], the care of Resident #66's leg brace, Resident #361's constipation and Resident #20's contractures/ROM needs. Additionally, the facility did not ensure that the CCP that addressed Resident #71's [MEDICAL CONDITION] included relevant interventions. This was evidenced by: Resident #71: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was understood, could understand, and had moderately impaired cognition. A physician's orders [REDACTED]. Finding #1: The facility did not ensure that a CCP was developed to address the use of [MEDICATION NAME]. During an interview on 07/25/18 at 09:52 AM Registered Nurse (RN) #3, covering for the Nurse Manager, reported the resident had been on [MEDICATION NAME] for two months and there should be a psychoactive medication care plan to address it. RN #3 did not know why the Nurse Manager she was covering for had not put one in place, but she would make sure it was done today. Finding #2: The CCP dated 6/4/18, titled: Sleep Disturbances - [MEDICAL CONDITION], documented one intervention, discuss with patient the rationale for assistive device at sleep. During an interview on 07/25/18 at 09:52 AM, RN #3 reported the care plan for [MEDICAL CONDITION] does not have any appropriate interventions. The resident does not use any sleep devices, not sure why that is there. There should be things staff can do to help the resident sleep. Resident #66: The resident was admitted to the nursing home on 5/10/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Physician order [REDACTED]. A CCP for Musculoskeletal Disorder: Fracture with the use of a splint/brace, dated 5/11/18, documented to monitor skin for red or open areas. A revision was added on 5/30/18 that the resident was seen by the orthopedic MD and a different brace was suggested before the resident could be weight bearing. The CCP was not personalized for the resident's needs, did not include timeframes for the skin checks, and that the brace could be removed for bathing. An Orthopedic Vendor Patient Note dated 6/13/18, documented that the resident was seen for a fitting and delivery of a left femoral fracture orthosis (a brace that was length of the entire leg with a hinge at the hip and continued up and around the resident's waist). PT staff would oversee the orthotic use with the CNAs applying and removing the brace. During an interview on 07/23/18 at 01:19 PM, Registered Nurse Unit Manager (RNUM) #1 stated that she was responsible for care planning and the resident should have had a person-centered care plan in place. She was not aware that the CCP did not address the brace coming off for care or that the brace could be removed to check the skin. During an interview on 07/25/18 08:35 AM, the Director of Nursing stated that instructions should have been made clearer so staff would know what to do and all staff should have been trained on putting on and removing the brace. Resident #361: The resident was admitted to the nursing home on 7/6/18, with [DIAGNOSES REDACTED]. acute [MEDICAL CONDITION], and unilateral primary osteo arthritis left knee. The resident was assessed as being alert, oriented and that he could understand. During an interview on 07/19/18 at 01:01 PM, the resident stated that he had needed bowel medication and had to continually ask for it. Physician (MD) Orders dated 7/7/18, documented [MEDICATION NAME] (a narcotic pain medication that causes constipation) 5 milligrams (mg)-325 milligrams one tablet every four hours for pain and [MEDICATION NAME] 5-325 mg one tablet every 4 hours as needed for pain; may give two hours after scheduled dose. The resident's medical record did not include a Comprehensive Care Plan for Constipation. During an interview on 07/24/18 at 09:09 AM, Registered Nurse Unit Manager (RNUM) #1 stated that she was responsible for care planning and that the resident should have had a care plan in place for constipation especially since he was on narcotic pain medication. 10NYCRR415.4(b)(1)(i)

Plan of Correction: ApprovedAugust 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F656 ? Development/Implementation of Comprehensive Care Plan
I. Immediate Corrective Actions
Resident #71
Finding #1. The Comprehensive Care Plans (CCPs) for Resident #71 were reviewed by an RN Supervisor. A Psychoactive Medication Use CCP was developed and implemented on 7/25/2018. The RN Unit Manager was provided with 1:1 educational reinforcement regarding the Care Planning process including mandatory development of CCPs for all residents receiving psychoactive medications.
Finding #2. The CCP for Sleep Pattern Disturbances: [MEDICAL CONDITION] was discontinued on 7/25/2018. A new CCP for [MEDICAL CONDITION] was developed o 7/25/2018 by the RN Supervisor; the new CCP includes several appropriate interventions for the prevention, management, and treatment of [REDACTED].
Resident # 66
Resident #66 was assessed by the RN Supervisor and was noted to have no apparent ill-effects from the deficient CCP development. The RN Unit Manager reviewed and revised the CCP and the certified Nursing Assistant (C.N.A.) Care Card to reflect clear timeframes for skin checks and instructions regarding brace removal for bathing on 7/23/2018. The RN Unit Manager has been provided with 1:1 Educational Counseling regarding the development of personalized CCPs that provide clear interventions to meet resident needs.
Physical Therapy (PT) staff have provided education and demonstration of Resident #66?s orthotic use and the PT staff are providing oversight with the Nursing staff applying and removing the resident?s brace.
Resident #361
The RN Unit Manager responsible for the development of resident #361?s CCP completed a person-centered care plan for Constipation for this resident on 7/24/2018. The RN Unit Manager has been provided with 1:1 Educational Counseling regarding the development of personalized CCPs that provide clear interventions to meet resident needs.
Resident #20
Resident #20 was assessed by the Physical Therapist and was noted to have no functional decline in his lower extremities since his last assessment. The RN Assistant Director of Nursing (ADNS) reviewed and revised the Comprehensive Care Plan (CCP) and the certified Nursing Assistant (C.N.A.) Care Card on 7/23/2018. The resident?s passive range of motion(ROM) instructions now have clear instructions regarding number of ROM repetitions and to notify the nurse if the resident complains of pain and/or refuses range of motion exercises. The RN Unit Manager who was initially assigned to develop this resident?s CCP and his C.N.A. Care Card is no longer employed by this facility.
The current LPN Unit Manager has been provided with 1:1 Educational Counseling regarding the development of CCPs and C.N.A. Care Cards that provide clear interventions and timeframes that have been personalized to meet resident needs in accordance with her scope of practice. The RN Supervisor who oversees management of the resident?s care plan has been provided with educational reinforcement regarding monitoring of care plans and comprehensive review of CCP?s upon admission/readmission assessments, and also prior to all quarterly reviews, significant changes in condition and annual assessments.
Physical Therapy (PT) staff are providing education and demonstration of Resident #20?s Range of Motion (ROM) exercises and the PT staff are providing oversight with the Nursing staff providing ROM exercises.
II. Identification of Others
All residents have potential to be affected by deficient Care Planning practice, none required modification
III. System Changes
1. Licensed nursing staff will undergo enhanced education for the development and maintenance of person-centered Comprehensive Care Plans. This education will also be provided to all newly hired licensed nurses during their orientation periods and to all licensed nurses on an annual basis.
The lesson plan will specifically address management of Care Plans for Medications, Diagnoses, ADL?s and for MD orders that require modification of care plans and for the development of clear and specific instructions and timeframes for nursing tasks required to meet resident needs when indicated.
2. The Admission Review Checklist/Audit document has been modified by the addition of a Care Plan Completion worksheet. This new worksheet will be completed upon Admission/Readmission and prior to each Quarterly, Annual, and Significant Change care plan meeting. This worksheet has a list of specific CCPs that are to be activated on all residents, additional CCPs for Medication-related care, and for Diagnosis-related care. All residents are to have an active CCP for Constipation. All residents treated with Psychoactive medications will have a person-centered CCP developed, and all residents with splints, adaptive devices, and residents with Contractures will have a person-centered CCP with specific Range of Motion exercise instructions. In addition, the presence of ?Valid? interventions is to be reviewed and documented on this worksheet.
3. The Policy and Procedure for ?Comprehensive Care Plans? was reviewed and revised by the Director of Nursing, the Medical Director, and the RN Educator/Infection Control Nurse to include the following modifications:
A. Additional CCPs, interventions, and goals are to be completed as resident care needs change.
B. A Certified Nursing Assistant (C.N.A.) Care Card with clear directions and timeframes will be developed upon admission/readmission; it is to be revised as resident care needs change. The C.N.A. Care Card is to be placed inside the resident?s closet door in order to provide guidance to nursing staff regarding resident care needs and any special precautions. Splints, devices, and Range of Motion orders are to be specified with clear instructions on affected residents? C.N.A. Care Cards.
4. The Policy and Procedure for ?Adaptive & Supportive Devices? was reviewed by the Director of Nursing, the Rehabilitation Director and the Medical Director and it was revised to include and enhanced process for the care of residents who require adaptive/supportive devices:
A. Licensed Nurse to obtain MD Treatment Order to check device and surrounding skin for signs of impairment to skin integrity or any changes in skin condition at least one time per shift and nurse signage for skin checks on the Treatment Administration Record (TAR). In addition, transcription of instructions to C.N.A. Care Cards regarding the use of adaptive/supportive devices
B. PT Staff will oversee staff education for and use of Orthotic/Splints/Braces/Casts/Adaptive devices for all affected residents. Tracking of all adaptive/supportive devices will be maintained by the Rehabilitation Department.
C. Care planning for the use of adaptive /supportive devices including potential for skin breakdown related to the use of same.
5. The RN Staff Development Director and designated RN Supervisors facility will conduct training as noted below:
Topic: ?Comprehensive Care Plans? including policy revisions as noted above
Targeted Staff: Licensed nurses

A comprehensive course outline has been prepared and will be used as a guide for the instructors. The Instructors will conduct the initial training to re-educate the licensed nurses on the revised Comprehensive Care Plan policy. Educational reinforcement will be provided regarding the person-centered care planning process with emphasis on the on-going modifications required to maintain care plans that reflect all care required by each individual resident in order to provide for each resident?s individual needs. In addition, educational reinforcement will be provided regarding the use of clear and specific instructions and timeframes when MD orders are required for nurse monitoring of residents. Educational instruction will also be provided for Nurse entering of special C.N.A. instructions and guidelines into the C.N.A. Care Cards and the C.N.A. electronic Accountability Records when C.N.A. documentation is required for individual residents.
Following education, licensed nurses will be required to do repeat demonstration of CCP development a modification according to their scope of practice and for entering clear and specific instructions and timeframes for MD Orders and on required documentation for data entry by the C.N.A.s into the electronic medical record. This process will be completed successfully in order to demonstrate competency in care planning and in the provision of nurse instructions to C.N.A.s.
Competency evaluations for the above tasks will be completed initially for all licensed nurses, to all newly hired nurses during their orientation periods, and to all licensed nurses on an annual basis.
IV. Quality Assurance
An initial QAPI audit has been completed on all current resident medical records for completion of all required Comprehensive Care Plans. The initial audit tool specifically focused on development of care plans for residents receiving psychoactive medications, for the [DIAGNOSES REDACTED]. All negative findings have been addressed as indicated.
Upon Admission/Readmission, Quarterly, upon Significant Change in Condition, and Annually, all resident care plans will be reviewed by the Unit Manager/designee utilizing a Care Plan Completion Worksheet that specifies all Mandatory care plans, resident Diagnosis-related care plans, and resident Medication-related care plans for use a tool to assure that all resident needs have been addressed in the person-centered Comprehensive Care Plan. Completed sheets will be reviewed by the Assistant Director of Nursing Services (ADNS)/designee and audited per the process noted below:
An on-going QAPI audit tool has been developed for the development and maintenance of Comprehensive Care Plans. All current resident care plans will be audited by the RN Supervisors/ RN designees for completion of Mandatory, Diagnosis-specific, and Medication-specific CCPs. Completed audits will be given to the ADNS. Negative findings will be addressed within 48 hours of submission to the ADNS. Educational reinforcement and/or disciplinary actions will be provided when deemed appropriate. All findings will be reported to the Director of Nursing Services (DNS).
Following the initial audits, 20% of resident medical records will be audited on a monthly basis for 6 months, then 20% of resident medical records will be audited quarterly until otherwise directed by the Administrator after review by the QAPI Committee.
An additional mechanism for monitoring and evaluating the effectiveness of the program will be through nurse competency evaluations developed to assure compliance with facility policy and procedures for Comprehensive Care Plans.
V. Responsibility
The Director of Nursing is responsible for monitoring all audits and reporting findings to the Administrator and the Interdisciplinary QAPI Committee at the Post-survey Plan of Corrections QAPI Meeting and at subsequent QAPI Meetings.

FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash dumpster was leaking and not in good repair. This is evidenced as follows. The trash compactor area was inspected on 07/18/2018 at 11:44 AM. The dumpster was leaking an odorous greasy milky liquid, and a rust hole was found in the side of the dumpster The Director of Food and Nutrition, a corporate manager, stated in an interview conducted on 07/18/2018 at 11:44 AM, that he had been aware for a while that the dumpster leaks and has a hole, and when the vendor was called they said that they did not have replacements. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedAugust 17, 2018

I. Immediate Corrective Action
The trash dumpster leaks have been repaired
II. Identification of Other
The remaining recycling dumpster has been inspected for leaks
III. System Change
To ensure this deficient practice does not reoccur, the Maintenance Director has been inserviced on the importance of keeping the dumpsters leak free.
IV. Quality Assurance
To ensure this deficient practice does not reoccur the facility has developed a monthly audit tool to be completed by the Director of Maintenance or designee. The results will be reported to the QA committee.
V. Responsible Future Compliance
The Director of Maintenance will be responsible for future compliance.

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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure it developed a policy and procedure for the medication regimen review (MRR) that included time frames for the different steps in the process. Specifically, the policy provided did not include the steps the pharmacist must take when her or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: The facility provided the policy Drug Regimen Review dated 5/11/18 on 7/23/18. This policy documented under Medication Regimen Review Frequency: Notification of irregularities to the facility is dependent on severity. Some clinically significant medication issues require urgent attention. If there is a potential for serious harm, the consultant pharmacist will notify the facility immediately. The facility will be responsible for reaching the attending physician or Medical Director for necessary interventions. Mode of notification can be via phone, or electronically, fax or email. During interview on 7/23/18 at 10:07 AM, the consulting Pharmacist stated immediate concerns would be addressed directly with nursing or the physician, or email to the DON or the MD directly. There would be follow up that the concern is addressed. During interview on 7/23/18 at 1:18 PM, the Director of Nurses (DON) said the policy was written by the consulting pharmacist. To her immediately means as soon as the pharmacist notices. The DON thought immediately was a time frame. 10NYCRR415,18(c)(1)

Plan of Correction: ApprovedAugust 17, 2018

F756 ? Drug Regimen Review
I. Immediate Corrective Actions
No residents have been identified as being affected by deficient practice
The Policy and Procedure for Drug Regimen Review was reviewed and revised by the Consultant Pharmacist, the Director of Nursing, and the Medical Director. The Instructions for Notification of Irregularities has been revised as follows:
? Notification of irregularities to the facility is dependent on severity. Some clinically significant medication issues require urgent attention. If there is a potential for serious harm, consultant pharmacist will notify the facility within 2 hours by telephone and speaking with the Nursing Supervisor who will be provided with instructions to notify the attending physician/covering provider in order for the MD/covering provider to resolve the issue within 24 hours. The facility will be responsible for reaching the attending physician or medical director if unable to reach the physician/covering provider for necessary interventions. Mode of notification can be made electronically, by fax or email if unable to reach the facility by telephone.
II. Identification of Others
All residents who take medications/supplements/herbals have potential to be affected by deficient practice. None were effected by this practice.
III. System Changes
Drug Regimen Review Policy and Procedure modified as described above.
IV. Quality Assurance
An audit tool will be developed to monitor compliance with the Drug Regimen Review Policy and Procedure. All irregularities with potential for serious harm will be reported to the Director of Nursing Services (DNS) and to the Medical Director via secure e-mail. The DNS will track and monitor for compliance.
V. Responsibility
The Director of Nursing is responsible for completing all audits and reporting findings to the Medical Director Administrator and the Interdisciplinary QAPI Committee at the Post-survey Plan of Corrections QAPI Meeting and at all subsequent QAPI Meetings.

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not provide operative oversight to ensure that an effective system was in place to communicate malfunction of equipment essential to maintain health, safety and the highest practicable well-being of residents. Staff did not report to the Administrator when electrical beds were in disrepair and when electrical receptacles were dislodged from the metal receptacle wall boxes. This is evidenced as follows. Observations on 07/24/2018 at 11:15 AM, revealed that the electrical receptacle wall outlet behind the bed in resident room S-8 was pulled away and hanging from the resident room wall; the bed was located approximately 5-inches from the wall and the bed wheel castors were locked precluding resident access. The metal bed-bumper attached to the bed was loose and damaged. No nursing or housekeeping staff or residents were present during survey observations. The maintenance department work order logs for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed on 07/25/2018. No work order regarding the loose electrical receptacle outlet and damage to the resident bed were available for survey review. The Director of Building Services stated in an interview conducted on 07/24/2018 at 12:15 PM, that his department too often does not receive necessary repair work orders, and a work order for the outlet and bed repair should have been submitted. Review of the work order policy on 07/25/2018, revealed that work orders are to be submitted when repairs to the facility or facility equipment are needed. 483.70

Plan of Correction: ApprovedAugust 17, 2018

I Immediate Corrective Actions

The receptacle in room S8 and the metal bed casters on the bed were immediately repaired.
II Identification of Other
All receptacles and metal bed casters were checked immediately.
III System Change
To ensure this deficient practice does not reoccur, maintenance staff, nursing staff and housekeeping staff will be inserviced on the work order policy to ensure it is reported when repairs to the facility or facility equipment are needed.
IV Quality Assurance
To ensure the deficient practice does not reoccur, the facility has developed a room audits tool which will be completed weekly by the Director of Maintenance or designee. The results of the audits will be compared to the work order requests to ensure the work order policy is being followed. The results of this review will be reported to the QA committee.
V Responsible for Compliance
The Director of Maintenance will be responsible for future compliance.


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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Adequate handwashing facilities are to be provided in food preparation areas; food contact surfaces shall be cleaned after use; and floors are to be kept clean. Specifically, the main kitchen handwashing sink was not accessible and food contact surfaces and floors were not clean. This is evidenced as follows. The main kitchen and unit kitchenettes were inspected on 07/18/2018 at 9:27 AM. The handwashing sink was blocked from access with carts; upon survey observation, the carts were moved away from the sink then returned blocking sink within 5 minutes. The can opener holder, Buffalo chopper, and the main kitchen and unit kitchenette floors were not clean. The Director of Food and Nutrition (corporate manager) and the Food Service Director stated in an interview conducted on 07/18/2018 at 9:27 AM that the handwashing sink would be more convenient for use if located near the cooking line and the areas identified in the kitchen and kitchenettes will be cleaned. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.110, 14-1.143, 14-1.170

Plan of Correction: ApprovedAugust 17, 2018

Pine Haven Home submits that its policies, procedures and systems are in place for food procurement, storage, preparation serving and sanitation maintenance according to the professional standards governing food safety to ensure a safe and clean environment. This Directed Plan of Correction is required by federal and state regulations and is not to be construed as an admission that the cited deficiency is accurate or that at the time of the survey the facility did not have policies, procedures and systems in place to maintain compliance with federal and state requirements. However, to enhance the care furnished to our residents, we have reviewed and augmented existing policies, procedures, protocols and systems, as needed,
Corrective action(s) for area (s) affected:
Main Kitchen
1. The kitchen handwashing sink is accessible and free of obstruction.
2. The can opener holder was replaced on (MONTH) 16, (YEAR).
3. The Buffalo chopper (bowl holder) was thoroughly cleaned on (MONTH) 13, (YEAR) using a steel brushis clean and free from debris.
4. The food contact surfaces are clean.
5. The floor was power washed on (MONTH) 16, (YEAR) and is clean.
Unit Kitchenette Areas
6. The floor(s) was power washed on (MONTH) 16, (YEAR) and is clean.
Identification of residents that could be affected by the deficient practice:
All residents in the nursing home could be affected by this deficient practice.
Systemic Measures to prevent recurrence:
1. Food Service and Environmental Service staff will be educated on the procedures to maintain a clean, obstacle-free environment in the kitchen and unit kitchenette areas.
2. Food Service staff will be educated on the cleaning and maintaining equipment procedures used for food preparation.
3. A weekly environmental audit tool is to be completed by the Director of Food Services, the Registered Dietician and the Environmental Services Supervisor and or their designees to monitor cleanliness of food contact surfaces, equipment, obstructions.
4. The kitchen sink will be accessible and free of obstacles (carts). The floor area two feet in front of the hand washing sink is clearly marked with tape. A printed sign is in place alerting staff to not block the sink. The carts are stored in an area away from the sink.
5. All identified deficiencies will be corrected at the time they are identified and/or a work order will be initiated if more complicated repair is necessary.
Quality Assurance & Improvements with On-going Monitoring:

1. The Director of Food Services, Registered Dietician and Environmental Services will present the assessment of the causative factors of the kitchen and kitchenette survey findings, the specific interventions taken and the plan to monitor the maintenance of the sanitation of such areas at the (MONTH) 31, (YEAR) QAPI Committee meeting.
2. The Nursing Home Administrator or designee will review completed audits with Director of Food Services, Registered Dietician and Environmental Services or designees every two weeks to identify status of environmental findings and determine timeliness of corrective actions.
3. The Director of Food Services or designees will manage a current Project Plan identifying items found on audit, date corrected with initials and items requiring work orders for completion.
4. Items requiring more than 30-day completion will be reported to the Nursing Home Administrator immediately upon notification.
5. Audits will be analyzed and reported to the Quality Assurance Performance Improvement Committee until 100% compliance is obtained or as deemed completed by the Nursing Home Administrator.
Responsible Person: Director of Food Service or Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion (ROM) and/or to prevent further decrease in ROM for one (Resident #20) of three residents reviewed for ROM during the recertification survey. Specifically: the facility did not ensure that ROM was performed as planned; that the performance of ROM was monitored; and that the resident's refusal of ROM was communicated between nursing and therapy. Additionally, the facility did not ensure a Comprehensive Care Plan CCP) specific to contractures/ROM needs was developed. This is evidenced by: Resident #20: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 4/30/18, assessed the resident was understood and understands, and had moderately impaired cognitive ability. It documented the resident did not walk, had limitation in ROM of lower extremity on one side, with mobility devices of wheel chair. The admission MDS of 7/4/16, documented no walking, limitation in ROM one side lower extremity. A Contracture assessment dated [DATE], documented a contracture of the right and left legs. Therapy recommendations documented: refuses bilateral knee splints, staff to perform PROM (Passive Range of Motion) to bilateral (both) lower extremities two times a day. On 7/19/18 at 2:25 PM, the resident was observed in bed. His legs were contracted, right worse than left. The Comprehensive Care Plan (CCP) of 6/30/17 for Alteration in comfort related to [DIAGNOSES REDACTED]. Interventions included: Staff to do PROM bilateral lower extremities twice a day. The resident refuses knee splints. The intervention was dated 5/2/18. There was no CCP specific for Contracture/ROM . The computerized Care Card (used by care givers to provide needed care) was undated. It documented: PROM to bilateral lower extremities with AM and PM care. During interview on 7/23/18 at 11:00 AM, Physical Therapist #9 said the resident has contractures of the legs and was not on therapy at this time. He is at baseline for last year, so therapy is not warranted. Directions to nursing after he finished therapy were to do passive ROM with AM and PM care to both lower extremities. This recommendation was ongoing, we have not changed it. Nursing does the CCP for contractures/ROM During interview on 7/23/18 at 12:11 PM, CNA #10 said today the resident would not let her touch him, yesterday he did. He refuses to get out of bed past couple of months. He does not have splints for legs, just put pillows between legs, right is very contracted, the left is bent inward a little. He came from north wing so don't know if the resident was able to walk when he came in. Do not do any ROM to legs, if touch him he screams. He is very strong minded, in 5 days he may let me care for him 3 days. During interview on 7/23/18 at 3:27 PM, CNA #13 said the resident usually lets her care for him; wash him up, put pillows between his legs, however, sometimes he does not want them. She does not do ROM to his legs, he yells if you touch his legs the wrong way, it hurts him. She said she had been here since (MONTH) and the resident had not gotten out of bed that she knew of. The nurses know the resident does not allow ROM. She had not reported it, but was told he would not allow ROM when she first started. During interview on 7/23/18 at 3:33 PM, Licensed Practical Nurse Manager (LPNM) #7 stated the resident did not have a CCP specific to contractures/ROM, she thought it would be in a pain or activities of daily living CCP. She looked at the Care Card and and said it was there to do ROM. She would expect there to be a CCP to address contractures/ROM. She said she had been there only since December. She stated the resident refuses alot, they could give pain medication before trying ROM, but it was not in a CCP. The CNAs should let the nurse know they were not doing ROM. She was not notified. She said the CNAs were not documenting they were not doing ROM for the resident. When the ROM was put in the CNA kiosk(computerized care card) it was not set up for them to document if doing it/refusing it. LPNM #7 stated the CNAs are still required to let nursing know the resident was refusing ROM. During interview on 7/25/18 at 1:12 PM. the Occupational Therapy Director of Rehabilitation said the resident refuses a lot. He was not aware of a referral from nursing that staff were not able to do ROM due to pain. If he was made aware he would screen the resident. He stated, contractures are irreversible, so try to prevent further decline. He said they do a yearly inservice on how to do ROM for residents. The best thing for the resident is to do the ROM. If staff are not doing it, they need to document it. During interview on 7/25/18 at 1:26 PM, LPN #5 said the CNAs have told her they could not do ROM for the resident. She did not think she told the Nurse Manager, During repeat interview on 7/25/18 at 1:28 PM, LPNM #7 said she thought she was told the aides were not able to do ROM for the resident. She did not know if she notified therapy. If she was made aware the aides were consistently not doing ROM for the resident, she would have talked with him. If she was aware there was a major problem with pain and not allowing ROM she would have told therapy. 10NYCRR415.12(e)(1)

Plan of Correction: ApprovedAugust 17, 2018

F688 ? Range of Motion/ Mobility
I. Immediate Corrective Actions
Resident #20
Resident #20 was assessed by the Physical Therapist and was noted to have no functional decline in his lower extremities since his last assessment. The RN Assistant Director of Nursing (ADNS) reviewed and revised the Comprehensive Care Plan (CCP) and the certified Nursing Assistant (C.N.A.) Care Card on 7/23/2018. The resident?s passive range of motion(ROM) instructions now have clear instructions regarding number of ROM repetitions and to notify the nurse if the resident complains of pain and/or refuses range of motion exercises. The RN Unit Manager who was initially assigned to develop this resident?s CCP and his C.N.A. Care Card is no longer employed by this facility.
The current LPN Unit Manager has been provided with 1:1 Educational Counseling regarding the development of CCPs that provide clear interventions and timeframes that have been personalized to meet resident needs in accordance with her scope of practice. The RN Supervisor who oversees management of the resident?s care plan has been provided with educational reinforcement regarding monitoring of care plans and comprehensive review of CCP?s upon admission/readmission assessments, and also prior to all quarterly reviews, significant changes in condition and annual assessments.
Physical Therapy (PT) staff are providing education and demonstration of Resident #20?s Range of Motion (ROM) exercises and the PT staff are providing oversight with the Nursing staff providing ROM exercises.
Completion Date: 8/17/2018 & on-going
II. Identification of Others
All residents with contractures have potential to be affected by deficient practice, no modifications were needed
III. System Changes
1. All nursing staff will undergo educational training to be provided by the Rehabilitation Department that is specific to the care and monitoring of residents with contractures and prevention of contractures. This education will also be provided to all newly-hired nursing personnel during their orientation periods and annually thereafter.
2. The Policy and Procedure for ?Range of Motion? was reviewed by the Director of Nursing, the Rehabilitation Director and the Medical Director and it was revised to include and enhanced process for the care of residents who require ROM exercises including C.N.A. reporting of pain, changes in ability, and refusal of ROM exercises immediately to the nurse in charge, and documentation of services provided in the electronic medical record.
3. The Physical Therapy staff, RN Staff Development Director and designated RN Supervisors facility will conduct training as noted below:
Topic: ?Range of Motion? including policy revisions as noted above
Targeted Staff: nursing staff

A comprehensive course outline will be prepared and will be used as a guide for the instructors. The Instructors will conduct the initial training to re-educate the nursing staff on the revised policy. In addition, this education will be provided to all newly-hired nursing personnel during their orientation period and annually thereafter.
IV. Quality Assurance
A new QAPI audit tool has been developed for the management of residents with contractures. Initial audits will be completed on all residents who have been identified with contractures. Negative findings will be submitted to the ADNS/RN designee for corrective actions. All audit findings will be reported to the Director of Nursing Services (DNS) and to the Director of Rehabilitation.
Following the initial audits, all medical records for residents with contractures will be audited on monthly basis for 3 months, then quarterly until otherwise directed by the Administrator after review by the QAPI Committee. Negative findings will be submitted to the ADNS/RN designee. All audit findings will be reported to the Director of Nursing Services (DNS) and to the Director of Rehabilitation.

V. Responsibility
The Director of Nursing is responsible for monitoring all audits and reporting findings to the Administrator and the Interdisciplinary QAPI Committee at the Post-survey Plan of Corrections QAPI Meeting and at subsequent QAPI Meetings.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based staff interview and record 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 4-2.3 requires that environmental assessments be updated annually, and Section 4-2.4 requires that by (MONTH) 1, (YEAR), a potable water system Legionella culture sampling and management plan (SMP) be adopted and implemented. Specifically, the facility did not adopt and implement a SMP and did not maintain a current Legionella Environmental Assessment Form (EAF) as required by New York State regulation. This is evidenced by the following. When requested on 07/19/2018, an EAF and SMP were not available for survey review. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 1:30 PM, that he did not know an EAF was required and that the facility has a basic policy for Legionella testing but does not have a comprehensive sampling and management plan. 415.19(a)

Plan of Correction: ApprovedAugust 24, 2018

I Immediate Corrective Action
A comprehensive plan for Legionella growth control measures, culture sampling and management (SMP) has been adopted and implemented. In addition the Legionella Environmental Assessment Form (EAF) has been completed.
II System Change
The Director of Maintenance will be educated on the requirements of the water management plan and the Environmental Assessment Form
III Quality Assurance
Water testing will be completed as outlined in the water management plan. The results of the testing will be reviewed by the QA committee.
IV Responsible for Compliance
The Director of Maintenance will be responsible for future compliance.

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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation, interview and record review during a 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. Specifically, the facility did not develop a Water Management Plan (WMP) in accordance with adopted regulations, and did not ensure that proper hand hygiene occurred while cleaning an isolation room. This is evidenced as follows. Finding #1: When requested on 07/19/2018, a WMP that included a description of the potable water system with a flow chart and written description, and a description of Legionella growth control measures was not available for survey review. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 1:30 PM, that a comprehensive WMP that includes the required elements to control Legionella growth has not been developed. Finding #2: During observation on 07/18/18 at 11:21 AM, a housekeeper was noted in a contact isolation room changing the garbage without gloves. The full garbage bag was removed from the trash can and brought out to the garbage on the housekeeping (HK) cart. The HK then dust mopped the floor, brought the dust mop back out and placed it on the HK cart, took a broom and dustpan from the cart, cleaned up a pile of dirt, and brought the items back out to HK cart. At no time during this process did the HK wash his hands or wear gloves. The HK left the area then returned a couple minutes later, put a liner in the resident's trash can and left the room again without gloves or hand hygiene. 07/18/18 11:36 AM, the HK stated that the resident in that room was on isolation, but there was no special protocol that he should be using while cleaning the room. During an interview on 07/23/18 at 01:36 PM, RNUM #1 stated that the resident in that room was on isolation for Methacillin Resistant Staphylococcus Aureus (MRSA) in a wound. The HK should have worn gloves because they were cleaning things and should have assumed what they were cleaning was contaminated. The HK definitely should have washed hands. During an interview on 07/24/18 at 11:56 AM, the Infection Control Nurse (ICN) stated the HK should wash hands and wear gloves when going in and leaving the isolation room. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f)

Plan of Correction: ApprovedAugust 17, 2018

Finding #1
I Immediate Corrective Action
A comprehensive water management plan that includes a description of the potable water system with a flow chart and a written description, and written description of Legionella growth control measures has been developed and implemented.
II System Change
The Director of Maintenance will be educated on the requirements of the water management plan.
III Quality Assurance
Water testing will be completed as outlined in the water management plan. The results of the testing will be reviewed by the QA committee.
IV Responsible for Compliance
The Director of Maintenance will be responsible for future compliance.
Finding #2
I. Immediate Corrective Actions
No residents were identified as being affected by deficient practice
The Housekeeper responsible for cleaning the isolation room was identified and 1:1 educational counseling was provided regarding infection prevention and control protocols for cleaning isolation rooms.
II. Identification of Others
All residents on isolation precaution have potential to be affected by deficient practice, none were identified.
III. System Changes
A. All employees will undergo educational training to be provided by the RN Staff Development Director/ Infection Preventionist/RN designee that is specific to handwashing/hand hygiene protocols and Infection prevention. This education will also be provided to all newly-hired employees during their orientation periods and annually thereafter.
B. The Policy and Procedure for ?Hand Hygiene? was reviewed by the Infection Preventionist RN, the Director of Nursing and the Medical Director and it was revised to include the hand hygiene responsibility for housekeepers when cleaning isolation rooms.
C. The RN Staff Development Director and designated RN Supervisors facility will conduct training as noted below:
Topic: ?Infection Prevention and Control- Hand Hygiene? including policy revisions as noted above
Targeted Staff: facility staff

A comprehensive course outline will be prepared and will be used as a guide for the instructors. The Instructors will conduct the initial training to re-educate the licensed nurses on the revised policy. In addition, this education will be provided to all newly-hired nurses during their orientation period and annually thereafter.
IV. Quality Assurance
An initial QAPI audit tool is being developed for monitoring of employee hand hygiene practices. Negative findings will be submitted to the Infection Preventionist RN/RN designee for corrective and disciplinary actions. Audits will be completed on a weekly basis for 3 months, then monthly for 3 months, then quarterly until otherwise directed by the Administrator after review by the QAPI Committee.
V. Responsibility
The Infection Preventionist is responsible for monitoring all audit findings and reporting findings to the Director of Nursing. The Director of Nursing is responsible for reporting findings to the Administrator and the Interdisciplinary QAPI Committee at the Post-survey Plan of Corrections QAPI Meeting and at subsequent QAPI Meetings.

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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that all care was provided 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 for one (Resident #66) of one resident reviewed for orthotic devices. Specifically, the facility did not ensure that Resident #66's leg brace was removed and skin checked for breakdown. This is evidenced by: Resident #66: The resident was admitted to the nursing home on 5/10/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Physician order [REDACTED]. A CCP for Musculoskeletal Disorder: Fracture with the use of a splint/brace, dated 5/11/18, documented to monitor skin for red or open areas. A revision was added on 5/30/18, that the resident was seen by the orthopedic MD and a different brace was suggested before she could be weight bearing. The CCP was not personalized for the resident's needs and did not include timeframes for the skin checks or that the brace could be removed for bathing. Treatment Administration Records (TAR) from 5/10/18-7/ 22/18, documented to check brace for proper placement and for skin breakdown; may remove for for bathing, and knee brace (splint) at all times, remove splint daily for care and skin assessment. There were initials in the boxes for 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM, since 5/10/18, indicating that the brace was removed and that skin checks were done. An Orthopedic Vendor Patient Note dated 6/13/18, documented that the resident was seen for a fitting and delivery of a left femoral fracture orthosis (a brace that was length of the entire leg with a hinge at the hip and continued up and around the resident's waist) and that nursing and Physical Therapy (PT) were present for education of proper use and wear. PT staff will oversee the orthotic use with the CNAs applying and removing the brace. During an interview on 07/19/18 at 12:07 PM, the resident stated that she wore the brace all the time and staff did not remove it. During an interview on 07/23/18 at 01:19 PM, Registered Nurse Unit Manager (RNUM) #1 stated that she was responsible for care planning and the resident's care plan should have addressed her particular needs regarding skin checks, brace removal to check the skin . She thought that staff were looking under the brace every shift to check the skin because they were signing that they were. She did not believe the CNAs were trained to remove and replace the brace and would not expect them to do it without training, but could get Physical Therapy to do it. During an interview on 07/23/18 at 11:12 AM, Licensed Practical Nurse (LPN) #2 stated she had never done anything with the resident's brace. The resident got a bath on the night shift and they checked her skin. During an interview on 07/23/18 11:15 AM, CNA #2 stated that when care is provided she undoes the strap around the waist to push her shirt down. The brace stays on at all times. During an interview on 07/23/18 11:20 AM, LPN #1 stated that she would check to see that the brace was on properly, but she did not check the skin under the brace, because the resident got up on night shift and a complete skin check was done then. During an interview on 07/23/18 11:24 AM, LPN #4 stated that she checked the brace placement, but not the skin. The CNA s checked the skin when they removed the brace for bathing, and if they notice an issue they would alert the nurse. During an interview on 07/23/18 at 01:51 PM, the resident's Physical Therapist (PT) stated she did not inservice nurses or CNAs on how to put on and remove the brace. When the prosthetic person came in to deliver the brace, there was a CNA there when the orthotist showed them how to put on and remove the brace. During an interview on 07/24/18 at 12:20 PM, Certified Nursing Assistant (CNA) #5, stated that she gave the resident a bed bath every day but had never removed the brace. It was not supposed to come off; she would loosen the waist and tuck her clothes under the brace so they do not rub on her skin. CNA #5 stated she was never trained to remove the brace. During an interview on 07/25/18 08:35 AM, the Director of Nursing stated that instructions should have been made clearer so staff would know what to do and all staff should have been trained on putting on and removing the brace.

Plan of Correction: ApprovedAugust 17, 2018

F684 ? Quality of Care
I. Immediate Corrective Actions
Resident #66
Resident #66 was assessed by the RN Supervisor and was noted to have no apparent ill-effects from the deficient CCP development. The RN Unit Manager reviewed and revised the CCP and the certified Nursing Assistant (C.N.A.) Care Card to reflect clear timeframes for skin checks and instructions regarding brace removal for bathing on 7/23/2018. The RN Unit Manager has been provided with 1:1 Educational Counseling regarding the development of CCPs that provide clear interventions and timeframes that have been personalized to meet resident needs.
Physical Therapy (PT) staff have provided education and demonstration of Resident #66?s orthotic use and the PT staff are providing oversight with the Nursing staff applying and removing the resident?s brace.
II. Identification of Others
All residents with orthotic devices have potential to be affected by deficient practice, no modifications were needed
III. System Changes
1. Licensed nursing staff will undergo educational training to be provided by the Rehabilitation Department that is specific to the care and monitoring required regarding any orthotic devices in use by any residents in the facility. This education will also be provided to all newly-hired nursing personnel during their orientation periods.
2. The Policy and Procedure for ?Adaptive & Supportive Devices? was reviewed by the Director of Nursing, the Rehabilitation Director and the Medical Director and it was revised to include and enhanced process for the care of residents who require adaptive/supportive devices:
A. Licensed Nurse to obtain MD Treatment Order to check device and surrounding skin for signs of impairment to skin integrity or any changes in skin condition at least one time per shift and nurse signage for skin checks on the Treatment Administration Record (TAR). In addition, transcription of instructions to C.N.A. Care Cards regarding the use of adaptive/supportive devices
B. PT Staff will oversee staff education for and use of Orthotic/Splints/Braces/Casts/Adaptive devices for all affected residents.
C. Care planning for the use of adaptive /supportive devices including potential for skin breakdown related to the use of same.
D. Following education, nursing staff will be required to do repeat demonstration of orthotic device management per resident-specific orders. This process will be completed successfully in order to provide care to affected residents.
3. The Physical Therapy staff, RN Staff Development Director and designated RN Supervisors facility will conduct training as noted below:
Topic: ?Adaptive & Supportive Devices- Skin Check Protocol? including policy revisions as noted above
Targeted Staff: Licensed nurses

A comprehensive course outline will be prepared and will be used as a guide for the instructors. The Instructors will conduct the initial training to re-educate the nursing staff on the revised policy. In addition, this education will be provided to all newly-hired nursing personnel during their orientation period and annually thereafter.
IV. Quality Assurance
A new QAPI audit tool has been developed for the management of adaptive and supportive orthotic devices. Initial audits will be completed on all residents who require the use of adaptive and supportive orthotic devices such as braces and splints. Negative findings will be submitted to the ADNS/RN designee for corrective actions. All audit findings will be reported to the Director of Nursing Services (DNS) and to the Director of Rehabilitation.
Following the initial audits, all medical records for residents with adaptive and supportive orthotic devices will audited on monthly basis for 6 months, then quarterly until otherwise directed by the Administrator after review by the QAPI Committee. Negative findings will be submitted to the ADNS/RN designee. All audit findings will be reported to the Director of Nursing Services (DNS) and to the Director of Rehabilitation.

V. Responsibility
The Director of Nursing is responsible for monitoring all audits and reporting findings to the Administrator and the Interdisciplinary QAPI Committee at the Post-survey Plan of Corrections QAPI Meeting and at subsequent QAPI Meetings.

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure it maintained medical records on each resident that were complete for one (Resident #30) of one residents reviewed for [MEDICAL TREATMENT] during the recertification survey. Specifically: The Treatment Administration Record (TAR) for the resident did not consistently document that an ordered treatment was done. This is evidenced by: Resident #30 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 5/4/18, assessed the resident had no cognitive impairment. Physician orders [REDACTED]. The TAR for (MONTH) documented: [MEDICAL TREATMENT] catheter right chest wall, assess site for bruising/bleeding/symptoms of infections every day 3-11 shift. Start date 5/11/18. It documented this was done 6 times. The TAR for (MONTH) documented: [MEDICAL TREATMENT] catheter right chest wall, assess site for bruising/bleeding/symptoms of infections every day 3-11 shift. Start date 5/11/18. It documented this was done 15 times. The TAR for (MONTH) documented: [MEDICAL TREATMENT] catheter right chest wall, assess site for bruising/bleeding/symptoms of infections every day 3-11 shift. Start date 5/11/18. It documented this was done 3 times between 7/1-7/18/19. During interview on 7/24/18 at 10:02 AM, LPN # 8 looked at the TAR for (MONTH) and said the Registered Nurse (RN) does the signing of that treatment ([MEDICAL TREATMENT] catheter site), it looks like it was not always done. During interview on 7/24/18 at 10:50 AM, Licensed Practical Nurse Manager (LPNM) #7 looked at the (MONTH) TAR and said the treatment was not always documented as being done. She said before 7/19/18 it was the RN who had to sign the TAR. She looked at the (MONTH) TAR and said if it was not signed it was not done. She could not guarantee that it was done or not done. During interview on 7/24/18 at 11:11 AM, the Director of Nurses (DON) looked at the TAR for the catheter site. She said there were a lot of omissions. She stated the order changed (MONTH) 19, (YEAR). The order added every shift and the word observe was put in to replace assess. LPNs can follow the order now. Previously the LPNs thought because the order said assess the RN had to do it. The DON said the evening LPN should have reminded the RN to do it since the RN is not on the medication cart. 10NYCRR415.22(b)

Plan of Correction: ApprovedAugust 17, 2018

F842 ? Resident Records- Identifiable Information
I. Immediate Corrective Actions
Resident #30-
The resident was assessed by an RN on 7/24/2018 and found with no apparent catheter complications.
The RN responsible for checking the resident?s catheter and for signing the Treatment Accountability Record (TAR) was identified and the RN provided a written statement that she has completed the daily assessments, however the RN failed to document the assessments in the TAR. 1:1 educational counseling was provided along with progressive disciplinary action.
II. Identification of Others
All residents requiring treatments have potential to be affected by deficient practice, none were identified
III. System Changes
A. Catheters may be checked by Licensed Practical Nurses, therefore the resident?s MD order had been changed prior to the deficient findings for the LPN to check the catheter every shift and to report any bleeding, swelling, or redness to the RN for assessment. This process has improved compliance and increased clinical observation of the catheter from once daily to 3 times daily.
B. All licensed nurses will undergo educational training to be provided by the RN Staff Development Director/ RN designee that is specific to the recording of treatments provided into the TAR. This education will also be provided to all newly-hired licensed nurses during their orientation periods and annually thereafter.
C. The Policy and Procedure for ?Recording Medication/Treatment Administration? was reviewed by the Director of Nursing and the Medical Director and it was revised to include licensed nurses? responsibility for documentation of services provided in the electronic medical record.
D. The RN Staff Development Director and designated RN Supervisors facility will conduct training as noted below:
Topic: ?Recording Medication/Treatment Administration? including policy revisions as noted above
Targeted Staff: nursing staff

A comprehensive course outline will be prepared and will be used as a guide for the instructors. The Instructors will conduct the initial training to re-educate the licensed nurses on the revised policy. In addition, this education will be provided to all newly-hired nurses during their orientation period and annually thereafter.
IV. Quality Assurance
An initial QAPI audit tool is being developed for monitoring for nurse medication and treatment administration documentation. Initial audits will be completed electronically for each individual licensed nurse. Negative findings will be submitted to the ADNS/RN designee for corrective and disciplinary actions. All audit findings will be reported to the Director of Nursing Services (DNS).
Following the initial audits, a report of administration record charting omissions will be obtained all licensed nurses on a weekly basis for 1 month, then monthly until otherwise directed by the Administrator after review by the QAPI Committee. Negative findings will be submitted to the ADNS/RN designee. All audit findings will be reported to the Director of Nursing Services (DNS). Any other educational reinforcement and/or disciplinary actions will be provided when deemed appropriate.
V. Responsibility
The Director of Nursing is responsible for monitoring all audits and reporting findings to the Administrator and the Interdisciplinary QAPI Committee at the Post-survey Plan of Corrections QAPI Meeting and at subsequent QAPI Meetings.

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation and staff interview during the recertification survey it was determined that the facility was not in compliance with the minimum construction standards for health care facilities. 10 NYCRR section 713-2.22(g)(1) requires that nurse calling systems shall activate a visible signal in the corridor at the resident's door. Specifically, the nurse calling system did not active visible signals at all resident room doors. This is evidenced as follows. The nurse calling system was spot checked on 07/24/2018 at 10:25 AM. When tested , a visual signal (light) did not active at the doors for resident rooms N-24 and N-27. The Director of Building Services stated in an interview conducted on 07/24/2018 at 12:15 PM, that the bulbs were out for rooms N-24 and N-27, and he will have all nurse calling system door light checked. 10 NYCRR 713-2.22(g)(1)

Plan of Correction: ApprovedAugust 17, 2018

I Immediate Corrective action
Visual signals (lights) in N24 and N27 were immediately repaired.
II Identification of Other
All nurse call system visual signals (lights) were check to ensure compliance
III System Changes
To ensure this deficient practice does not reoccur staff will be inserviced on the work order policy to notify Maintenance if the nurse call system visual (lights) are not working.
IV Quality Assurance
To ensure this deficient practice does not reoccur the facility has develop an audit tool. The Maintenance Director or designee will conduct weekly audits of the call bell system. The results of the audits will be reviewed by the QA committee
.
V. Responsible for Compliance
The director of Maintenance will be responsible for future compliance

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the exit discharges to the public way were not hard packed all-weather travel surfaces. On (MONTH) 14, 2005 The Center for Medicare and Medicaid Services/Survey and Certification Group published Notice S&C-05-38 clarifying exit discharge surfacing requirements. S&C-05-38 requires that exit discharges are to have a hard surface pathway to the public way if there is much rain or snow and if patients are expected to exit or be evacuated in wheelchairs or beds. NFPA 101 Life Safety Code 2012 edition section 7.1.10.1 requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, 2 of 10 resident area exit discharges did not have a hard surface pathway to the public way. This is evidenced as follows. The exit discharges around the perimeter of the building were inspected for impediments on 07/23/2018 at 12:25 PM. A 30-foot section of the South Wing Fire Exit discharge and a 50-foot section of the Physical Therapy room exit discharge were composed of earth and grass only and is not passible in all weather conditions. The Director of Building Services stated in an interview conducted on 07/23/2018 at 12:25 PM, that he will install appropriate materials on all exit discharges to make a hard surface. 42 CFR 483.70 (a) (1); 2012 NFPA 101 7.1.10.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedAugust 17, 2018

1. Facility will hire a contractor to install an appropriate hard surface pathway from the South Wing fire exit and the Physical Therapy room.
2.All exit discharges will be checked to ensure they have a hard surface pathway to a public way
3.The Maintenance Director will be inserviced on the importance of hard pathways at all exits
4. The Maintenance Director will audit all exit discharges to ensure the means of egress be maintained free of obstructions or impediments The results of the audit will be reviewed by the QA committee.
5. The Maintenance Director will be responsible for future compliance.

K307 NFPA 101:ELECTRICAL EQUIPMENT - OTHER

REGULATION: Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not inspect electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Sections 6.3.3.2 and 6.3.4.1 requires that receptacles not listed as hospital-grade, at patient bed locations shall be tested at intervals not exceeding 12 months; the testing shall include: the physical integrity shall be confirmed by visual inspection; the continuity of the grounding circuit shall be verified; correct polarity of the hot and neutral connections shall be confirmed; the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Specifically, the facility did not ensure receptacles not listed as hospital-grade, at patient bed locations, were tested as required. This is evidenced as follows. Observations on 07/24/2018 at 10:25 AM, revealed receptacles not listed as hospital-grade were found in all North and West Unit resident rooms by the handwashing sinks; the Personal Care rooms on the North, South, and West Units; and the Physical Therapy Room. The Director of Building Services stated in an interview conducted on 07/24/2018 at 12:15 PM that no receptacles not listed as hospital-grade are being tested . 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.3.3.2, 6.3.4.1

Plan of Correction: ApprovedAugust 17, 2018

1.All non hospital grade receptacles in all North and West Unit resident rooms by the handwashing sinks, the Personal Care rooms on the North, South and West Units and the Physical Therapy room will be tested .
2. The non hospital grade receptacles in patient locations will be tested at least every 12 months.
3.The Maintenance director has been inserviced on the importance of annual electrical outlet testing.
4.To ensure that this identified deficient practice does not reoccur the Facility is instituting a new Preventative Maintenance and Life safety Task Schedule. This program will be reviewed by the QA committee.
5.The Director of Maintenance will be responsible for future compliance.

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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on employee interview and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities maintain PCREE with consideration of the owner's manuals. Specifically, PCREE such as nebulizers and suction machines were not maintained as prescribed in the owner's manuals. This is evidenced as follows. Observations on 07/24/2018 at 10:25 AM, revealed the electric inhalation-treatment nebulizer assigned to the residents in rooms N-5, S-14, and W-8 were not in use and plugged into an electrical outlet. The suction machines found in the North Unit Resident Lounge, South Unit Resident Lounge, West Unit Resident Lounge, and Main Dining Room were not in use, plugged into an electrical outlet, and were not attended by staff. Review of the nebulizer owner's manual dated 07/24/2018, revealed that the unit is to be unplugged after use. Review of the suction machine owner's manual on 07/24/2018, revealed that to reduce the risk of burns, electrocution, fire, or injury to persons, the unit should not be left unattended when plugged in. The Nurse Educator stated in an interview conducted on 07/24/2018 at 12:30 PM, that staff receive no specific training on the safe use of PCREE and she does not think the owner's manuals are consulted for information on the safe use of PCREE. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedAugust 17, 2018

1. The electric inhalation treatment nebulizers in rooms N5, S14 and W8 have been unplugged per the owners manual. The suction machines in the North Unit resident lounge, South Unit Resident Lounge, West Unit resident lounge and Main dining Room have been unplugged per the owners manual.
2.All patient care related electrical equipment owners manuals will be consulted to ensure safe use.
3. The Facility will provide education to appropriate staff on the proper operation, including when not in use, of patient care related electrical equipment.
4.To ensure this identified deficient practice does not reoccur an audit tool has been developed to ensure safe operation of patient care related electrical equipment. Audits will occur on a weekly basis and be conducted by the unit managers. Results of the audits will be reported to the QA committee
5. The Director of Maintenance will be responsible for continued compliance.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 edition section 14.4.2.2 requires that smoke dampers be tested annually with the initiation devices. Section 14.4.5.3 requires the sensitivity of smoke detectors be checked every two years unless permitted otherwise under specific conditions. Specifically, smoke dampers and smoke detector sensitivity have not been checked as required. This is evidenced as follows. The fire alarm testing reports for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed on 07/25/2018. These reports do not document smoke damper inspections or smoke detector sensitivity tests. The Director of Building Services stated in an interview conducted on 07/25/2018 at 1:50 PM, that neither the damper or sensitivity checks were conducted. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.6.1.3; 2010 NFPA 72 14.4.2.2, 14.4.5.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.3, 9.6.1.4; 1999 NFPA 72: 3-9.5.2, 7-1.1.2, 7-2.2, 7-3.2

Plan of Correction: ApprovedAugust 17, 2018

1.The Facility will complete the smoke damper inspection and smoke detector sensitivity test.
2. The facility will ensure that contractors test the smoke dampers and the smoke detectors will be tested per NFPA requirements.
3, The Maintenance Director will be inserviced on the importance of smoke head and damper inspections.
4. The Facility will institute a new Preventative Maintenance and Life Safety Task Schedule to insure future compliance. This program will be reviewed by the QA committee.
5.The Director of Maintenance will be responsible for future compliance.

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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not 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 Staff Development nurse stated in an interview conducted on 07/24/2018 at 12:30 PM, that maintenance staff, registered nurses (RN), licensed practical nurses (LPN), and certified nurse assistants (CNA) routinely handle oxygen cylinders; and staff training on the risks and use of oxygen cylinders is conducted during orientation only and not periodically. Documentation of staff oxygen cylinder safe handling and risk training was requested on 07/25/2018. This review revealed that no maintenance staff, RNs, or LPNs received the training. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedAugust 17, 2018

1. Facility will provide training to the maintenance staff, registered nurses and licensed practical nurses on the safe handling and risk associated with the medical oxygen cylinders.
2. Training will be provided to appropriate staff on a ongoing basis on the usage requirements and the risks associated with the handling of oxygen cylinders. The training will be provided at least annually.
3.The Staff Development Coordinator is responsible for future 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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include sharing emergency preparedness policies and procedures with residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 07/19/2018, revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with all resident family members and resident representatives. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 9:00 AM, that the Emergency Plan will be communicated to all residents' families or their representatives. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedAugust 17, 2018

1. A communication has been developed to share relevant portions of the emergency preparedness plan with residents and responsible parties.
2. The communication, which shares key components of the emergency preparedness plan, has been provided to all current residents and responsible parties. It has been included in the facility admission agreement and welcome packet for all new residents and responsible parties.
3.The communication will be reviewed annually during the evaluation of the emergency preparedness manual.
4. The Administrator will be responsible for continued compliance.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 27, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include the use of volunteers, such as State and Federal health care professional to address surge needs, in an emergency. This is evidenced as follows. A review of the Emergency Plan on 07/19/2018, revealed the policies and procedures did not include the use of medical volunteers to address an emergency, such as an influx of patients or residents. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 9:00 AM, that the facility Emergency Plan will be revised to include the use of medical volunteers. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedAugust 17, 2018

1. The Emergency Preparedness polices and procedures have been updated to reflect the use of medical volunteers and credentialing of said volunteers during an emergency such as an influx of patients.
2. The new policy and procedure reflects that emergency privileges may be granted to a volunteer practitioner when the Emergency Operations Plan has been activated. The procedure includes credentialing of physicians and other licensed staff during a disaster.
3. Staff will be provided education on the policy and procedure of credentialing medical volunteers during an emergency as part of their annual emergency preparedness training.
4. The policy will be reviewed annually as part of the Facility's annual evaluation of the emergency preparedness manual
5. The Administrator will be responsible for future compliance.

PROCEDURES FOR TRACKING OF STAFF AND PATIENTS

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:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 25, 2018
Corrected date: September 27, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include a system for tracking the location staff that are part of an emergency. This is evidenced as follows. A review of the Emergency Plan on 07/19/2018, revealed the policies and procedures did not include a procedure for tracking staff involved in an emergency. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 9:00 AM, that the Emergency Plan will be revisited and revised to include a procedure for tracking staff involved in an emergency. 42 CFR: 483.73(b)(2)

Plan of Correction: ApprovedAugust 17, 2018

1. The Emergency Preparedness policies and procedures have been updated to include a procedure for tracking staff involved in an emergency.
2. The new procedures provides for staff to be tracked both during and after an emergency. The staff tracking form will be utilized.
3. Staff will be provided education on the procedure for tracking staff involved in an emergency as part of their annual emergency preparedness training.
4. The policy will be reviewed annually as part of the Facility's annual evaluation of the emergency preparedness manual
5. The Administrator will 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: July 25, 2018
Corrected date: October 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include provisions for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 07/19/2018, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 9:00 AM, that the Emergency Plan does not currently have, but will be revised to include provisions for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedAugust 17, 2018

1.The emergency preparedness policy and procedure has been updated to reflect provisions of care at an alternative site identified by emergency management officials.
2 The new policy and procedure reflects the role of the Facility if assistance is needed at a non healthcare facility.
3.Staff will be provided education on the new policy and procedure of care at an alternative site as part of their annual Emergency Preparedness training.
4. The policy will be reviewed annually as part of the Facility's annual evaluation of the emergency preparedness manual.
5. The Administrator will be responsible for future 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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on staff interview and review of inspection records during the recertification survey, the automatic sprinkler system was not tested and maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 14.2.1 requires that an internal inspection of piping and branch line conditions shall be conducted every 5 years. Specifically, an internal inspection of sprinkler piping was not conducted within the past 5 years. This is evidenced as follows. The sprinkler system inspection records were reviewed on 07/25/2018. The 04/09/2014 report states that the 5-year obstruction inspection is due; no subsequent reports document that the inspection was conducted. The Director of Building Services stated in an interview conducted on 07/25/2018 at 12:10 PM, that he will contact the vendor and have the obstruction inspection conducted as required. 2012 NFPA 101 9.7.5; 2011 NFPA 25 14.2; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6; 1998 NFPA 25 10-2.2

Plan of Correction: ApprovedAugust 17, 2018

1. The Facility will complete the sprinkler system obstruction inspection.
2. The internal inspection of piping and branch line conditions will be conducted every five years.
3. The Maintenance Director will be inserviced on the importance of 5 year internal sprinkler pipe inspection.
4. The Facility will initiate a new Preventative Maintenance and Life safety Task schedule to insure future compliance. The program will be reviewed by the QA committee.
5.The Director of Maintenance will be responsible for future compliance.

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: July 25, 2018
Corrected date: September 7, 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 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Specifically, in 1 of 1 smoke barriers observed, metal boxes were not fire protected, the wall was not continuous, and the fire-resistance rating was not maintained. This is evidenced as follows. The West Unit smoke barrier wall (wall) was inspected on 07/23/2018 at 10:50 AM. In the Activities Room, a 6-inch by 4-inch unsealed hole for utility piping and a 24.5 square-inch unprotected metal electrical box were found. The Director of Building Services stated in an interview conducted on 07/23/2018 at 12:20 PM, that he will repair and seal the areas found. 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: ApprovedAugust 20, 2018

1.The West Wing smoke barrier wall in the Activities room will be repaired and sealed with UL approved Hilti fire stop penetration W-L-1289
2.An audit of all smoke barrier walls to insure penetrations and electrical boxes 16 square inches or larger will be sealed/fire protected with UL-Approved fire stopping system Any smoke barriers/electrical boxes needing repair will be repaired.
3.The Maintenance Director will be inserviced on the importance of maintain smoke walls penetration free.
4. To ensure that the identified deficient practice doe not reoccur, the Facility has developed an audit tool to monitor all smoke barrier walls. The Maintenance Director will conduct the audits monthly.
Additional audits will be conducted if work is completed that effects the integrity of the smoke barrier walls. The results of the audits will be reported to the QA committee.

5. The Director of Maintenance will be responsible for future compliance.

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: July 25, 2018
Corrected date: September 7, 2018

Citation Details

Based on observation and staff interview during the recertification, the facility did not maintain electrical wiring and equipment in accordance with the adopted regulations. NFPA 70 National Electrical Code 2011 Edition Article 210.8 requires that Ground Fault Circuit Interrupter protection (GFCI) be provided on electrical outlets within six-feet of a sink rim or water source. 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 be included in a circuit directory. Specifically, electrical outlet GFCI protection was not provided near water sources, panelboards were not dead front, and panelboard directories were not legible. This is evidenced as follows. Observations 07/24/2018 at 10:25 AM, revealed that the electrical outlets within 6-feet of sinks in the South Unit resident room sinks, South Unit shower suite, resident rooms W-5 and W-15, and the Personal Care room beauty shop did not have GFCI protection. Electrical panelboard PP-2 had an unused opening, and panelboards PP-2 and LP-2 did not have legible directories. The Director of Building Services stated in an interview conducted on 07/24/2018 at 12:15 AM, that as per survey observations, the facility will be audited to install GFCI outlets near water sources, and electrical panelboards will be checked for unused openings and legible directories. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.2; 2011 NFPA 70 Article 210.8; 408.38, Article 408.4; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 70 Article 210.8

Plan of Correction: ApprovedAugust 20, 2018

1.All outlets within six feet of sinks on the South Unit, South Unit shower suite, resident rooms W5 and W 15 and the Personal care room beauty shop will be equipped with GFCI protection.
Electrical panelboard PP2 opening has been filled. Panelboards PP2, LP2 directories have been replaced so they are legible.
2. An audit will be completed of all electrical outlets within six feet of a sink rim or water source outlets for GFCI protection. GFCI protection will be provided if necessary. An audit of all electrical panelboards to ensure openings are protected and directories are legible. Corrections will be made if needed.
3.The Maintenance Director will be inserviced on the importance of GFCI within 6'of water source, unused openings in panel board and legible directories.
4.To ensure that this identified deficient practice does not reoccur an audit to ensure GFCI protection will be completed of all electrical outlets within six feet of sink rim or water source and annually thereafter. The Maintenance Director or designee will be responsible to complete the audit. The results of the audit will be reported to the QA committee.
5. The Director of Maintenance will be responsible for future 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: July 25, 2018
Corrected date: October 1, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition Section 8.3.5.6.3 restricts the installation of metal electrical boxes in fire-rated assemblies when the required fire resistance is reduced. Sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls, including rated ceiling assemblies, shall be fire-sealed. Specifically, in 1 of 1 stairwells observed, metal electrical boxes were not fire protected as required, and rated ceiling assemblies were not continuous. This is evidenced as follows. The West Unit stairwell and the South Unit basement were inspected on 07/23/2018 at 11:30 AM and again at 12:15 PM. Twenty unsealed holes and penetrations for utility piping were found in the rated ceiling, and a 17 square-inch unprotected metal electrical box was found in the West Unit Stairwell. The Director of Building Services stated in an interview conducted on 07/23/2018 at 12:20 PM, that he will seal the holes found in the ceilings and have the electrical box fire-protected. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.3.5.6.3, 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: ApprovedAugust 20, 2018

1.The electrical box in the West Unit stairwell will be fire protected. The twenty unsealed holes and penetrations will be sealed using UL approved Hilti fire stop penetration W-L-1289
2.An audit will be completed for both basement ceilings and all stairwells for unsealed penetrations. Any corrections will be completed.
3. The Maintenance Director will be inserviced on the importance of penetrations being sealed
4.To ensure that the this identified deficient practice does not reoccur, the Facility has developed an audit tool to monitor all penetrations and miscellaneous openings in vertical walls are fire sealed and that metal electrical boxes are fire protected. Audits will occur monthly then every three months thereafter.
Additional audits will occur if work is conducted that may have resulted in the integrity of the wall being compromised. The results of the audit will be presented to the QA committee.
5. The Director of Maintenance will be responsible for future compliance.