Elderwood at Grand Island
July 26, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/17, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain good grooming and personal hygiene. One (Resident #33) of four residents observed for ADL's had dark, crusted material under the fingernails over four days of observations. The finding is: 1. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/13/17 revealed the resident has severe cognitive impairment and sometimes understands. Further review of the MDS revealed there was no documentation of behavioral symptoms and no rejection of care. The MDS documented that the resident requires the extensive assistance of one person for personal hygiene, dressing and eating and is totally dependent on one person for bathing. Observation on 7/21/17 at 1:52 PM revealed Resident #33 had dark, crusted substance under the fingernails on both hands. The fingernails were at least 1/8 inch over the tips of each finger. Observation of morning care on 7/24/17 at 7:49 AM, CNA #2 and CNA #3 washed and dried the resident's upper body and dressed the resident in a top. The resident's hands were not washed during morning care. The resident's nails remained soiled with a dark crusted substance under the fingernails on both hands with the length of the fingernails remaining at least 1/8 inch over the tips of each finger. Observation on 7/25/17 at 10:40 AM, Resident #33 fingernails remained long and dirty. Review of the Comprehensive Care Plan with a revised date of 7/3/17 revealed the resident has a deficit in ADL function and is totally dependent on one staff for bathing and requires extensive assistance of one person for personal hygiene. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed instructions for Skin examination report to RN (Registered Nurse) and document in Medical Record if new skin condition is identified, every day shift every Thursday. Review of the undated CNA (Certified Nurse Aide) Kardex (used by staff to provide care) revealed the resident is totally dependent on one person for physical assistance with bathing and extensive assistance of one person with personal hygiene. Review of the undated Second Floor Resident Shower Schedule revealed Resident #33 is scheduled for a shower on Sunday evening and Thursday during the day. During an interview on 7/25/17 at approximately 9:30 AM, Licensed Practical Nurse (LPN #5) stated that the CNA's are responsible for the resident's nail care. During an interview with the Registered Nurse (RN #1) Unit Manager (UM) on 7/25/17 at 10:51 AM, the UM stated the nurse would check on any resident skin concerns that would need to be tracked. The nurse would sign off for skin checks on the TAR. The UM continued to state that the CNA is responsible to check and care for the resident's nails on shower days. During further interview with the UM (RN #1) on 7/25/17 at 2:00 PM, the UM stated she had asked the aides to take care the resident's nails last week but no one told me she refused. I will get someone to take care of her nails right away. 415.12(a)(3)

Plan of Correction: ApprovedAugust 31, 2017

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident # 33 fingernails were trimmed and cleaned on 7/25/17.
2. All resident fingernails were checked to ensure that they are clean and trimmed to resident preference. This will be completed by 7/26/17.
3. Aides, LPN's and Supervisors are to be educated on cleaning and trimming resident fingernails on shower days.
4. Unit Manager or designee will audit 10 residents per unit weekly to ensure fingernails are cleaned and trimmed to resident preference. This will be done for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/17, the facility did not ensure housekeeping and maintenance services necessary to maintain sanitary, orderly, and comfortable resident care equipment had issues with a soiled wheelchair. Specifically, one (Resident #33) of 35 residents observed for sanitary resident care equipment was using a wheelchair with dried sticky substances and crusted material on the wheelchair frame, arm rest and seat over several days of observations. The findings are: 1. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/13/17 revealed the resident has severe cognitive impairment and sometimes understands. The MDS documented that the resident requires the extensive assistance of two persons for transfers and locomotion on and off the nursing unit. The resident's mobility device is a wheelchair. Observation of the resident on 7/21/17 at 1:52 PM revealed the resident was sitting in a tilt-in-space wheelchair (specialty wheelchair for positioning) with a light brown sticky substance on the right curved chair support and on the wheelchair frame connecting the right leg rest. Observation of the resident's wheelchair sitting outside the resident's room on 7/24/17 at 6:46 AM revealed soiled crusting on seat frame of the wheelchair. The dycem (non-slip, self-adhesive mat) on the wheelchair seat was embedded with crumb size crusted material. The wheelchair arm rests were discolored and the left arm rest had a dry, crusted substance build up. Observation of morning care on 7/24/17 at 7:49 AM, the Certified Nurse Aides (CNA #2, 3) completed morning care and transferred the resident into the wheelchair using a mechanical lift. The wheelchair condition was unchanged from the earlier observation on that morning. Observation of the resident sitting in her wheelchair on 7/25/17 at 10:40 AM revealed the resident's wheelchair continued to have crusted material on the wheelchair frame and the arm rest remain soiled. During an interview with the Registered Nurse (RN #1) Unit Manager (UM) on 7/25/17 at 10:53 AM, the UM stated that the resident's wheelchairs are cleaned by housekeeping staff on Wednesday evening. The UM further stated that housekeeping schedules the wheelchair cleanings. During interview with the Director of Housekeeping on 7/25/17 at 11:00 AM, the Director of Housekeeping stated that wheelchairs are cleaned by housekeeping staff on the second shift and the facility will alternate cleaning wheelchairs on the two floors each week. The Director of Housekeeping stated that there was no documentation of when wheelchairs were cleaned. During further interview with the UM (RN #1) on 7/25/17 at 2:00 PM, the UM stated that she did not think the wheelchair cleaning machine cleaned the chairs well enough and she will be asking the aides on the night shift to scrub the resident's wheel chair. The UM further stated that therapy will be asked to replace the wheelchair arm rests because the plastic is breaking down and will not get cleaner. During further interview with the Director of Housekeeping and the Administrator on 7/26/17 at approximately 10:00 AM, the Director of Housekeeping stated that he rechecked the wheelchair cleaning schedule. The Director of Housekeeping clarified that each resident's wheelchair is cleaned by housekeeping every four weeks. The Director of Housekeeping further stated that previously there was also a schedule for the night shift CNA's to wipe down five resident wheelchairs on each unit each night. That schedule is not currently in place but will be restarted. Review of facility policy, Cleaning/ Disinfection of Non-Critical Care Items, printed 7/26/17 revealed the following: - Non-critical care items will be disinfected on a routine basis in an effort to diminish/ prevent cross-contamination of organisms that may be present. - The non-critical care items include but are not limited to, items that come in contact with intact skin surfaces of the residents such as: Adaptive equipment/ wheelchairs: - The facility will have a routine schedule in place for cleaning/ disinfection of non-critical care equipment. 415.5(h)(2)

Plan of Correction: ApprovedAugust 24, 2017

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. On 7/25/17, Resident #33 wheelchair was cleaned and worn armrest was replaced.
2. All residents with wheelchairs had their wheelchairs inspected to and cleaned where appropriate. This was completed by 8/4/17.
3. Aides, LPN's and Supervisors are to be educated on weekly wheelchair cleaning schedule and how to clean wheelchairs.
4. Environmental Services Director will conduct weekly audits of 10 resident wheelchairs to ensure that all wheel chairs are cleaned, that the wheelchair cleaning procedure and the wheel chair cleaning schedule is being completed properly. Findings will be reviewed weekly for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee every two months in which process will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Environmental Services Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: (g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY 094) during the Standard survey completed on 7/26/17 the facility did not inform the resident's legal representative or interested family member or immediately consult with the resident's Physician when there is a significant change in the resident's physical, mental or psychological status and a need to alter treatment significantly. One (Resident #126) of one residents reviewed for family and Physician notification had issues. Specifically, nursing staff did not immediately notify the Physician and family of the resident's blood pressure of 209/94 and of the development of swelling of the face and lower extremities. The findings are: 1. Resident #126 was admitted to the facility on [DATE] and discharged to an acute care facility on 3/29/16 with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 3/15/16 revealed the resident has moderate cognitive impairment, usually understands and is usually understood. Review of the Admission Record, printed on 7/26/17 revealed in the section labeled Contact had the name, address and phone numbers of a daughter and two sons. The resident's daughter was listed as the Health Care Proxy and the first emergency contact. Review of the Telephone/ Verbal Order Signature Details from 1/6/15 to 3/29/16 revealed a Physician's Order signed 1/6/15 to obtain a blood pressure every week, one time a day, every Tuesday. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] - 3/1/16 150/90 (normal,120/80) - 3/8/16 132/64 - 3/15/16 122/64 - 3/22/16 132/68 - 3/30/16 209/94 Review of the electronic Progress Notes revealed the following: - On 3/29/16 at 1:05 PM, Licensed Practical Nurse (LPN #5) documented, Lethargic, lt (left) leg [MEDICAL CONDITION] (swelling caused by excess fluid accumulation), lt side of face swelling, vitals 96.6 (temperature, normal, 98.6F), 76 (heart rate, normal 80- 100), 209/94 (blood pressure), accucheck (blood glucose monitor) ac (before meals) b/fast (breakfast) 112 (normal 70 to 100 mg/dL), recheck accucheck at noon 65, supervisor updated. - On 3/29/16 at 6:42 PM, the Physician documented, I came to evaluate (Resident #126) due to concerns expressed via phone about lethargy, incr (increased) LE (lower extremity) [MEDICAL CONDITION] and incr BP (blood pressure). See Nursing Notes. Pt (patient) unable to express any c/o (complaints) - not answering my questions. BP improved to 150's. Pt awake and makes eye contact but not following any commands. PERL (pupils equal reactive to light). Left side of face with mild droop. Left arm is floppy at elbow. Cor (heart) regular. Lungs clear bilateral. Both LE's have [MEDICAL CONDITION] up to knee 3+. Coughs after a sip of water. A/P (Assessment/ Plan) AMS (altered mental status) and left sided weakness, [MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), spoke with daughter (HCP- health care proxy). Discussed conservative vs aggressive Rx (treatment). She would like pt evaluated in ED (emergency department) - will arrange. - On 4/5/16 at 12:20 PM, the Registered Nurse (RN #3) documented, Late entry for 3/29/16. This writer was informed after lunch that there was a change in resident's condition. This writer immediately went to assess resident who was laying in bed at this time. Left lower extremity noted with 4+ [MEDICAL CONDITION], right leg 2+ [MEDICAL CONDITION], temp (temperature) 96.5, b/p (blood pressure) 171/79, spO2 (oxygen saturation) 95% @ (at) RA (room air), slight swelling of left side of face/ neck. Message was sent to MD (Medical Doctor) awaiting response. Review of the undated Facility Investigation revealed the following: - On 3/29/16 at approximately 7:30 AM, the Certified Nurse Aide (CNA #2) informed LPN #5 of swelling in the resident's left leg. - LPN #5 observed the swelling of the left leg and informed to RN Supervisor (RN #2). - The RN Supervisor requested LPN #5 obtained the resident's vital signs and inform the RN Charge (RN #3) or the RN Supervisor (RN #2) of the findings. - At approximately 8:30 AM to 9:00 AM, LPN #5 obtained the vital signs as documented in the Progress Notes and administered the resident's medication. - LPN #5 informed the RN Charge (RN #3) of the resident vital signs and requested an RN assessment. Further review of the undated Facility Investigation reveals: - RN #3 completed an assessment of the resident and left a message for the Physician. The facility investigation does not identify when the RN's assessment was completed or when the Physician was informed of the change in the resident's status. - The Physician returned a call to the facility (time of call not included) and received an update of the resident's status as follows: LPN #1 checked on the resident (whom was in bed) and it was reported that (Resident #126) was noted to have 2+ [MEDICAL CONDITION] to leg and that her face did appear to be slightly puffy and that it had been communicated during report that (resident) was lethargic and had an elevated b/p. The Physician stated he would be in later to evaluate. The facility obtained a statement from the Physician during course of the investigation that revealed the Physician received a secure message from RN #3 in the early afternoon regarding the resident have a high BP (blood pressure) and 4+ LE (lower extremity) [MEDICAL CONDITION]. The Physician statement continued, I called back to the floor and spoke to one of the floor nurses to clarify the details and was told that the [MEDICAL CONDITION] was 2+. They did not notice any facial swelling. Lethargy was mild. I informed them that I would come in later in the evening to evaluate her. Further review of the Physician's statement revealed the Physician saw the resident at approximately 6:00 PM. The Physician noted mild left facial droop and LUE (left upper extremity) weakness. The resident was not answering any questions- this was a change from her baseline. The Physician noted there was [MEDICAL CONDITION] in both LE equally. The Physician documented he was concerned about a possible stroke and contacted the resident's daughter on the phone immediately and explained the situation and options. Interview with LPN #5 on 7/25/17 at 11:26 AM revealed LPN #5 gave report on Resident #126 to the RN Charge (RN #3) early in morning on 3/29/16. LPN #5 stated he was asked to check the resident blood pressure. LPN #5 stated he was concerned about the swelling in the resident's legs and brought it to the attention of RN #3. LPN #5 stated that the resident was gotten out of bed and he remembered feeding the resident lunch in the dining room. The resident was put back to bed after lunch because the resident appeared more tired looking. LPN #5 stated he gave verbal report including the residents vital signs to RN #3 and thought she was following up on the resident concerns. During an interview with the Administrator and Director of Nursing (DON) on 7/25/17 at 12:46 PM, the DON stated she would expect nursing staff to call immediately call the Physician regarding a change in the resident's condition, follow the Physician orders and inform the responsible party. The Administrator stated that RN #3 was no longer employed with the facility. The Administrator further stated that the facility had completed an investigation of the situation. Review of the facility policy entitled Notification of Changes, dated 12/14 printed 7/26/17 revealed the facility will immediately inform the resident; consult with the resident's Physician and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 415.3 (e)(2)(ii)(b)

Plan of Correction: ApprovedAugust 31, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident # 126 was discharged on [DATE] and is unavailable for immediate correction.
2. All residents with Change of Condition in the last 72 hours were identified and reviewed to ensure immediate notification of resident's legal representative or interested family member and physician did occur. This was completed on 8/10/17.
3. RN's and LPN's are to be educated on timely notification to resident's legal representative or interested family member and physician upon change of condition.
4. Unit Manager or designee will audit 10 residents each month per unit to ensure notification of resident's legal representative or interested family member and physician occurs immediately upon change of condition. This will be done for a period of 6 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 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, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during Complaint Investigations (Complaint #NY 094) during the Standard survey completed on 7/26/17, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Two (Residents #66, 126) of 30 residents reviewed for quality of care had issues involving the lack of a Registered Nurse (RN) assessment and on- going monitoring for a resident with an elevated blood pressure and the lack of facility oversight of the resident's pacemaker to ensure proper function. The findings are: 1. Resident #126 was admitted to the facility on [DATE] and discharge to an acute care facility on 3/29/16 with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 3/15/16 revealed the resident had moderate cognitive impairment, usually understands and is usually understood Review of the Telephone/ Verbal Order Signature Details from 1/6/15 to 3/29/16 revealed a Physician order [REDACTED]. The Physician order [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] - 3/1/16 150/90 (normal,120/80) - 3/8/16 132/64 - 3/15/16 122/64 - 3/22/16 132/68 - 3/30/16 209/94 Review of the electronic Progress Notes revealed the following: - On 3/29/16 at 1:05 PM, the Licensed Practical Nurse (LPN #5) documented, Lethargic, lt (left) leg [MEDICAL CONDITION], lt side of face swelling, vitals 96.6 (temperature, normal, 98.6F), 76 (heart rate, normal 80- 100), 209/94 (blood pressure), accucheck (blood glucose monitor) ac (before meals) b/fast (breakfast) 112 (normal 70 to 100 mg/dL), recheck accucheck at noon was 65, supervisor updated. - On 3/29/16 at 6:42 PM, the Physician documented, I came to evaluate (Resident #126) due to concerns express via phone about lethargy, incr (increased) LE (lower extremity) [MEDICAL CONDITION] and incr BP (blood pressure). See nursing notes. Pt (patient) unable to express any c/o (complaints) - not answering my questions. BP improved to 150s. Pt awake and makes eye contact but not following any commands. PERL (pupils equal reactive to light). Left side of face with mild droop. Left arm is floppy at elbow. Cor (heart) regular. Lungs clear bilateral. Both LE's (lower extremities) have [MEDICAL CONDITION] up to knee 3+. Coughs after a sip of water. A/P (Assessment/Plan) AMS (altered mental status) and left sided weakness, [MEDICAL CONDITION]([MEDICAL CONDITION]-stroke), spoke with daughter (HCP- health care proxy). Discussed conservative vs aggressive Rx (treatment). She would like pt evaluated in ED (emergency department) - will arrange. - On 3/29/16 at 6:59 PM, an LPN documented, (Physician) spoke with RP (responsible party and N.O. (new order obtained to send to (acute care facility) for evaluation. - On 3/29/16 at 7:22 PM LPN #1 documented, Alert, slow to respond. Color pale, skin warm and dry to touch. VS 97.8, 72, 18, 155/73, pox (oxygen saturation) 96% on room air. Accucheck at 1700 (5:00 PM) 93, LE 2+ noted. In bed, legs elevated as tolerated. Facial swelling noted, also left sided weakness. (Physician) in to eval (evaluate), spoke with responsible party, daughter. New order received to send to (acute care facility) ER (emergency room ) for eval, ambulance in to transport at this time. - On 4/5/16 at 12:20 PM, the Registered Nurse (RN #3) documented, Late entry for 3/29/16. This writer was informed after lunch that there was a change in resident's condition. This writer immediately went to assess resident who was laying in bed at this time. Left lower extremity noted with 4+ [MEDICAL CONDITION], right leg 2+ [MEDICAL CONDITION], temp (temperature) 96.5, b/p (blood pressure) 171/79, spO2 (oxygen saturation) 95% @ (at) RA (room air), slight swelling of left side of face/neck. Message was sent to MD (medical doctor) awaiting response. Review of the undated Facility Investigation revealed the following: - On 3/29/16 at approximately 7:30 AM, the Certified Nurse Aide (CNA #2) informed the LPN (LPN #5) of swelling in the resident's left leg. - LPN #5 observed the swelling of the left leg and informed to RN Supervisor (RN #2). - The RN Supervisor requested LPN #5 obtained the resident's vital signs and inform the RN Charge (RN #3) or the RN Supervisor (RN #2) of the findings. - At approximately 8:30 AM to 9:00 AM, LPN #5 obtained the vital signs as documented in the Progress Notes and administered the resident's medication. - LPN #5 informed the RN Charge (RN #3) of the resident vital signs and requested an RN assessment. Further review of the undated Facility Investigation revealed: - RN #5 completed an assessment of the resident and left a message for the Physician. The facility investigation does not identify when the RN's assessment was completed or when the Physician was informed of the change in the resident's status. - The Physician returned a call to the facility (time of call not included) and received an update of the resident's status as follows: LPN #1 checked on the resident (whom was in bed) and it was reported that (Resident #126) was noted to have 2+ [MEDICAL CONDITION] to leg and that her face did appear to be slightly puffy and that it had been communicated during report that (resident) was lethargic and had an elevated b/p. The Physician stated he would be in later to evaluate. - Resident was then transferred OOB (out of bed) for dinner and brought to the dining room. The resident did not eat dinner. Physician was in to assess the resident at approximately 6:00 PM. - The facility obtained a statement from the Physician during the course of the investigation that revealed the Physician received a secure message from RN #3 in the early afternoon regarding the resident have a high BP (blood pressure) and 4+ LE [MEDICAL CONDITION]. The Physician statement continued, I called back to the floor and spoke to one of the floor nurses to clarify the details and was told that the [MEDICAL CONDITION] was 2+. They did not notice any facial swelling. Lethargy was mild. I informed them that I would come in later in the evening to evaluate her. - Further review of the Physician statement revealed the Physician saw the resident at approximately 6:00 PM. The Physician noted mild left facial droop and LUE (left upper extremity) weakness. The resident was not answering any questions- this was a change from her baseline. The Physician noted there was [MEDICAL CONDITION] in both LE (lower extremities) equally. The Physician documented he was concerned about a possible stroke and contacted the resident's daughter on the phone immediately and explained the situation and options. Request of the facility 24-hour shift report for 3/29/16 revealed the facility was unable to locate a copy of the 24-hour shift report for the nursing unit. There is no documented evidence of a timely assessment by the Registered Nurse of the resident's elevated blood pressure and ongoing assessments of the resident's status, including a neurological assessment, while awaiting a response from the Physician. Interview with LPN #5 on 7/25/17 at 11:26 AM revealed LPN #5 gave report on Resident #126 to the RN Charge (RN #3) early in morning on 3/29/16. LPN #5 stated he was asked to check the resident blood pressure. LPN #5 stated he was concerned about the swelling in the resident's legs and brought it to the attention of RN #3. LPN #5 stated that the resident was gotten out of bed and he remembered feeding the resident lunch in the dining room. The resident was put back to bed after lunch because the resident appeared more tired looking. When asked if the LPN obtained any additional vital signs on the resident on that day, LPN #5 stated he gave verbal report including the resident's vital signs to RN #3 and thought she was following up on the resident concerns. During an interview with the Administrator and Director of Nursing (DON) on 7/25/17 at 12:46 PM, the Administrator stated that RN #3 was no longer employed with the facility and the evening RN Charge Nurse working on the unit when the Physician arrived was no longer working in the facility. The Administrator further stated that the facility had completed an investigation During an interview with LPN #1 on 7/25/17 at 3:04 PM, LPN #1 stated she begins work at 2:00 PM. LPN #1 further stated that she was asked to check on Resident #126 when she first came in on 3/29/16 because the evening charge nurse was on the phone with the Physician. LPN #1 stated, I checked her legs and her face. The doctor was coming in. The resident was in dining room when doctor came in and he asked me to check her vital signs. During an interview with the Physician on 7/26/17 at 1:01 PM, the Physician stated that he would expect staff to reassess a resident blood pressure within a couple of hours if the resident was symptomatic. The Physician further stated that he should be called immediately if there are neurological changes in a resident. 2. Resident #66 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired and is usually understood and usually understands. Review of physician's orders [REDACTED]. Review of both, the electron medical record (eMAR) and paper medical record revealed the resident did not have any advanced directives. Review of the provider progress notes dated 2/12/16 through 5/22/17 revealed no documented plan to monitor the resident pacemaker to ensure proper functioning. During an interview on 7/21/17 at 1:27 PM the Registered Nurse (RN) Regional Educator stated that a pacemaker would be checked per the doctor's protocol, and the only reason why a resident would not have a pacemaker check would be if the resident was on palliative care. During an interview on 7/21/17 at 1:34 PM, the Registered Nurse Unit Manager (RN#2) stated if a resident has a pacemaker it would be documented on the initial assessment. Then we usually contact the resident's cardiologist to see if they check the pacemaker function at their office or if we can conduct the check over the phone. It is usually case by case. The RN further stated that a care plan should be developed to address the pacemaker. Review of a Nursing Admission Evaluation dated 2/11/16 revealed the resident had a permanent pacemaker in her right upper chest. Review of both, the electron medical record (eMAR) and paper medical record revealed there was no documented evidence that the resident had a pacemaker check since admission to the facility to ensure its proper function. During an additional interview on 7/21/17 at approximately 2:06 PM, the RN #2 Unit Manager stated they were unable to find any reports or documentation the resident had a pacemaker check since her admission. RN #2 Unit Manager stated the resident should have had a pacemaker check. The RN further stated that she will contact the family to find out who the resident's cardiologist is and set something up to have the resident's pacemaker checked. During an interview on 7/21/17 at approximately 2:17 PM, the Director of Nursing (DON) stated the resident should have had a pacemaker check completed to ensure proper functioning. During a phone interview on 7/21/17 at approximately 2:24 PM, the Physician stated the need for a pacemaker check would be determined by the resident's care goals and if the resident was not receiving palliative care; the resident should have had a pacemaker check at least every six months. Review of a policy and procedure entitled Pacemaker, Monitoring and Transmission of, dated 8/00 revealed that residents who have permanent pacemakers will be monitored to insure proper functioning of the pacemaker 415.12

Plan of Correction: ApprovedAugust 31, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident # 126, was discharged [DATE] and is not available for immediate correction. Resident #66, had Cardiologist appointment on (MONTH) 31, (YEAR). Cardiologist inspected pacemaker and found that pacemaker is functioning properly and 5 years remain on the battery. Cardiologist provided order for facility to conduct pacemaker monitoring once every 6 months.

2. a)Upon receipt of SOD, all residents with current change in condition in last 48 hours were identified to ensure proper monitoring is in place. This was completed by 8/10/17.
b)All residents with pacemakers were identified and have pacemaker monitoring in place. This was completed by 7/26/17.
3. a)Incident had occurred on 3/29/16. Staff member involved with the resident # 126 incident was educated on 4/06/16. The following education was put in place after the specified incident. LPN's and RN's were educated on ensuring proper monitoring is in place for change of condition with the implementation of the Inter Act Change in Condition Tool. This was completed by 7/1/16.
b)LPN's and RN's will be educated to identify upon admission in the Hospital D/C Summary if the resident has a pacemaker with orders for monitoring. This will be completed by 9/24/17.

4. a)Unit Manager or designee will audit Changes in Condition Monthly to ensure proper monitoring in place. Audits will occur for a period of 6 months.
b)Unit Manager or designee will audit Hospital D/C Summaries monthly for all previous month admissions to ensure orders for pacemaker monitor are in place for residents with pacemakers. Audits will occur for a period of 6 months.
All Results will be reported to the Quality Assurance Committee in which time progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (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 (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 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during Complaint Investigations (Complaint # NY 037) during the Standard survey completed on 7/26/17 it was determined that the facility did not maintain clinical records for each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #128) of two residents' medical records reviewed for accidents lacked complete and accurate documentation that neurological assessments were completed as order by the Physician. The finding is: 1. Resident #128 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 10/14/17 revealed that the resident was mildly cognitively impaired, understood and understands. Review of a Resident Accident/ Incident Report dated 10/27/16 revealed that the resident was found in the doorway on the floor by a staff member at approximately 1:50 PM. The fall was not witnessed. The report documented the physician was notified and that there were new orders. Review of a Nurse's Note dated 10/27/17 at 2:30 PM revealed that new orders were received to continue neuro (neurological) checks (checks that are used to assess brain function and/or injury). Review of a Neurological Evaluation Flow Sheet revealed neurological checks were initiated on 10/27/16 at 3:15 PM and were to be continued until the midnight shift on 10/29/16. Review of the flow sheet revealed that the column for 10/27/16, 10/28/16, and 10/29/16 for the day, afternoon, and night shifts were left blank. Review of a Resident Accident/ Incident report dated 11/18/16 revealed that at approximately 1:45 PM the resident was found on the floor in the bathroom and was bleeding near his left eye from a laceration. The report documented the physician was notified and indicated that there were new orders for neurological checks. Review of a Neurological Evaluation Flow Sheet was initiated on 11/18/16 at 1:45 PM and was to be completed on the day shift on 11/21/16. The column for 11/20/16 day shift and 11/21/16 afternoon shift column, the neurological checks were left blank. During an interview on 7/26/17 at approximately 8:00 AM, Licensed Practical Nurse (LPN #3) revealed that if a resident has an unwitnessed fall they do neurological checks every 15 minutes for the first hour, then every 30 minutes for the next two hours, then at least once a shift. She stated that they are to document the neuro checks on the Neurological Evaluation Flow Sheet. The LPN then stated that this is the only paper document (Neurological Evaluation Flow Sheet) that they use in the facility. Interview on 7/26/17 at approximately 8:30 AM with LPN #4 revealed that they are supposed to use the Neurological Evaluation Flow Sheet to document any unwitnessed fall by a resident. Interview on 7/26/17 at approximately 8:35 AM with the Registered Nurse (RN #2) revealed that the Neurological Evaluation Flow Sheet is still on paper and she expects her staff to follow the directions on the Neurological Evaluation Flow sheet. Interview on 7/26/17 at approximately 9:00 AM with the Director of Nursing (DON) revealed that she expects her staff to complete the Neurological Evaluation Flow Sheet. Review of a facility document entitled Neurological Observation Guidelines dated 8/11 revealed that a neurological observation is completed by an appropriately trained licensed nurse following a head injury, suspected head injury, acute status change ad as needed/recommended by physician. 415.22 (a)(1)(2)

Plan of Correction: ApprovedSeptember 4, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident # 128 was discharged [DATE], therefore is unavailable for immediate correction.
2. Upon receipt of SOD on 8/9/17 all resident falls in last 48 hour period were reviewed to ensure that Neurological Observation was completed for falls that note head injury or suspicion of head injury. This was completed on 8/10/17. Facility determined this was an appropriate time frame to review upon receipt of SOD. This facility routinely reviews nursing documentation daily to ensure that Changes in Condition are identified. Facility reviewed the policy, no changes were made.
3. Physician, LPN's and RN's are to be educated that when a head injury is suspected or identified, Neurological Observation must be initiated and documented.
4. Unit Manager or designee will audit all documented falls monthly. This will be done for a period of 6 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


FF10 483.55(a)(1)(2)(4):ROUTINE/EMERGENCY DENTAL SERVICES IN SNFS

REGULATION: (a) Skilled Nursing Facilities A facility- (a)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; (a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; (a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location;

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/17, the nursing facility did not provide or obtain from an outside resource, routine dental services to meet the needs of each resident. One (Resident #10) of three residents reviewed for dental services was not provided annual dental examinations. The finding are: 1. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 4/25/17 revealed the resident has moderate cognitive impairment, understands, and is understood. Review of oral/dental status section revealed there were no concerns. Review of an Order Summary Report of active orders as of 7/1/17 revealed a physician's orders [REDACTED]. Review of the medical record revealed the responsible party/ resident's wife signed a Dental Consent for Examination and Treatments on 6/20/14, requesting the facility's dental consultant provide dental services for the resident. Review of the medical record revealed there was no evidence that the resident was seen by a dentist or declined to see a dentist since admission to the facility. Review of the Comprehensive Care Plan revealed a focus area of Oral/ Dental, with a revision date of 5/26/17. Interventions included, upper and lower denture and has history of not wearing them. Review of a CNA (Certified Nurse Aide) Kardex (used by staff to provide care), printed 7/26/17, revealed the resident declines wearing his upper and lower dentures and involve my wife in my care decisions. During an interview with the Registered Nurse (RN #1) Unit Manager (UM) on 7/24/17 at 1:35 PM, the UM stated the resident's care and services are paid by the (name of provider) and the resident receives all health care services through the (name of provider). The UM stated the (name of provider) medical center sends the facility a list of the resident's scheduled appointments. After speaking with the Unit Secretary, the UM stated there have been no scheduled dental appointments for the resident. The UM further stated she was not sure of the facility policy for providing dental services to residents receiving (name of provider) health care services. During an interview with the Director of Nursing on 7/24/17 at 1:40 PM, the DON stated that all residents should see a dentist at least annually. The DON further stated that if the (name of provider) provides a list of medical appointments for a resident and no dental appointment has been scheduled then the Unit Manager or designee should contact the (name of provider) regarding the need for a dental visit. Review of the undated facility policy, Dental Care Agreements reveals, While residing at this facility, the resident will be required to have a dental screening and evaluation on admission and annually. Required dental services will be arranged within 30 days of recommendations by a licensed dentist, or as deemed necessary by the attending Physician. All dental services will be documented in the Medical Record of the resident. Reasons for delaying or not providing recommended dental services will be recorded in the resident's Medical Record, including the resident's refusal of care or contraindications for care. 415.17(c)

Plan of Correction: ApprovedSeptember 5, 2017

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident # 10 appointment for dental services was arranged on 7/26/17, resident refused this appointment. On 8/15/17, seen by Attending Physician with normal oralpharnyx, documented in progress notes.
2. All residents with dental consents were reviewed to ensure dental services are in place. Audit confirmed that all residents received of have been scheduled for annual dental exam. This was completed by 7/26/17.
3. RN's, LPN's and Unit Clerks are to be educated that all residents are to be placed on Dental Visit List upon admission and that they are to be seen annually.
4. Unit Manager or designee will audit 10 residents each monthly to ensure that Dental Visits are provided annually unless resident refuses. This will be done for a period of 6 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


Standard Life Safety Code Citations

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

Based on observation and interview conducted during a Life Safety Code survey completed on 7/26/17, stairway exit egress doors equipped with electromagnetic delayed egress locking devices were not properly maintained. Issues included, stairway exit egress doors equipped with electromagnetic delayed egress locks, did not have signage indicating how the doors could be opened in case of an emergency. This affected one (Second Floor) of three resident use floors. The findings are: 1. a.) Observation on the Second Floor on 7/20/17 at approximately 11:00 AM revealed the Stairway B corridor exit door was equipped with an electromagnetic delayed egress lock and the door did not have signage stating the following: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. Interview with the Administrator and the Maintenance Director at the time of the observation revealed the following: - the door was equipped with an electromagnetic delayed egress locking device. - an outside contractor had recently painted the door as part of a remodeling project on the Second Floor. - the outside contractor must have removed the signage on the door to paint it and forgot to replace the signage. - all of the stairway corridor exit doors in the building were equipped with electromagnetic delayed egress locking devices. b.) Observation on the Second Floor on 7/20/17 at approximately 11:05 AM revealed the Stairway A corridor exit door was equipped with an electromagnetic delayed egress locking device and the door did not have signage stating the following: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. Interview with the Maintenance Director at the time of the observation revealed the following: - the door was equipped with an electromagnetic delayed egress locking device. - an outside contractor had recently painted the door as part of a remodeling project on the Second Floor. - the outside contractor must have removed the signage on the door to paint it and forgot to replace the signage. Interview with the Administrator on 7/24/17 at approximately 10:30 AM, revealed the last time the outside contractor had been in the building working on the Second Floor remodeling project was approximately two months ago. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.2.4(2), 7.2.1.6.1, 7.2.1.6.1(4)

Plan of Correction: ApprovedAugust 18, 2017

1. On 7/20/17, signage stating, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS was installed on 2nd Floor Stairway Doors labeled A & B.
2. All exit doors equipped with electromagnetic delayed egress locking device were audited to ensure signage stating, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS is in place. This was completed by 7/20/17.
3. Maintenance staff were educated that all exit doors equipped with electromagnetic delayed egress locking device were audited to ensure signage stating, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.
4. Maintenance Director will monthly audit all exit doors equipped with electromagnetic delayed egress locking device to ensure signage stating, PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS is in place. This will be done for a period of 3 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 7/26/17, electrical equipment was not properly maintained. Issues included in-use power strips that were plugged together with other power strips (daisy chained) and unapproved power strips were being used to supply power to electrical and medical devices. This affected three (Basement, First, and Second Floors) of three resident use floors. The findings are: 1 a.) Observation on the First Floor on 7/20/17 at approximately 12:08 PM revealed two power strips were daisy chained together and supplying power to two telephone chargers in the Nursing Supervisor's office. b.) Observation in the Basement on 7/20/17 at approximately 2:30 PM revealed two power strips were daisy chained together and supplying power to three walkie talkies and four walkie talkie chargers in the laundry folding room. Interview with the Maintenance Director at the time of the observation revealed he was not aware the power strips had been plugged together to supply power to the walkie talkies. c.) Observation on the First Floor on 7/24/17 revealed the following: -12:05 PM a power strip that was not rated to be used in a resident room, was supplying power to a television, a wireless television converter device, a fan, and a telephone charger in Resident room [ROOM NUMBER]. - 12:10 PM a power strip that was not rated to be used in a resident room or with medical devices, was supplying power to a television and three hearing aid chargers in Resident room [ROOM NUMBER]. Interview with the Maintenance Director at the time of this observation revealed he was not aware the power strip was being used to supply power to the hearing aid chargers. - 12:13 PM a power strip that was not rated to be used in a resident room or with medical devices, was supplying power to a bed, a lamp, and a telephone charger in Resident room [ROOM NUMBER]. A second power strip that was not rated to be used in a resident room was supplying power to a fan, headphones, and a television. - 12:23 PM a power strip that was not rated to be used in a resident room, was supplying power to a fan, a television, and a clock radio in Resident room [ROOM NUMBER]. A second power strip that was not rated to be used in a resident room was supplying power to a television and a digital photo album. d.) Observation on the Second Floor on 7/24/17 revealed the following: - 12:43 PM a power strip that was not rated to be used in a resident room, was supplying power to a television, a clock, and an electric razor in Resident room [ROOM NUMBER]. A second power strip that was not rated to be used in a resident room was supplying power to a clock, a television, a fan, and a phone charger in the room. - 12:53 PM two power strips that were not rated to be used in a resident room or with medical equipment, were supplying power to two beds in Resident room [ROOM NUMBER]. A third power strip that was not rated to be used in a resident room was supplying power to a television and a clock radio in the room. Interview with the Maintenance director at the time of the observations revealed he was not aware the power strips were being used to supply power to the beds in the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.2.3.6 Centers for Medicare and Medicaid Services (CMS), Survey and Certification Letter, Ref: S&C: 14-46-LSC 9/26/14

Plan of Correction: ApprovedAugust 18, 2017

1. Power strips currently in use in Nursing Supervisors Office and in Laundry Folding Room, rooms 116, 118, 122, 119, 210 and 216 were removed and replaced with approved for use UL1363A power strips. Hospital grade quad receptacle outlets have been ordered and will be installed in these identified areas. This will eliminate the use of power strips in the rooms identified.
2. All rooms audited to ensure that power strips are not to be, daisy chained together and unapproved power strips are not in service. This was completed on 8/10/17.
3. All facility staff will be educated that that power strips are not to be, daisy chained together and unapproved power strips are not to be in use at the facility.
4. Maintenance Director will monthly audit all rooms to ensure power strips are not to be, daisy chained together and unapproved power strips are not in use. This will be done for a period of 3 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


K307 NFPA 101:ELEVATORS

REGULATION: Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

Based on interview and record review, during a Life Safety Code survey completed on 7/26/17, documentation for the monthly testing of the elevator's Firefighter's Service was not properly maintained. Issues included the facility did not have documentation for the monthly testing of the elevator's Firefighter's Service. This affected two (Elevators 1 and 2) of two elevators located in the building. The findings are: 1. Record review of Firefighter's Service Monthly Test Record logs on 7/21/17 revealed the logs contained no documentation for the monthly testing of the Firefighter's Service for Elevator's #1 and #2 for the months of January, February, March, April, and (MONTH) of (YEAR). Further review of the logs on 2/21/17 revealed they contained no documentation for the monthly testing of the Firefighter's Service for Elevator's #1 and #2 in (YEAR). Interview with the Maintenance Director on 7/24/17 at approximately 9:10 AM revealed he had conducted monthly testing of the Firefighter's Service for Elevator's #1 and #2 in (YEAR) but he was unable to find the (YEAR) Firefighter's Service Monthly Test Record logs. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.5.3, 9.4.2, 9.4.3, 4.5.8, 4.6.7.5

Plan of Correction: ApprovedAugust 18, 2017

1. An audit was conducted on all elevators in the building. Testing of Firefighter Service for all elevators resumed in (MONTH) (YEAR).
2. Maintenance Director scheduled new contractor to conduct monthly testing of Firefighter Service for all elevators in the building. This was completed 8/10/17.
3. Maintenance staff will be educated that monthly testing of Firefighter Service for all elevators in the building must be conducted by contractor or Maintenance Director.
4. Maintenance Director will monthly audit monthly testing of Firefighter Service for all elevators in the building. This will be done for a period of 3 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


K307 NFPA 101:PROTECTION - OTHER

REGULATION: Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/17, manual fire alarm boxes were not properly maintained. Issues included manual fire alarm boxes that were obstructed from immediate use. This affected one (First Floor) of three resident use floors. The findings are: 1 a.) Observations on the First Floor on 7/21/17 at approximately 10:20 AM and on 7/24/17 at approximately 12:28 PM revealed two patient care carts were stored in the corridor obstructing the manual fire alarm box located between the nurse's station and the resident dining room. Observations on the First Floor on 7/21/17 at approximately 12:47 PM and 1:27 PM revealed a medication cart was stored in the corridor obstructing the manual fire alarm box located between the nurse's station and the resident dining room. Interview with the Maintenance Director on 7/21/17 at approximately 1:27 PM revealed facility's staff knew they were not to block or obstruct the manual fire alarm boxes. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3, 19.3.4.2, 19.3.4.2.1, 9.6.2, 9.6.2.7

Plan of Correction: ApprovedAugust 18, 2017

1. 7/21/17 and on 7/24/17 facility equipment was moved so that it did not obstruct manual fire alarm box.
2. All manual fire alarm boxes were audited to ensure that they are not obstructed from immediate use. This was completed on 7/24/17.
3. Facility staff will be educated that manual fire alarm boxes are not to be obstructed from immediate use.
4. Maintenance Director will monthly audit all manual fire alarm boxes to ensure that they are not obstructed from immediate use. This will be done for a period of 3 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.


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 26, 2017
Corrected date: September 24, 2017

Citation Details

Based on observation, interview, and record review, during a Life Safety Code survey completed on 7/26/17, smoke barrier walls were not properly maintained. Issues included smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30 minutes fire resistance rating, and were not designed to resist the passage of smoke, due to opened and unsealed penetrations. This affected two (First and Second Floors) of three resident use floors. The findings are: 1 a.) Observation above the ceiling tiles on the Second Floor, above the corridor smoke barrier doors located between the bathing room and Resident Room #211, on 7/21/17 at approximately 11:23 AM revealed the following penetrations on the bathing room side of the doors: - an approximate one half inch long by one have inch wide, unsealed penetration, above a gray colored electrical line installed through the smoke barrier wall. - an approximate one half inch long by one have inch wide, unsealed penetration above a flexible metal electrical line installed through the smoke barrier wall. b.) Observation above the ceiling tiles on the First Floor, above the corridor smoke barrier doors located between the Chapel and the Nursing Supervisor's office, on 7/21/17 at approximately 11:43 AM revealed two, greater than one quarter inch unsealed penetrations next to two, green colored electrical lines that were installed through the smoke barrier wall. c.) Observation above the ceiling tiles on the First Floor, above the corridor smoke barrier doors located between the Chapel and the Nursing Supervisor's office, on 7/21/17 at approximately 11:45 AM revealed an approximate three inch wide, circular, unsealed penetration on the Nursing Supervisor's office side of the wall. Further observation at this time revealed an approximate three inch wide circular piece of the block smoke barrier wall and pieces of mineral wool were lying on top of the ceiling tiles. An interview with the Maintenance Director at the time of this observation revealed an outside contractor had been installing camera wiring in this area of the building last week and they must not have resealed the penetration they made through the smoke barrier wall. d.) Observation above the ceiling tiles on the First Floor, above the corridor smoke barrier doors located between the bathing room and Resident Room #110, on 7/21/17 at approximately 12:31 PM revealed and approximate one inch long by one inch wide unsealed penetration above an insulated pipe that was installed through the wall. Further observation at this time revealed an approximate two inch long by two inch wide penetration located to the right side of the insulated pipe was filled with mineral wool that was not sealed with a fire rated material. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedAugust 18, 2017

1. The following penetrations were sealed with Fire Rated Caulk on 7/21/17:2nd floor above corridor smoke barrier doors adjacent to room 211 (2 penetrations), 1st floor above corridor smoke barrier doors adjacent to the Chapel(3 penetrations), and 1st floor above smoke barrier doors adjacent to room 110 (1 penetration).
2. To identify other potential areas affected: Maintenance Director will be responsible for ensuring that the Maintenance Department checks that all smoke barriers are complete from floor to ceiling to ensure one half hour fire resistance rating in accordance with 8.3 by 8/31/17.
3.Systematic changes made to ensure that the deficient practice does no reoccur: Maintenance Department will be educated to ensure that all smoke barrier walls are complete from floor to ceiling.
4.Maintenance Director will monthly audit all smoke barrier walls for a period of 6 months. All results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5.The Director of Maintenance will be the responsible party. This will be completed by 9/24/17.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2017
Corrected date: September 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Life Safety Code survey completed on 7/26/17, smoke barrier doors were not properly maintained. Issues included smoke barrier doors were not designed to resist the passage of smoke. This affected one (Second Floor) of three resident use floors. The findings are: 1. a.) Observation on the Second Floor, on 7/20/17, at approximately 10:42 AM, revealed when the cross corridor smoke barrier doors located near resident room [ROOM NUMBER] were released from their magnetic hold open devices and allowed to fully close, there was an approximate one half inch gap between the doors. Further observation at this time revealed the door located closest to Resident room [ROOM NUMBER] struck (bounced off) its door frame instead of properly closing, after being released from its magnetic hold open device resulting in the one half inch gap between the doors. An interview with the Maintenance Director, at the time of this observation, revealed he had never seen the door bounce off its door frame before. b.) Observation on the Second Floor, on 7/20/17, at approximately 11:08 AM, revealed when the soiled utility room corridor door, located near Resident room [ROOM NUMBER], was allowed to fully close, there was an approximate one-half inch wide gap between the soiled utility room door and its door frame. Review of the facility floor plan at the time of the observation revealed this door was a smoke barrier door, which made up a portion of the smoke barrier wall. Interview with the Maintenance Director at the time of this observation revealed the soiled utility room corridor door located near Resident room [ROOM NUMBER] was a smoke barrier door. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.7.8, 8.5.4, 8.5.4.1

Plan of Correction: ApprovedAugust 18, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Smoke barrier doors adjacent to room [ROOM NUMBER] and soiled utility room door adjacent to room [ROOM NUMBER] did not close and were repaired to ensure they fully close. This was completed on 7/20/17.
2. All smoke barrier doors were inspected to ensure that they close properly to resist passage of smoke. This will be completed by 8/31/17.
3. Maintenance staff will be educated that all smoke barrier doors are to close properly to resist passage of smoke.
4. Maintenance Director will monthly audit smoke barrier doors are to ensure that they close properly to resist passage of smoke. This will be done for a period of 3 months.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 9/24/17.