Greene Meadows Nursing and Rehabilitation Center
November 17, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (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: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure it developed and implemented a comprehensive person-centered care plan for one Resident #4 of one reviewed for continuous ambulatory peritoneal [MEDICAL TREATMENT] (PD) (a tube permanently inserted through the abdomen to allow a fluid called [MEDICATION NAME] to be emptied and replaced every day to cleanse the body of built up toxins). Specifically: the facility did not ensure that that a comprehensive care plan was developed PD. This is evidenced by: Resident #4 The resident was admitted to the nursing home on 10/16/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and that the resident usually understood and was usually understood by others. A Comprehensive Care Plans (CCP) did not include a care plan to address the resident's care and treatment for [REDACTED]. During an interview on 11/13/17 at 4:30 pm, RN #3 stated that it was her responsibility to ensure that a care plan was in place for the resident's PD. She had just become aware that it was not done and had added one. 10NYCRR 415.11(c)(1

Plan of Correction: ApprovedDecember 18, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F279
Corrective Action regarding affected residents:
The facility strives to use the assessment results to develop, review and revise the resident?s comprehensive care plan (CCP).
Resident # 4 Care Plan was updated to include but not limited to parameters for administration, all monitoring orders including B/P, abdominal girth and weight.

Identification of other residents possibly affected and corrective actions taken:
There are no other residents currently in facility receiving PD

Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
All licensed nurses will receive education on facility policy related to the development, review and revision of CCP.
The Registered Nurse will initiate a CCP upon admission/readmission, with significant changes, change in medical condition/acute illness for any area identified to include those residents requiring [MEDICAL TREATMENT].
ADON/Designee will review all PD residents upon admission or addition of PD for resident specific P/D Care Plans.
How the current action will be monitored to ensure the deficient practice does not recur:
Comprehensive Care Plans will be audited for all triggered areas that are identified on admission, readmission, significant change or change in medical condition. Licensed nursing staff will audit weekly for 4 weeks and then monthly for 3 months. The Director of Nursing and/or designee will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee. Audits will continue as needed and determined by the QAPI committee.
Responsible Party and Date for Correction:
The Director of Nursing will be responsible to ensure compliance by 1/11/18.

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs for 4 (Resident's # 2, 7, 46, and 89) of 13 residents reviewed during the recertification survey. Specifically, the facility did not ensure that there was documentation of the reason for giving or the effectiveness when as needed (PRN) antianxiety medication was administered to Resident # 46 and #89, and a PRN muscle relaxant medication to Resident #2. Additionally, for Resident #7, who was on 2 different pain medications, the facility did not ensure that there were parameters on when to use each medication. This is evidenced by: A facility policy titled, Medication Administration, revised on 7/2017, documented the date, time, initials of nurse, medication, dose given, reason for administration, and results/effectiveness of the medication should be documented on the Electronic Medical Record (EMR). Resident #89 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus). The Minimum Data Set ((MDS) dated [DATE] documented the resident as moderately impaired cognitively and usually understands and usually understood. Physician (MD) Orders dated: 5/5/17; reordered 6/29/17 documented [MEDICATION NAME] 0.5 mg by PEG tube 3 times per day as needed (PRN). 10/20/17 documented [MEDICATION NAME] 0.5 mg by PEG tube 3 times per day for 14 days PRN. 10/23/17 documented [MEDICATION NAME] 0.5 mg, give one tablet by GT route one daily at bedtime. Discontinue PRN [MEDICATION NAME]. The Electronic Medication Administration Record [REDACTED]. The PRN monitoring documentation on the EMAR for (MONTH) through (MONTH) was blank. Review of Nursing Progress Notes: 5/16/17 at 3:53 am documented given [MEDICATION NAME] for restlessness with good effect. 6/4/17 at 4:9 documented given [MEDICATION NAME] with some positive effect noted. 6/14/17 at 10:4 documented resident in bed with anxiety , PRN antianxiety and pain med administered with little effect. 6/16/17 at 2:9 documented PRN [MEDICATION NAME] given results pending. Resident #46 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS of 10/3/17 assessed that the resident understands, was understood, and had intact cognitive abilities. A MD Order dated 7/21/17 documented, [MEDICATION NAME] 1 mg once daily as PRN, offer once daily with plan she comes out of room. Document resident willingness to comply with plan to leave room after dose of [MEDICATION NAME] given. An eMAR for (MONTH) (YEAR) documented the resident received [MEDICATION NAME] 17 times. There was no documentation on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no documentation on the eMAR or in Progress Notes regarding the reason the medication was administered, effectiveness of the medication, or the resident's willingness to comply with the plan to leave her room. During an interview on 11/15/17 at 8:10 am, Licensed Practical Nurse (LPN) #1 reported there was no place in the MAR indicated [REDACTED]. It can be documented in Progress Notes but the nurses don't typically do that here. During an interview on 11/15/17 at 10:00 am, Registered Nurse (RN) #1 stated, the nurses should document in Progress Notes that a PRN anxiety medication was given and the effectiveness. Resident #2 The resident was readmitted to the nursing home on 8/17/17 with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having intact cognitive skills for daily decision making; The resident understood and was understood by others. A MD order dated 8/7/17 documented [MEDICATION NAME] ( a muscle relaxant) 5 milligrams (mg); one tablet three times a day PRN. A MAR indicated [REDACTED]. The EMR did not include documentation of symptoms the resident was experiencing prior to administrations or a response to the medication after administrations. During an interview on 11/14/17 at 12:30 pm, RNM #3 stated that staff should be asking the resident about symptoms and documenting the response to the medication.

Plan of Correction: ApprovedDecember 18, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329
Corrective action regarding affected residents:
The facility strives to ensure that there is adequate indication for use and adequate monitoring of effects for those residents receiving [MEDICAL CONDITION] medication.
Medical Doctor Evaluation, reassessed, medications discontinued/continued, justified with documentation, etc. for each.
Resident # 89
Review of the medical record was conducted. The findings showed that there was a lack of documentation found when the resident received as needed doses of [MEDICATION NAME] (anti-anxiety). The resident has behavioral anxiety and exhibits various forms of agitated state. The medical record and the Electronic Medication Administration Record (EMAR) did not consistently indicate the specific reason the medication was being administered. On other occasions there was documentation for the reason for administration, but lacked documentation for the effectiveness of the medication.
The resident has since been discharged and no further monitoring is needed for her.
Resident # 46
Review of the medical record was conducted. The findings showed that there was a lack of documentation found when the resident received as needed doses of [MEDICATION NAME] (anti-anxiety). The resident has agoraphobia and major [MEDICAL CONDITION] and the purpose of the prescribed [MEDICATION NAME] was to get her to leave her room. The medical record and the Electronic Medication Administration Record (EMAR) did not consistently indicate the specific reason the medication was being administered. On other occasions there was documentation for the reason for administration, but lacked documentation for the effectiveness of the medication.
The resident is being monitored for behaviors that indicate the use of [MEDICATION NAME] and the effectiveness of the medication. Both the indication for use and effectiveness of the medication are documented accordingly in the nursing progress notes and the EMAR.
Resident # 2
Review of the medical record was conducted. The findings showed that there was a lack of documentation found when the resident received as needed doses of [MEDICATION NAME] (muscle relaxer). The resident had been readmitted to the facility with [DIAGNOSES REDACTED].
The resident is being monitored for signs and symptoms that indicate the use of [MEDICATION NAME] and the effectiveness of the medication. Both the indication for use and effectiveness of the medication are documented accordingly in the nursing progress notes and the EMAR.
Resident # 4
Review of the medical record was conducted. The findings showed that there was a lack of parameters for the use of 2 different pain medications. This has been clarified with the PCP and is documented on EMAR and in resident record.
Identification of other residents possibly affected and corrective actions taken:
Director of Nursing/Designee have identified, via Record Review, all residents who currently receive anxiolytics, muscle relaxers, and more than one pain medication.
All residents, identified were referred to Medical Doctor for follow-up review for medical necessity. Residents, if appropriate, were referred to Psychiatrist. All orders will include pre and post administration documentation.
III. Nurses re-educated on documentation for effectiveness. Rational for administering medications as ordered. Pharmacy Consultant will include pre and post administration documentation audit during facility review. The Assistant Director of Nursing and/or designee will, via EMR print Sigma Report that identifies medication requiring pre and post documentation for effectiveness/parameters.
This report will be reviewed by the Director of Nursing. Any nurse, identified as not documenting as per facility policy will be notified, and a late entry nurse?s note will be entered by nurse.
Shift Supervisor will monitor all unit EMR Dashboards prior to end of shift to assure compliance with pre and post documentation

Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
All licensed nurses will receive education on the facility policy on documentation expectations. An emphasis will be placed on specific documentation for as needed (prn) [MEDICAL CONDITION], pain, muscle relaxers and anxiolytic medication administration.
Any resident receiving prn [MEDICAL CONDITION], pain, muscle relaxers and anxiolytic medication will be placed on the twenty- four hour report, indicating reason for administration, effectiveness of medication and the completion of EMAR and nursing note. This information will be discussed during clinical report Monday- Friday (The weekend information will be discussed on the following business day).
How the current action will be monitored to ensure the deficient practice does not recur:
Audits will be conducted weekly by Assistant Director of Nursing/Designee, to ensure compliance of documentation, adequate indication of use and monitoring of effectiveness.
Assistant Director of Nursing/Designee will audit weekly for 4 weeks and then monthly for 3 months. The Director of Nursing and/or designee will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Responsible Party and Date for Correction:
The Director of Nursing will be responsible to ensure compliance by 1/11/18.

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 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. The FDA Food Code, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that automatic dishwashing machines are to operate in accordance with manufacturer specifications; equipment, surfaces, and the preparation area shall be kept clean; and food temperature thermometer shall be calibrated. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications, various food contact surfaces and the preparation area in the kitchen were not clean, and not all food temperature thermometers were calibrated. This is evidenced as follows. The main kitchen was inspected on 11/14/2017 at 8:40 am. The automatic dishwashing machine final rinse when checked during normal operation was 170 degrees Fahrenheit (F), 20 pounds per square inch (psi) water pressure and 0 (zero) parts per million (ppm) chlorine. The floors and ceiling, slicer, food processor, microwave oven, shelving, ice cream freezer, stove drip pans, and fire extinguishers were soiled with food particles, and oily film, and/or dirt. When checked by the standard method in an ice bath one food temperature thermometer read 25 degrees Fahrenheit (F) and a second thermometer read 35F. The Food Service Director was interviewed on 11/41/2017 at 9:20 am. He stated that he will contact the maintenance department regarding the automatic dishwashing machine, contact a cleaning service for the floors, clean then devise a schedule for cleaning the other surfaces found, and recalibrate the thermometers. Additionally, the Food Service Director stated that the automatic dishwashing machine is a low-temperature sanitizing machine and the final rinse should be 50 ppm chlorine. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-1.113, 14-1.170

Plan of Correction: ApprovedDecember 18, 2017

F371
Corrective Action regarding affected residents:
The main kitchen was inspected on 11/14/2017 at 8:40 am. The automatic dishwashing machine final rinse when checked during normal operation was 170 degrees Fahrenheit (F), 20 pounds per square inch (psi) water pressure and 0 (zero) parts per million (ppm) chlorine. The floors and ceiling, slicer, food processor, microwave oven, shelving, ice cream freezer, stove drip pans, and fire extinguishers were soiled with food particles, and oily film, and/or dirt. When checked by the standard method in an ice bath one food temperature thermometer read 25 degrees Fahrenheit (F) and a second thermometer read 35F.
The Food Service Director was interviewed on 11/14/2017 at 9:20 am. He stated that he will contact the maintenance department regarding the automatic dishwashing machine, contact a cleaning service for the floors, clean then devise a schedule for cleaning the other surfaces found, and recalibrate the thermometers. Additionally, the Food Service Director stated that the automatic dishwashing machine is a low-temperature sanitizing machine and the final rinse should be 50 ppm chlorine.
On 11/14/17, calibration of manual thermometers was checked and deemed incorrect. The Food Service Director immediately re-calibrated the thermometers in the method shown by the surveyor.
On 11/14/17 the Food Service Director contacted the company responsible for servicing the dish machine and it was fixed that day so the final rinse should be 50 ppm chlorine
Identification of other residents possibly affected and corrective actions taken:
All residents had the potential to be affected by this.
Corrective actions taken:
? Dishwashing machine was serviced to function properly
? Dietary staff in-serviced on how to properly calibrate a thermometer
? The kitchen ceiling was repaired and repainted
? The kitchen floor was repaired and cleaned
? All kitchen equipment was cleaned and sanitized
? All shelving was cleaned and sanitized
? All dishes and small wares were rewashed and sanitized and stored properly
Measures put into place or systematic changes put into place to ensure the deficient practice does not recur:
In-Services for all dietary staff on the following:
? How to properly calibrate an analog thermometer.
? How to properly operate the automatic dishwashing machine and check final rinse ppm.
and what to do if the final rinse solution ppm level is not correct.
? How food can become contaminated
? When and how to wash hands
? How to store food properly
? Proper ways to serve food
? Cleaning vs. Sanitizing
? How to clean and sanitize in a three-compartment sink
? Safe food handling
A preventative maintenance program and a detailed cleaning schedule were implemented and staff in-serviced on the tasks identified to ensure standards are maintained.


How the current action will be monitored to ensure the deficient practice does not recur:
The facility Administrator/designee will conduct twice weekly for 4 weeks, weekly for 4 weeks and then monthly for three months, F371 sanitation audits and address any findings with the Food Service Director.
Final rinse ppm levels are recorded daily, before use of the automatic dish machine. The Food Service Director will audit final rinse solution ppm level readings daily for 4 weeks, weekly for 4 weeks and then monthly for three months.
Thermometers have been changed to digital which do not require calibration.
Food Service Director will report results at the QAPI meetings quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Responsible party and date for correction: The Food Service Director will be responsible to ensure compliance by 1/11/18

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (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: (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 (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure that it established an infection prevention and control program (IPCP) that included , at a minimum, the following elements; a system for preventing, identifying, reporting, investigating and controlling infections and communicable disease and maintaining a safe, sanitary and comfortable environment for 5 Residents (# 2, 4, 7, 87, 89) on 2 of three units Specifically, the facility did not ensure that hand hygiene procedures were followed by staff involved in direct resident care, during a tube feeding observation on Resident #89 and an observation of peritoneal dialysis exchange on Resident #4. Additionally, the facility did not ensure Resident # 87 was screened for [DIAGNOSES REDACTED] upon admission, that results for PPDs (a test for [DIAGNOSES REDACTED] where a serum is injected just under the skin and 72 hours later the skin is checked for a skin reaction (induration) (a localized hardening of soft tissue) to determine if the PPD is positive or negative), were obtained after the injections were placed for Resident #2 and 7 and that Resident #2 had a completed step one and two and that Resident # 4, and 7 received the second step PPD; Also, the facility did not ensure that personal care items were labeled for individual resident use. This is evidenced by: A Facility Policy and Procedure titled [MEDICATION NAME] Skin Testing revised 7/12/17, documented that all residents receive a PPD with in 72 hours of admission, again 2-3 weeks after the initial negative skin test, then annually thereafter; The reaction to the PPD should be read by a nurse or MD within 48-72 hours after injection; If more that 72 hours have elapsed and there is not an easily palpable and measurable induration, repeat the test on the other arm and read this result in 48-72 hours. Resident #7 The resident was admitted to the nursing home on 8/24/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and that the resident understood and was understood by others. A review of the Electronic Medication Administration Record (eMAR) dated from 8/24/17- 11/13/17, documented a PPD was administered on 8/25/17, but the medical record did not include the results of the PPD. A PPD was administered on 9/8/17 and read 72 hours later. The medical record did not include a completed 2nd step PPD. During an interview on RNM #3 stated she became aware recently that there was an issue with the residents reviewing PPDs; they used to use a calendar and she is going back to that. The PPD is supposed to be added into the eMAR but whoever does the admission and it was not getting done or done wrong. Additionally, some residents had PPDs placed but not read. Resident #87 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident as moderately impaired cognitively and rarely understands and rarely is understood. Review of eMAR documented a PPD was given on 2/17/17 with no documentation found for the reading. The second PPD was ordered for 3/3/17, the eMAR documented it was not given and the reason given on the eMAR was na. The resident received a PPD on 7/24/17 and was read 3 days later with documentation of negative, no induration. On 11/14/17 at 2:40 pm, Registered Nurse Manager (RNM) #2 stated the resident's PPD's should be documented on the immunization record and the eMAR. After review of the records, RNM #2 stated she does not know why the PPD's were not done correctly and they should be given again. On 11/16/17 at 9:42 am, Licensed Practical Nurse (LPN) #4 stated, after reviewing the electronic medical record, there was no documentation the 2/17/17 PPD was read and the 3/3/17 PPD was not given. LPN #4 stated that when PPD's are ordered, the nurse entering the order should also put an order in for the PPD to be read 72 hours later. Resident #4 The resident was admitted to the nursing home on 10/16/17 with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and that the resident usually understood and was usually understood by others. During a PD exchange observation on 11/15/17 at 8:20 am, LPN #5 washed her hands and had multiple dangling bracelets on both wrists; While LPN # 5 washed her hands, she washed up on the bracelets for less than 5 seconds. When LPN #5 rinsed her hands she went up over the bracelets and the water from the bracelets was dripping over her hands and fingers; LPN #5 pressed the handle on the paper towel dispenser with her hand to advance the paper towels then her hands came in contact with the privacy curtain. When LPN #5 donned her gloves the bangle bracelets her hanging over her gloved hands. During an interview on 11/16/17 at 8:31 pm, LPN #3 stated that the rooms were remodeled and the paper towel holder is in a bad spot so you couldn't use your elbow to dispense the towel and her hands touched the privacy curtain when tearing off the paper towel. Additionally, LPN #3 stated that it wasn't aseptic technique when she was wearing all the bangle bracelets hanging over her gloved hands. During an interview on 11/17/17 at approximately 11:00 am, the Infection Control Nurse (ICN) stated that staff should not be wearing bangle bracelets but may wear a ring. Additionally, the ICN stated she was not aware that the placement of the paper towel holders were causing a problem and that she should have been notified so they could be moved. Resident #89 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus). The MDS dated [DATE] documented the resident as moderately impaired cognitively and usually understands and usually understood. During a tube feeding observation on 11/15/17 at 9:45 am, LPN #2 washed her hands, manually pumped paper towel out of the paper towel dispenser, allowed the end of the paper towel to enter the garbage can next to the sink, then dried her hands. LPN #2 left the room to go to the medication cart. She returned and set up supplies, did not wash her hands, donned clean gloves and began procedure. After the procedure, LPN #2 washed her hands, allowed paper towel to enter garbage can and then dried her hands. During an interview on 11/15/17 at 10:10 am, LPN #2 stated that she should have washed her hands when she returned to the room and should not have allowed the paper towels to touch the garbage can. During an interview on 11/17/17 at approximately 11:00 am, the Infection Control Nurse (ICN) stateds she was not aware that the placement of the paper towel holders were causing a problem and that she should have been notified so they could be moved. Finding # 1 - Unit 2 North During an observation on 11/13/17 at 9 am, unlabeled personal care items were noted in a Resdient Bath on Unit 2 North, and unlabeled body wash and shampoo in both shower stalls. During an observation on 11/16/17 at 7:43 am, unlabeled antibacterial moisturizing body wash, shampoo and hand wash in were noted in stall #1 and unlabeled shampoo and body wash and moisturizing body lotion in stall #2 of the shower room. Additionally, dirty towels and patient gown were observed on the floor outside the shower stalls. During an interview on 11/16/17 at 7:54 am, Certified Nurse Assist (CNA) #2 stated that all personal care items were supposed to be labeled. During an interview on 11/16/17 at 7:55 am, RNM #2 stated that all personal care items should be labeled and dirty linens should not be left on the floor. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedJanuary 9, 2018

F441:
Corrective Action regarding affected residents:
Residents # 2, 7 and 87 medical records were reviewed by nursing and the medical provider to ensure a two-step PPDs will be provided to the affected residents. Nursing staff obtained orders from the medical provider. PPD Step 2 were administered on 12/6/17 for resident 87, 12/8/17 for resident 2. Resident 7 medical record did identify that he received a 1st PPD on 8/25/17 and a Step 2 on 9/8/17 and both PPDs were negative.
Resident # 4 and # 89 did not have a negative impact from hand hygiene procedures that were not followed by staff involved in direct resident care.
Finding # 1 - During an observation on 11/13/17 at 9 am, unlabeled personal care items were noted in a Resident Bath on Unit 2 North, and unlabeled body wash and shampoo in both shower stalls. During an observation on 11/16/17 at 7:43 am, unlabeled antibacterial moisturizing body wash, shampoo and hand wash in were noted in stall #1 and unlabeled shampoo and body wash and moisturizing body lotion in stall #2 of the shower room. Additionally, dirty towels and patient gown were observed on the floor outside the shower stalls. During an interview on 11/16/17 at 7:54 am, Certified Nurse Assist (CNA) #2 stated that all personal care items were supposed to be labeled. During an interview on 11/16/17 at 7:55 am, RNM #2 stated that all personal care items should be labeled and dirty linens should not be left on the floor. The above noted observation were immediately corrected.
Identification of other residents possibly affected and corrective actions taken:
PPDs ? New. All new admissions for past six months, medical records were audited to identify those residents without a two-step PPD. Identified resident(s) were reviewed with the medical provider to ensure two-step PPDs will be provided then orders were obtained from the medical provider.
All Nursing Staff have been re-educated on Proper Handwashing and Verified Competency Audit completed.
Assistant Director of Nursing/Designee have completed a full facility environmental audit to assure all personal care items are properly labeled.
No other unlabeled items were identified.
Measures put into place or systematic changes put into place to ensure the deficient practice does not recur:
PPDs - Order sets were created in the Sigma Care EMR to ensure PPDs are placed then read in accordance with policy. Infection Control Nurse will monitor all new admissions for compliance with facility Two-Step PPD Policy. Infection Control Nurse will maintain a current and on-going log of all completed and pending PPD administration.
Hand hygiene - All licensed nurses will receive education on facility policy related to the hand hygiene.
All Nursing Staff will have competency completed by 1/18/18; Handwashing Competency will be included in all new employee orientation.
Finding # 1 - All nursing staff will receive education on proper labeling and storage of personal hygiene items. The facility is converting to new products in bulk capacity for use in the shower areas to eliminate the use of individual containers of personal care products.
Shift Supervisor, during routine rounds will monitor all shower/bath stalls for soiled linen and towels.

How the current action will be monitored to ensure the deficient practice does not recur:
PPDs - Audits will be conducted weekly to ensure compliance of documentation and reviewed weekly in the At Risk Committee Meeting. These audits include Resident Name, Date of PPD #1 and results, Date of PPD #2 and results.
Licensed nursing staff will audit compliance weekly for 4 weeks and then monthly for 3 months. The Director of Nursing and/or Assistant Director of Nursing will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Hand hygiene ? Hand-washing Competency audits will be conducted on 20 licensed staff weekly for 4 weeks and then monthly for 3 months. The Director of Nursing and/or Assistant Director of Nursing will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Finding # 1 ? The charge nurse on each unit will audit shower rooms each shift each day to ensure no unlabeled items are stored improperly for 4 weeks and then weekly for 3 months. The Director of Nursing and/or Assistant Director of Nursing will report audit results at the QAPI committee meeting quarterly until compliance is satisfactory and maintained. Audits will continue as needed and determined by the QAPI committee.
Responsible party and date for correction:
The Director of Nursing and/or Assistant Director of Nursing will be responsible to ensure compliance by 1/18/2018.

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey and abbreviated surveys (Case #'s NY 813 and NY 369) the facility did not have ensure that all alleged violations of abuse, neglect and or mistreatment were thoroughly investigated for 3 (Resident #'s 4, 106, and #108) of 4 residents reviewed for incidents, and did not conduct the minimum required background checks on new employees. Facilities may not employ individuals with a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Specifically, for Resident #4 the facility did not ensure an investigation was done when resident's continuous ambulatory peritoneal [MEDICAL TREATMENT] (PD) (a tube permanently inserted through the abdomen to allow a fluid called [MEDICATION NAME] to be emptied and replaced every day to cleanse the body of built up toxins) was held without an Medical Doctor (MD) order; For Resident # 106 the faciliy did not do a thorough investigation into why the resident, who was complaining of neck pain, was moved after a fall and; For Resident #108 the faciltiy did not ensure a thorough investigation and follow up was completed after an attempted elopement on 5/25/2016; As a result, interventions were not put back in place after a hospital admission, enabling the resident to actually elope in 6/2017. This is evidenced by: Resident #106: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had severe cognitive impairment, could understand others and sometimes able to be understood. A Policy & Procedure (P&P) titled Falls Management and dated 3/1/16 documented, The Fall Risk Evaluation will determine fall risk factors. The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Documented under heading Post fall/injury resident management, If the resident is conscious, provide reassurance and comfort. Resident is not to be moved until assessed for injury by a nurse. Upon arrival of the nurse, a quick head-to-toe scan will be performed without unnecessary movement. If injury, severe pain or abnormal assessments observed, call 9-1-1 for transfer. A Nursing Progress Note, written by who, dated 9/24/17 at 6:59 am, documented, received call from Licensed Practical Nurse (LPN) to assess resident who had been found on the floor in her room; The resident was observed sitting on her buttocks beside her wheelchair screaming loudly-resident had known dementia and often yells out behaviorally. Resident complained of neck pain and stiffness. No visible injuries observed from current fall. The Nurse Practitioner (NP) was notified of the neck pain and 4 plus leg [MEDICAL CONDITION]. Order received to send resident to the emergency room (ER) for evaluation. An Incident Report dated 9/24/17 at 2:40 am documented, found resident sitting on buttocks on floor next to wheelchair in her room. Resident stated, my neck hurts, my neck hurts. Under first aide rendered, it documented: Registered Nurse (RN) assessment, range of motion (ROM) to all extremities; Under Comments, it documented: 2-man lift back into wheelchair with body kept in neutral alignment. The Investigational Summary dated written by the Director of Nursing (DON) documented, that on 9/24/17 at 2:40 am resident #106 was observed by staff to be sitting on bedroom floor next to her wheelchair. RN Supervisor (RNS) assessed the resident who complained of neck pain and stiffness, and had 4 plus leg [MEDICAL CONDITION]. RNS called the NP and received an order to send the resident to the ER. The Investigational Summary did not include documentation regarding the RNS manually lifting the resident with neck pain into a wheelchair and/or education to the RNS regarding moving a resident with injury. Under Action Plan, it documented: Care plans and P&P were followed. Under Conclusion, it documented: after review of all facts in this case, no abuse, neglect and/or mistreatment was identified. Resident #106 showed no signs or symptoms of psychological harm. A CT Scan (special X-ray tests that produce cross-sectional images of the body using X-rays and a computer) of the head and cervical spine dated 9/24/17 documented; findings consistent with a type 3 [MEDICAL CONDITION] (a protruding part of the second bone in the neck) extending into the lateral masses (the main part of the 2nd neck bone) bilaterally. There is minimal displacement of the fragments. During an interview on 11/16/16 at 1:50 pm, LPN #3 stated that if a resident was on the floor she would call a RN to assess; If a resident on the floor had injury, fracture or was complaining of pain then 911 would be called and the resident would not be lifted. During an interview on 11/17/17 at 2:20 pm, the Registered Nurse Manager (RNM) #2 stated that after a resident fall, if they are complaining of pain she would not lift the resident; She would call an ambulance and not move the resident. During an interview on 11/17/17 at 9:10 am, the Assistant Director of Nursing (ADON) stated if she saw a resident after a fall and the resident was complaining of neck pain she would not move the resident. The ADON stated that if she was aware of an RNS moving a resident with neck pain after a fall that she would speak with the RNS. The ADON would want to know from the RNS what happened and why the resident was moved. During an interview on 11/17/17 at 10:30 am the Director of Nursing (DON) stated the RNS who assessed the resident was from an agency. The RNS should have completed an assessment of the environment and the resident to ascertain what happened, and to determine injury. The DON stated he could not say what the P&P documented about moving a resident with pain, but he would have left the resident on the floor and waited for the ambulance to arrive. Additionally, the DON stated that the RNS had used her assessment skills in the past and they were good: The RNS used her clinical judgement and he did not see there was a problem with her lifting the resident with neck pain. Resident #108 The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment. A Policy & Procedure (P+P) titled Unsafe Wandering/Elopement Management was revised on 06/17. The facility was unable to produce the Policy and Procedure in place prior to the revision and whether the revision occurred after the elopement on 6/13/17. The P+P dated 6/17, documented that all residents admitted are assessed for risk of unsafe wandering and elopement. The assessment is completed upon admission, quarterly, and after each unsafe wandering, an elopement Care Plan is initiated with appropriate approaches to manage this behavior, clinical departments will be aware of unsafe wandering/elopement risk through Interdisciplinary Care Plan and /or daily team meetings (M-F). The tag (wander guard bracelet) issuing sheet must be filled out indicating what resident the tag (wander guard bracelet) was issued to; Tag tracking sheet must be completed. When tag is removed it must be documented on the issuing sheet and the Tag tracking sheet. The nurse is responsible to check placement daily on 11-7 for functioning and lastly the tag will be documented on the MAR (medication administration record) for placement and functioning checks. The facilities incident report not dated documented that on 6/13/17, the resident walked down to the reception area and requested that a cab be called. The receptionist called a cab, the resident exited the facility and got in the cab. While driving through the parking lot, a couple of facility staff members saw the resident in the cab and immediately called the cab service to return the resident. The resident was returned without incident. During the facility's investigation, it was noted that the resident attempted to elope on 5/25/17. The RN supervisor placed a wander guard bracelet on the resident, did not contact the physician regarding the elopement, did not notify the physician that she had placed a wander guard on the resident and did not obtain an order for [REDACTED]. Nursing progress note dated 5/25/17 at 12:36 am documented the resident packed her suitcase, went down the elevator to the front desk and requested that the receptionist call a cab to take her home. The receptionist notified the unit, the resident was brought back to the unit and a wander guard bracelet was placed. Elopement was noted daily in progress notes from 5/25/17 to 5/27/17 at 10:51 am. Resident was sent to the hospital on [DATE] at 2:15 pm and returned to the facility that same day. Upon arrival, there is no further documentation regarding elopement or wander guard bracelet in the progress notes until the 6/13/2017 elopement. MD Orders dated 6/16/17 Document Monitoring of wander guard every date during each shift. Elopement Risk assessment dated : 5/25/17, 6/14/17, 7/17/17, 10/13/17. Facility unable to provide elopement risk assessments prior to 5/25/17. Care Plan Risk for Elopement effective 5/25/17, documented Assess resident for risk of elopement. There were no other interventions documented on the care plan. On 6/13/17, a Wander guard to right ankle was added. During the interview with the Director of Nursing (DON) on 6/17/2017 at 10:00 am, who stated that the elopement attempt on 5/25/2017 did not require an incident report since the resident did not leave the facility. The DON stated that he was made aware of all resident issues in daily team meetings. He stated staff should not have documented elopement in the resident's progress notes, since the resident did not elope. The DON further stated that the P+P for elopement was revised 6/17, however he did not know if it was before or after the resident elopement on 6/13/17. The DON stated that he is made aware of all resident issues in daily team meetings, including elopement and elopement attempts. The DON stated that he was not aware of the elopement attempt on 5/25/17, until the surveyor showed him the facility document titled Quality Assurance Investigational Summary. During an interview with the Assistant Director of Nursing (ADON) on 6/17/17 at 9:15 am, the ADON stated that the DON, and ADON would be notified of elopements and elopements attempts. The RN Supervisor would be notified when the DON and ADON were not onsite. It is expected that an elopement assessment would be performed, a care plan updated, MD order given for the wanderguard bracelet and documentation placed in MAR for daily checking of wander guard. The DON could not produce the P+P for wandering/elopement that was in place prior to the revised P+P dated 06/17. Resident #4: The resident was admitted to the nursing home on 10/16/17 with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and that the resident usually understood and was usually understood by others. During an interview on 11/13/17 at 11:30 am, the resident's spouse stated that the resident was supposed to get a PD exchange twice daily and to call the MD if the resident's blood pressure was low; The nurse did not call the MD when the resident's blood pressure was low and did not perform the PD exchange and the resident's condition went down hill. The MD orders did not include an order to hold the PD. The Medication Administration Record dated from 11/4/17 - 7/17/17, documented that PD was performed at 8:00 pm on 11/4, and held on 11/6 at 8:00 pm and 11/7 at 8:00 am and 8:00 pm. A progress note dated 11/7/17 at 6:22 pm, by the Nurse Practitioner, documented that the resident was seen for a change in mental status; Nurses reported the resident was more groggy and confused over the past few days and he had missed a couple PD exchanged because of his blood pressure; the resident reported feeling weak but refused to go to the emergency room for evaluation. During an interview on 11/14/17 at 4:10 pm, Licensed Practical Nurse (LPN) #5 stated she was told verbally on 11/2/17 by LPN #6, to hold the PD if the Systolic (top number) Blood Pressure (SBP) was less than 100; She held the PD exchange at 8:00 am on 11/7 and at 8:00 pm on 11/4, 11/6, and 11/7; She left a message for [MEDICAL TREATMENT] on one occasion but had not heard back and she notified the RNS on another occasion; She did not know why she signed that she did the PD on 11/4 at 8:00 pm; She may have done it by accident thinking she performed the PD. Additionally, on 11/16/17 at 10:10 am, LPN #5 stated that she had not been asked prior to today to write a statement regarding the missed PD; the ADON and RN#3 spoke to her after the incident but it was to see what happened; It was not disciplinary in nature. During an interview on 11/15/17 at 8:15 am, the [MEDICAL TREATMENT] Registered Nurse (DRN) stated that she was off on the weekend (11/4 - 11/5) and on Tuesday (11/7); She became aware that the PD was held on Wednesday, 11/8/17 when the resident's wife informed her. There there were instructions for contacting the [MEDICAL TREATMENT] center or PD nurse for issues; The resident's PD would not have been held when his BP was low rather, the concentration of the solution would have been adjusted. During an interview on 11/15/17 at 12:45 am, RN #3 stated that there was no order to hold the PD. During an interview on 11/16/17 at 9:25 am, the Director of Nursing stated that the investigation should have been completed by now. During an interview on 11/16/17 at 10:12 am, RN #3 stated that she was told today to do an investigation into the incident involving the resident's missed PD exchanges. During an interview on 11/16/17 at 10:30 am, LPN #6 stated that the ADON spoke to her a couple days after the incident to ask about holding the PD if BP was low but no statement or counseling was given: She had not spoken to anyone about it since. Finding #1: The personnel files for Certified Nursing Aide (CNA) #1 were reviewed on 11/14/2017. This record review revealed that CNA #1 was hired on 08/14/2017. The facility did not conduct a State nurse aide registry check for this individual until 09/21/2017, thirty-eight days after hiring. The Director of Human Resources stated in an interview conducted on 11/14/2017 at 1:00 pm that she did not recall as to why the State nurse aide registry for CNA #1 was late. 10 NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedDecember 18, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F225:
Corrective Action regarding affected residents:
Resident # 4 - primary care physician and [MEDICAL TREATMENT] RN, were made aware of resident peritoneal [MEDICAL TREATMENT] treatment was held. Primary care physician and [MEDICAL TREATMENT] RN reviewed and verified all current orders. Director of Nursing reviewed all clinical nursing documentation, including but to limited to PD order, resident weights, abdominal girth on B/P; all within acceptable parameters.
Resident #106 - Director of Nursing has completed investigation and revised investigative summary. Resident was discharged from facility on 9/24/17.
Resident # 108 - Elopement/Wandering Assessment completed, after survey (date), order for wander guard, placed on patient and EMAR, picture at Reception Desk/Nursing Station, Wandering Tag Sheet completed. Completed Accident and Incident for 5/25/17 incident and investigation.


Identification of other residents possibly affected and corrective actions taken:
Resident # 4 - Assistant Director of Nursing/Designee have reviewed all residents? MAR, EMR, and 24-Hour Report to identify any resident where a medication/treatment was held, and MD Order was obtained for past 30-days. No other resident was identified during audit.
Resident # 106 - The previous 3 in of A&I for falls were reviewed by Director of Nursing/Designee for compliance with facility investigative policy. All investigations and summaries completed, per policy.
Resident # 108 - All residents have potential to be affected. All residents wandering assessment were reviewed to ensure all safety measures are in place. No other residents were identified. Assistant Director of Nursing/Designee have reviewed all residents Elopement Risk Assessment for timeliness and accuracy. Assistant Director of Nursing and Unit Managers have reviewed all high risk residents? care plans for compliance with facility elopement prevention protocol. All residents identified as high risk for elopement were line listed per unit. Unit Manager will be responsible for updating list, as needed.

Measures put into place or systematic changes put into place to ensure the deficient practice does not recur:
Resident # 4 - Assistant Director of Nursing and/or designee will access report from EMR Sigma for all documented ?held? treatment as well any omissions of documentation, daily.
All nurses will be re-educated on MD Notification if treatment is held for any reason.
Resident # 106 - Accidents and Incidents will be reviewed and completed at Morning Clinical Meeting, by Director of Nursing, Assistant Director of Nursing/Designee and Inter-Departmental Team. Licensed staff were re-inserviced on Accidents and Incidents, policies and procedures. Assistant Director of Nursing will maintain a current line listing of all Accidents and Incidents to monitor, and assist in, status of all investigations. All Nursing staff were educated in maintaining and providing safety precaution in suspected neck/or other serious injury. Resident safety precautions will be included in new orientation training.
Resident # 108 ? Elopement - Assistant Director of Nursing will review all admission and re-admission orders [REDACTED]. All staff will be re-educated on facility Elopement Prevention Policy.

How the current action will be monitored to ensure the deficient practice does not recur:
Resident # 4 - The facility administrator, director of nursing, and assistant director of nursing will review all completed investigations on a weekly basis to ensure they are complete and thoroughly describe the event as well as determine how to prevent future occurrences.
Resident # 106 - We have changed format of our internal forms to include a methods/means to ensure compliance with policies and procedures. This will be monitored daily, on the following day in IDT Meeting. Monitoring will be reported to the Quality Assurance/Performance Improvement.
Resident # 108 ? All residents at risk for wandering will be reviewed at weekly Risk Committee meeting as part of the QAPI process.
Responsible party and date for correction:
Director of Nursing/Assistant Director of Nursing by 1/18/18.

F 225 Finding 1
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
No residents were affected by this practice
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
No residents were affected by this practice
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;

Facility had in the past relied on one person to verify nurse aide registry checks are completed prior to hire. The facility has since implemented a 2 person check and a sign off sheet to verify compliance.

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
The Administrator/designee will review all new hire paperwork and sign off to verify that the Nurse Aide Registry check was completed on each staff member and report compliance at QAPI meetings for 3 months then frequency to be determined thereafter.

The date for correction and the title of the person responsible for correction of each deficiency.
Date of correction ? 1/11/18 Responsible person ? Administrator

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure it maintained acceptable parameters of nutritional status, such as body weight, for 5 (#s 2, 44, 68, 87, and 89) of 13 residents. Specifically: for Resident #89 the facility did not ensure the resident received the physician-ordered amount of gastric tube feeding. Subsequently, the resident had a significant weight loss from 101.8 pounds on 7/12/17 to 91 pounds on 8/22/17 ; For Resident #44's the facility did not ensure that a significant weight gain was assessed, and that interventions were put into place to prevent further unplanned weight gain; For Resident #2 's the facility did not ensure that an unplanned weight loss and consistent refusal of Pro Stat ( a supplemental liquid that has a high concentration of protein and calories) was identified and that a comprehensive nutritional assessment was completed, Additionally, for Residents #68, #87 the facility did not ensure acceptable parameters of nutritional status This is evidenced by: The Weight Variance Policy and Procedure (P&P), dated 12/2006 and revised 3/2013 documented that all residents' weights were to be monitored monthly or more often as indicated by resident's condition, physician's orders [REDACTED]. The purpose of the P&P was to assist in determining the nutritional status of the resident, and to ensure that a resident maintained an acceptable body weight unless his/her clinical condition demonstrated this was not possible. The procedure documented that all new admissions needed an initial weight and a weekly weight for the following four weeks and on readmission. The Registered Dietician/Diet Technician was to review monthly weights, weekly weights and significant weight changes as determined by Dietary, and documentation was to be made in the medical record within three days of a re-weight. Appropriate interventions were to be initiated as determined by the interdisciplinary team. The P&P titled Weight - Measuring and Recording dated 1/1/2001, documented that residents were to be weighed between the 1st and 10th of each month, and Dietary was to review the weights between the 11th and 15th of each month. Weight changes were to be addressed to provide appropriate interventions. The P&P titled Weighing the Resident, dated 6/2016 documented it was the policy of the facility to maintain accurate information about weight gain or loss. Any unplanned weight loss/gain was to be reported to the physician, dietitian, nursing supervisor and addressed at the weekly At Risk Meeting. Re-weighing of a resident was required with fluctuation of 3 pounds from the previous weight. Resident #89: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition, usually understood others, and was usually understood by others. A Dietary Progress Note dated 5/8/2017 at 9:07 am, documented the resident was to be NPO, and was to receive 50 milliliters (ml) of Glucerna 1.5 every 4 hours (6 times a day) and a bolus flush of 50ml of water following the feedings. This provided 450 calories, 24 grams of protein and 527ml free fluids. This will not meet estimated needs. A full nutritional assessment is to follow. A Physician (MD) Order dated 5/9/17 at 3:54 pm documented the resident was to receive 100ml of Glucerna 1.5 through the PEG tube every 4 hours. Staff were to check for residual prior to providing the tube feeding, and if greater than 125ml, they were to call the MD and hold the feeding for 4 days. The Electronic Medication Administration Record [REDACTED]. A Physician order [REDACTED]. The order was transcribed in the eMAR as four times a day instead of every 4 hours. The Initial Nutrition Risk Assessment Short-Term Stay, dated 5/11/17, documented the resident was receiving 100ml of Glucerna 1.5 every 4 hours and a 50ml water flush every 4 hours. Nutrients from the tube feeding were calculated as a total volume of 1200ml, 900 calories, 50 grams (gm) of protein and 750ml of free water. The estimated nutrient needs were calculated as 1,325 calories/day, 67 grams of protein/day and 1700ml of fluid/day. The assessment documented the resident was at risk for weight loss and dehydration because the nutrition was not currently meeting needs. A Dietary Progress Note dated 5/11/17 at 1:25 pm, documented medical staff were aware that the tube feeding did not meet the resident's estimated nutritional needs. A Nursing Progress Note dated 5/11/17 at 8:44 pm, documented a new order was obtained to increase the resident's tube feed to 150ml every 4 hours on 5/13/17. A Physician order [REDACTED]. The order was transcribed onto the eMAR as four times a day instead of every 4 hours, and did not include the start date of 5/13/17. The eMAR dated from 5/11 to 5/13/17, documented Glucerna; 100 mL bolus per GT every 4 hours. The times on the eMAR were scheduled the Glucerna for 4 times a day, and the resident received the Glucerna 4 times a day instead of every 4 hours from 5/11/17 at 1:00 pm to 5/13/17 at 9:00 am. The eMAR did not include the 5/11/17 order for increased Glucerna until 5/15/17, and did not include evidence that the resident received any GT feedings from 5/13/17 at 9:00 am until 5/15/17 at 5:00 pm. A Dietary Progress Note dated 5/12/17 at 11:20 am, documented the MD increased the tube feeding as of 5/12/17 to Glucerna 150 cc every 4 hours, the flush remained at 50ml after each feeding, which provided 1,350cal/ 74-grams protein/683 cc free fluid, with flushes free fluid equaled 983ml. Total volume was 1,200ml/day. The Physician order [REDACTED]. The eMAR dated from 5/15/17 - 5/31/17, documented that the resident received 150ml of Glucerna 4 times a day instead of 6 times a day. A Dietary Progress Note dated 5/15/17 at 4:33 pm, documented the resident was tolerating the tube feeding. Estimated nutritional needs were documented as: 1,325cal, 67gm protein, 1700ml of water. The tube feeding and flushes provided: 1,350 calories, 74 gm protein and 983ml of free water. Recommended to add 50ml of water before and after each feeding to help maintain hydration, if tolerated then recommended increase fluids to 85ml before and after each bolus to provide a total of 1703ml free water. A Dietary Progress Note dated 5/17/17 at 10:03 am, documented the resident tolerated the tube feeding and the MD wanted the resident to receive 1800 calories via tube feeding per day. It was recommended to change tube feeding to a 200ml bolus of Glucerna 1.5 every 4 hours with a 65ml water flush before and after each bolus, which would provide 1800 calories, 98 gm of protein and 1690ml of free water. A Nursing Progress Note dated 5/17/17 at 11:50 am, documented a new order to increase Glucerna to 200ml every 4 hours. The medical records did not include an MD order for this increase or an order to discontinue the previous order of 150ml every 4 hours. A Medical Progress Note by MD #2 dated 5/19/17 at 4:26 pm, documented the tube feeding was OK, PEG tube NT (no tenderness), ND (no distention), and BS (bowel sounds) good. Recent labs reviewed - NL (normal limits). The first weight completed in the facility was documented in the Electron Medical Record (EMR) on 5/23/17 (18 days after admission) as 102.4 pounds. The eMAR dated from 6/14/17 - 6/20/17 documented Glucerna 150 mL every 4 hours. The order was transcribed as four times a day instead of every 4 hours. The resident received Glucerna 4 times a day from 6/15/17 at 9:00 am until 6/20/17 at 1:00 pm. A Nursing Progress Note documented that the resident was admitted to the hospital from 6/10 - 6/14/14 for a [MEDICAL CONDITION]. A Medical Progress Note by Nurse Practitioner #1, dated 6/15/17 at 1:42 pm, documented a readmission assessment from hospitalization after fall with [MEDICAL CONDITION]. The resident was seen by orthopedic group and was deemed not a good candidate for surgical repair, so she was returned to the facility. The plan was to continue tube feedings. The Initial Nutrition Risk Assessment Short-Term Stay, dated 6/16/17 and completed on 6/20/17, documented the resident's admission weight as 110.1 pounds with a BMI of 19.48. The resident was NPO, and received 150ml of Glucerna every 4 hours, and a flush with 65ml of water before and after the bolus. Nutrients from the tube feeding were: 1,350 calories, 74 gm of protein, 1463ml of free water, and total volume of 900ml from tube feeding. Estimated nutritional needs were: 1,500 calories/day related to low BMI, 60 gm of protein/day and 1500-1750ml/day; The Dietician recommended to increase the tube feeding by 20ml each feed to 170ml every 4 hours to provide 1,530 calories/day and 84 gm of protein/day. The medical record did not include an order for [REDACTED]. The EMARs dated from 6/30/17 through 7/31/17, documented the resident was to receive 200ml of Glucerna every 4 hours, flush with 65ml of water before and after bolus. The order had been transcribed as 4 times a day instead of every 4 hours. The EMAR documented the resident received Glucerna 4 times a day during this timeframe. Initial Nutrition Risk Assessment Short-Term Stay completed on 7/6/17, documented an admission weight had not been obtained, and that the resident had experienced weight loss for the last 6 months. The resident was receiving 200ml of Glucerna every 4 hours with 65ml of water before and after the feeding. The nutrient from the tube feeding provided 1,800 calories/day, 99 gm of protein/day, 1691ml of free water for a total volume of 1,200ml. The estimated nutrient needs were calculated to include: 1,500 calories of last known weight from last admission assessment, 60 gm of protein of last known weight from last admission and 1500-1700 mL of fluid/day of last known weight from last admission. On 7/12/17, weight was documented in the EMR as 101.8 lbs. Nursing Progress Note dated 7/15/17 at 7:12 pm, documented the resident transferred to the hospital with a displaced total hip replacement. A Nursing Progress Note dated 7/16/17 at 4:37 pm, documented the resident returned to the facility at 3:30 am. Medical Progress Notes by Nurse Practitioner #1, dated 7/17/17 at 4:25 pm, documented a readmission assessment after returning from the hospital, and the plan was to continue with tube feedings. The EMARs dated from 8/1/17 - 8/31/17, documented Glucerna 200 mL every 4 hours; Flush with 65 mL of water before and after bolus. The order was transcribed as four times a day instead of every 4 hours; The EMAR documented the resident received the Glucerna 200 mL 4 times a day during this time frame On 8/22/17, weight was documented at 91 pounds. During an interview on 11/14/17 at 2:40 pm, the Registered Nurse Manager (RNM) #2 stated she was unaware of the resident's weight loss as the resident was admitted to her unit on 11/9/17. During an interview on 11/15/17 at 8:47 am, the Dietician stated she had increased resident's tube feeding to 300ml 5 times a day, not long ago, because she saw that the resident was losing weight. She stated it appeared to her she should increase the tube feeding because of the resident's weight loss. The Dietician stated she monitored residents' weights twice per week and if there was an issue, she sent the paperwork to the charge nurse for weights or re-weights. She could not provide documentation of communication concerning the resident's weight. During an interview on 11/16/17 at 2:30 pm, Nurse Practitioner (NP) #1 stated she was not aware the resident was not receiving the ordered amount of tube feeding, and that Dietary and the nurse managers should have been on top of the resident's weights and tube feedings. The fact the resident was not receiving the ordered amount of tube feeding for that extended period of time may have impacted the resident adversely. During an interview on 11/16/17 at 2:55 pm, MD #2 stated she was not aware of the resident's weight loss or that the resident received the Glucerna 4 times daily rather than every 4 hours. The physician stated this probably contributed to the resident's decline. During an interview on 11/17/17 at 8:14 am, Licensed Practical Nurse (LPN) #3 stated nurses input medical orders and then the orders were to be reconciled 3 times, and should have been reviewed with the eMAR. All nurses were supposed to read the entire order prior to administration and bring discrepancies to someone's attention. She also stated that weight loss was to be reported to the unit manager for follow up, and she believed the resident's decline was related to the lack of nutrition. During an interview on 11/17/17 at 8:27 am, the Registered Nurse Manager (RNM) #3 stated she expected all nurses to utilize the 5 rights of medication administration when following orders on the eMAR. When orders were being transcribed, they were supposed to be checked 3 times to be sure they were entered correctly on the EMAR. She stated she should have, dug deeper into the resident's weight loss. During an interview on 11/17/17 at 10:35 am, the Director of Nursing (DON), stated that there was a systems failure with transcription of physician orders. The resident should have been on intake and output, and assessed for her nutritional needs. Nursing should have noticed that the order was not correct when administering the tube feeding, and when the end of the month medication checks was completed. The facility was not compliant with regulations, and he is still investigating to see where the process fell through. During an interview on 11/17/17 at 11:50 am, the Medical Director stated that the resident's weight loss probably contributed to her decline and that there should have been follow up with dietary when the resident was on a tube feeding and losing weight. Resident #44: The resident was admitted to the nursing home on 6/8/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident sometimes understood and was sometimes understood by others. The initial nutritional assessment dated [DATE], documented that the resident weighed 113 pounds (lbs). The medical record did not include any further nutritional assessments. MD order dated 6/29/17, documented that the resident had a poor appetite, noted weight loss, and would monitor intake. The following weights were documented in the Medical Record (MR): 6/20/17 = 112.8 lbs 6/16/17 = 112.8 lbs 7/10/17 = 115.8 lbs 7/17/17 = 119.4 lbs 7/24/17 = 123.12 lbs 8/7/17 = 124.8 lbs 9/7/17 = 139.8 lbs 10/19/17 = 138.9 lbs 11/9/17 = 155.0 lbs A Dietary Progress Note dated 9/26/17, stated that the resident consumed 100% of most meals; The resident's weight was 137.8 lbs weight was a significant weight gain times 1 month but was not a problem for the resident; Weight stability was desirable and she would continue to monitor. The MD notes did not include any notes regarding the resident's weight gain. During an interview on 11/15/17 at 10:00 am, RNM #1 stated that she or the unit secretary entered the weights into the computer and that if there was a change then a re-weight wound be done; She was not aware of the resident's weight gain this month and a re-weight was not done. During an interview on 11/15/17 at 10:30 am, the RD stated she reviewed weights every 2 weeks and had requested a re-weight for the for the 11/9/17 weight but could not provide the documentation of the request; The resident had a wound so any weight gain was good and she would not notify the MD about weight gains because they a good thing. Additionally, the RD stated that she started at the facility on 9/5/17, so she would not have addressed the weight gain from (MONTH) to September. During an interview on 11/15/17 at 12:45 am, NP #1 stated that she was not notified of the 12 lb weight gain in 8/2017 - 9/2017 or the 15 lb from 10/2017 - 11/2017; The resident should have been re-weighed and she should have been notified in order to assess and treat the resident. Resident #2 The resident was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making; The resident understood and was understood by others. The Medical Record did not include a Comprehensive Nutritional Risk Assessment on this residents since the initial assessment done on 5/17/17. A MD order dated 8/7/17, documented Pro Stat 30 cubic centimeters (CC) with medication pass; Scheduled for 8:00 am and 8:00 pm. A review of the Medication Administration Record [REDACTED]. Of the 29 opportunities, the resident refused it 40 times. MD order dated 8/7/17, documented to obtain weekly weights every week on Tuesdays. The following weights were documented in the Medical Record (MR): 8/8/17 = 143.8 lbs 8/14/17 = 138.3 lbs 8/22/17 = no weekly weight recorded 8/29/17 = 134.4 lbs 9/4/17 = 130.8 lbs The first Dietary Progress note after the resident's readmission to the facility on [DATE], was dated 9/26/17, and documented that the resident ate mostly 100 %; The resident was on ProStat 30 mL twice daily with the medication pass. It did not address the recent weight loss or that the resident was consistently refusing the ProStat. During an interview on 11/14/17 at the RD stated that she just started at the facility in (MONTH) and would review the resident when they came up for review quarterly. During an interview on 11/14/17 at 10:05 am, the Registered Dietician (RD) stated she had just started at the facility in (MONTH) and would review the resident when they came up for review quarterly; The resident was on a protein supplement to add extra protein to her diet and it was documented on the resident's MAR; She looked at the MAR indicated [REDACTED]. 1/15/17 at 10:00 am, LPN #3 stated that the resident's weight was supposed to be done every day before [MEDICAL TREATMENT]; The CNAs are supposed to get the weights and the resident's requiring weights, were written on their assignment sheets but LPN #3 was having a problem getting them to get the weights and reported it to the NM. During an interview on 1/15/17 at 12:45 pm, RN #3 stated that she was aware that the weights are not being done and it had been a big problem on the unit to get the CNAs to get the weights. She has now instituted that weights need to be done before staff breaks 10 NYCRR 415.12(i)(1)

Plan of Correction: ApprovedJanuary 3, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F325:
Corrective Action regarding affected residents:
Resident #2, 44, 68, 87, 89, were re-evaluated by the Registered Dietician. A complete Dietary Assessment was completed.
Resident #2 ? RDN assessment completed on 11/13/17. Discussed food preferences for increase pro increased calories. Care Plan and Meal Tracker have been updated.
Resident #44 ? RDN reassessment and care plan updated on 11/29/17. NO change in medical nutrition therapy.
Resident #68 ? Reassessment by RDN on 12/4/17, care plan was updated, health shake added.
Resident #8 ? Resident assessed by RDN on 11/16/17, Health shake was added, care plan updated.
Resident #89 ? Resident reassessed on 11/24/17, care plan was updated, no change in medical nutritional therapy. Resident was discharged on [DATE]
Identification of other residents possibly affected and corrective actions taken:
All residents? wants were reviewed by RDN for past 90 days to identify all significant weight changes. Care Plans for those residents identifies as significant weight loss were reviewed by IDC. Primary Care Physician was made aware if a resident continuous trending weight change for review.
Measures put into place or systematic changes put into place to ensure the deficient practice does not recur:
The Administrator and Director of Nursing have reviewed and approved facilities policy for weight changes with corrections to monitoring weight change.
All residents receiving enteral feedings had their nutritional plans reviewed by the Registered Dietician and the Primary Care Physician to ensure proper amount of feeding is provided.
All Nursing staff have been re-educated to the facility policy pertaining to weight loss and nutritional standards.
All weights, including admission, weekly, monthly, will be reviewed at Morning Clinical Meeting when they are obtained. Any need for a re-weight or further assessment will be documented.
RDM will verify all weights prior to entry in EMR to ensure accuracy.
All weight changes will be reviewed at weekly at risk QPIP Meeting. Any further recommendation will be documented and implemented accordingly.
Any resident receiving enteral feeding will be reviewed on a monthly basis by RDM.
The facility will review supplement refusals on a weekly basis and communicate concerns to the physician.
Assistant Director of Nursing/Designee will review all new admission/readmission for compliance with facility policy.
How the current action will be monitored to ensure the deficient practice does not recur:
The facility will review all residents weights as part of the Weekly Risk Committee meeting as part of the QAPI process. Frequency of this monitoring is weekly as part of facility practice. This monitoring includes a review of the weight trend report to monitor any weight loss or gain; a review of any identified resident?s Care Plans; any medication changes or physician examinations. All residents receiving nutrition via tube feeding have their nutritional needs reviewed by the Registered Dietician on a monthly basis provided they do not trigger on the weight trend report. All changes that fall outside parameters are communicated to the PCP for further instructions.

Responsible party and date for correction:
Date of correction ? 1/11/18 Responsible person ? Registered Dietician

FF10 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: (d) Food and drink Each resident receives and the facility provides- (d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

Based on resident interview and staff interview during the recertification survey and abbreviated survey (Case # 5), it was determined that the facility did not provide food that is attractive and palatable. Five of 7 residents interviewed during the Quality of Life Assessment Group Interview (group interview) commented that food is overcooked, undercooked, and/or cold. This is evidenced as follows. The group interview conducted on 11/15/2017 at 10:30 am revealed that residents stated that oftentimes chicken is overcooked, vegetables are undercooked, and grilled sandwiches are burned when served at meals. The Food Service Director was interviewed on 11/16/2017 at 8:30 am. He stated that when he was hired in (MONTH) (YEAR), he became aware of multiple problems with the food service including late meals, cold food, and the food not being palatable. Continuing, he stated that he is addressing the timeliness of meals and retraining staff on palatable food preparation, and will be implementing new menus with the intention of using steamtable service on the resident units. 10 NYCRR 415.14(d)(1)(2)

Plan of Correction: ApprovedDecember 18, 2017

F 364
Corrective Action regarding affected residents:
The facility will ensure that each resident receives food that is palatable, attractive and served at the proper temperatures, hot and/or cold.
Identification of other residents possibly affected and corrective actions taken:
All residents have the ability to be affected by the deficient practice.
Measures put into place or systematic changes put in place to ensure the deficient practice does not recur:
The Dietary Department will maintain temperatures of hot and cold food throughout each meal service. Hot foods will be maintained at a minimum of 140F degrees and cold foods will be maintained at a maximum of 41F degrees.
All food will be prepared in a manner which is both appetizing and maintains its nutritional value
?
Food temperatures will be taken prior to the food leaving the kitchen.
? Food temperatures will also be taken prior to serving in each of the dining rooms on the nursing units by dietary supervisor via test trays. Test tray temperatures will be completed on 1 unit per day for all 3 meals
?
Re-inservice all dietary staff on required food temperatures for hot and cold foods
?
In-service all staff to ice down all milks and juices before each meal service
? In-service cooks on proper recipe use, cooking techniques and safe food handling
? In-service dietary staff on proper plating and food presentation
How the current action will be monitored to ensure the deficient practice does not recur:
?
Food temperature log will be checked daily to assure food temperatures are being maintained.
?
If temperature is not within range, prior to serving the residents, the Food Service Manager will be notified immediately and corrected
? Test trays will be prepared each meal and checked by a senior dietary staff member for taste, appearance, temperature and presentation. Any issues will be communicated to the dietary department and corrected immediately. These tests will be done daily for 4 weeks then weekly for 2 months then frequency adjusted as determined by QAPI results

Responsible Party and Date for Correction:
The Food Service Manager is responsible for the correction of this deficiency and continued compliance.
All measures will be completed by 1/11/18
Findings will be reviewed by the Q&A committee for continued compliance.

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: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one Resident (#4) of one reviewed for continuous ambulatory peritoneal [MEDICAL TREATMENT] (PD) (a tube permanently inserted through the abdomen to allow a fluid called [MEDICATION NAME] to be emptied and replaced every day to cleanse the body of built up toxins). Specifically: the facility did not ensure that PD was not given and/or held without contacting the [MEDICAL TREATMENT] center for direction, that weights were obtained as required by [MEDICAL TREATMENT] and MD orders and that the MD was notified when the resident's abdominal girth was more than 113 cm. This is evidenced by: The Policy and Procedure for Peritoneal [MEDICAL TREATMENT] revised 7/19/17, documented under procedure to document the [MEDICAL TREATMENT] catheter exit site daily and to notify MD for antibiotic orders if signs of infection were noted; Other complications associated with peritoneal [MEDICAL TREATMENT] are rapid change in potassium level, initial hypovolemia, transfusion reaction, [MEDICATION NAME] syndrome, fluid or low sodium level and improper [MEDICATION NAME]; Residents should be monitored for complication during each exchange and up to one hour post procedure. The policy contained no further information, or reference, to follow [MEDICAL TREATMENT] center policies and procedures. Resident #4 The resident was admitted to the nursing home on 10/16/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and that the resident usually understood and was usually understood by others. A Physician order [REDACTED]. The Resident's admission weight was not obtained until 10/24/17, seven days after the resident was admitted . A Peritoneal [MEDICAL TREATMENT] Prescription dated 10 30/17 from the [MEDICAL TREATMENT] center documented the resident was to receive PD twice daily seven days a week: Solution to be used was 1.5%; Drain only 750 cc out each time and replace with only 250 cc each time. It documented to continue above order until notified by the MD or PD nurse; Notify the PD nurse if the blood pressure (BP) was low or elevated, if residents weight increased or decreased more than 3 pounds (lbs) of signs or fluid overload. Additionally, it included contact numbers during business hours, the number for the on-call PD nurse, and the number for the afterhours on-call number for the MD. The prescription included in capital letters that the PD nurses are not on call after 8:00 pm and to contact the MD. A physician's orders [REDACTED]. The order did not include directions for complications or contacting [MEDICAL TREATMENT], as was specified in the prescription. During an interview on 11/13/17 at 11:30 am, the resident's spouse stated that the resident was supposed to get a PD exchange twice daily and to call the MD if the resident's blood pressure was low; The nurse did not call the MD when the resident's blood pressure was low and did not perform the PD exchange and the resident's condition went down hill. A review of the Weekly Manual Exchange Worksheet PD (Exchange Logs) (a sheet to document the time of exchanges, vital signs, weight, the concentration of [MEDICATION NAME] used, how much fluid was drained from the abdomen, and how much [MEDICATION NAME] was put back in the abdomen) and eMAR dated from 10/30/17 - 11/4/17, documented that the resident had two PD exchanges on 10/30/17 and one on 10/31/17, prior to the order being written by the resident's nursing home doctor. The Worksheet did not include initials to indicate who did the exchange. The eMAR did not include an entry for the PD exchange until 11/31 at 8:00 pm. The Exchange Logs, for the 8 opportunities for PD exchanges from 11/4/17 - 11/7/17, the worksheet included documentation of the exchanges 2 occasions. The eMAR dated from 11/4/17 - 11/7/17, documented that PD was held on 11/6 at 8:00 pm, and 11/7 at 8:00 am and 8:00 pm. A Physician order [REDACTED]. A review of the PD Exchange Logs dated from 11/3/17 - 11/13/17, included boxes to document the resident's weight daily with PD. Of the 10 days during this time frame, the worksheet included documenatation that 3 weights were done. The medical record did not include weights for 7 of the 10 days from 11/3/17 - 11/13/17. The Progress Notes included following PD documentation: 11/6/17 at 2:37 pm, PD was completed and tolerated well. 11/7/17 at 8:20 pm, late note for 11/6/17 3:00 pm - 11:00 pm; BP 94/51; PD held due to blood pressure call placed to [MEDICAL TREATMENT]; PD held. 11/7/17 at 8:39 pm, late note for 11/7/17 confused PD held again call out to [MEDICAL TREATMENT] center. The Progress Notes did not include any further reference to the resident's PD during this time frame. The medical record did not include any further documentation regarding the resident's PD. A progress note dated 11/7/17 at 6:22 pm, by the Nurse Practitioner, documented that the resident was seen for a change in mental status; Nurses reported the resident was more groggy and confused over the past few days and he had missed a couple PD exchanged because of his blood pressure; the resident reported feeling weak but refused to go to the emergency room for evaluation. A Physician order [REDACTED]. An eMAR dated from 10/20/17 - 11/10/17 documented that the resident's abdominal circumference was over 130 cm (51.15 ) on 8 occasions. The medical record did not include any evidence that the MD was contacted on any of the 8 occasions the abdominal circumference was over 130 cm. A Staff Development sign in sheet for education on [MEDICAL TREATMENT], dated 6/9/17 and 6/12/17, did not include Licensed Practical Nurse (LPN) #6 as being educated on [MEDICAL TREATMENT]; the [MEDICAL TREATMENT] Registered Nurse's (DRN) education file did not include post-tests for Nurses #'s 3, 5, & 6. Of the seven nurses that signed they performed the resident's PD in the Electronic Medical Record (EMAR) from 10/30 - 11/13/17, four signed, as being present for the inservice and 1 completed the post test. Interviews: During an interview on 11/14/17 at 4:10 pm, Licensed Practical Nurse (LPN) #5 stated she was told verbally on 11/2/17 by LPN #6, to hold the PD if the Systolic (top number) Blood Pressure (SBP) was less than 100; She held the PD exchange at 8:00 am on 11/7 and at 8:00 pm on 11/4, 11/6, and 11/7; She left a message for [MEDICAL TREATMENT] on one occasion but had not heard back and she notified the RNS on another occasion; She did not document when she gave or held the PD in the resident's chart but should have and did not document on the PD Exchange Logs because it was not in the room; She did not know why she signed that she did the PD on 11/4 at 8:00 pm; She may have done it by accident thinking she performed the PD. Additionally, on 11/16/17 at 8:36 am, LPN #5 stated that she was educated previously and when the resident was admitted , the DRN gave her an overview on how to do the PD but did not recall instructions on what to do if the resident had low blood pressure. During an interview on 11/14/17 at 3:45 pm, LPN #3 stated that she did not write the PD prescription as an order on 10/30/17 but should have; One of the abdominal circumferences that were over 113 cm was done by her. On 1/15/17 at 10:00 am, LPN #3 stated that the resident's weight was supposed to be done every day before [MEDICAL TREATMENT]; LPN #3 was having a problem getting the Certified Nursing Assistants (CNA) to get the weights and reported it to the NM. On 1/15/17 at 10:00 am, LPN #3 stated that the resident was a brand-new PD resident and that had never had a new PD before; They usually didn't have orders about calling the PD center of PD nurse but he was different and could not be left alone during the PD exchange. Additionally, LPN #3 stated that there was a copy of the [MEDICAL TREATMENT] prescription kept in the resident's chart if there were any questions. During an interview on 11/16/17 at 10:30 am, LPN #6 stated that she had spoken to [MEDICAL TREATMENT] and was given instructions to hold the PD and call the [MEDICAL TREATMENT] center; She did not write it as an order because she thought it was just a monitor. During an interview on 11/15/17 at 8:15 am, the DRN stated that she works in the [MEDICAL TREATMENT] center but oversees the PD in the nursing home; When the resident was admitted , they were just removing excess fluid and not putting [MEDICATION NAME] back in, but when he started PD on 10/30/17, she put exchange logs in the resident's room. On 11/16/17 at 9:15 am, the DRN stated that she gets notified by the hospital liaison when a resident is being admitted on PD and then she would educate staff; Contacting [MEDICAL TREATMENT] about blood pressure issues was part of the inservice; She did post- tests but didn't always get them back from staff; She usually has a sign sheet of who got inserviced; She does not know everyone who has been trained; It is the responsibility of the facility to know who is trained. During interviews on: 11/13/17 at 4:30 pm, RNM #3 stated that staff should have been documenting twice daily how much fluid was taken off and put back in as well as an evaluation of the resident before and after the treatment; She got a copy of the 11/14/17 at 3:30 pm and 4:05 pm, LPN #3 took care of all the peritoneal [MEDICAL TREATMENT] residents and orders because she was knowledgeable about PD. There was no order to hold the PD but should have been if it was held. Additionally, the nursing supervisor was not notified that it was held nor was it put on the 24-hour report. 11/15/17 at 12:45 am, RN #3 stated that she was aware that the weights were not being done; It had been a big problem on the unit to get the CNAs to get the weights. She has now instituted that weights need to be done before staff breaks. During an interview on 11/15/17 at 3:15 pm, the NP stated she saw the resident per the request of staff on 11/7/17 for mental status changes; and was told at that time PD was held because the resident's blood pressure was low; Her impression was that the DRN gave direction to hold it; The NP stated that the resident was confused, shaky, and weak and stated that the resident was septic appearing but refused to go to the hospital; She did not realize until the surveyor showed her, how many PDs were missed and stated that could have been the reason the resident was in that condition when she saw him on 11/7/17. During an interview on 11/16/17 at 9:25 am, the Director of Nursing (DON) stated that the [MEDICAL TREATMENT] center kept the PD training records and that there was always someone who knew how to do [MEDICAL TREATMENT] working. The DON was unable to say how they would know who was trained if the training records were at the [MEDICAL TREATMENT] center and it was off hours or the weekend. During an interview on 11/16/17 at 12:30 pm, the MDIR stated that the [MEDICAL TREATMENT] center or the MD should have been notified before PD was held and if the order was to contact the MD if the abdominal girth was above 130 cm, then it should have been done. Additionally, the MDIR stated that he oversaw the facility policies but had not seen the [MEDICAL TREATMENT] policy, Additionally, the MDIR stated that it would make sense to add, as per [MEDICAL TREATMENT] center instructions to their existing policy because it did not include procedures. 10NYCRR 415.12

Plan of Correction: ApprovedJanuary 3, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F309:
Corrective Action regarding affected residents:
Resident orders were reviewed by Primary Care Physician and [MEDICAL TREATMENT] RN, following changes were implemented 12/14/17.
Director of Nursing has identified and listed all nurses having documented as completing training and compliance. Daily schedule will identify the nurse assigned to peritoneal [MEDICAL TREATMENT].

Identification of other residents possibly affected and corrective actions taken:
There are no other peritoneal [MEDICAL TREATMENT] residents in the facility at this time.


Measures put into place or systematic changes put into place to ensure the deficient practice does not recur:
Registered Dietician has reviewed all current residents? weight orders for compliance with residents? orders/care plan.
Assistant Director of Nursing/designee has reviewed all the residents EMR, MAR, TAR and 24-Hour Reports for past 30 days to identify any resident that have had a change in condition for Medical Doctor notification.
All orders pertaining to peritoneal [MEDICAL TREATMENT] including peritoneal [MEDICAL TREATMENT] prescription.
All peritoneal [MEDICAL TREATMENT] Orders will be added to EMR to facilitate monitoring.
The facility worked with the [MEDICAL TREATMENT] Center to revise policy and procedures for Peritoneal [MEDICAL TREATMENT] to include obtaining weights, abdominal girth and blood pressures, on which nursing staff was in-serviced.

In addition the Facility and [MEDICAL TREATMENT] Center collaborated to:
? Create standard PD orders which will be built into the EMR system
? Create an orientation/training for nursing staff who will provide PD
? Create a weekly manual exchange worksheet to monitor the PD
? Create a CAPD test to verify nurses? knowledge of the policy and procedure
? Create a PD Nurse Competency to audit proficiency with this procedure

How the current action will be monitored to ensure the deficient practice does not recur:

The facility will review all residents on PD [MEDICAL TREATMENT] as part of the Weekly Risk Committee meeting as part of the QAPI process. Frequency of this monitoring is weekly as part of facility practice.

Responsible party and date for correction:
The Director of Nursing will be responsible to ensure compliance by 1/11/18.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not utilize extension cords and power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.4 requires that all electrical adapters be listed for the purpose. NFPA 70 National Electrical Code 2011 Edition Article 590 section 590.3 (D) requires that temporary wiring, such as extension cords, shall be removed immediately upon completion of construction or purpose for which the wiring was installed, and the use of multi-plug adapters is prohibited. Specifically, multi-plug extension cords, multi-plug adapters, and non-compliant power strips were used to power patient care and non-patient care electrical devices in 5 of 8 resident care areas checked. This is evidenced as follows. A selection of resident areas was inspected for the use of power strips, extension cords, and multi-plug adapters on 11/15/2017 at 10:00 am. A non-compliant power strips were used to power a suction machine in resident room [ROOM NUMBER] and personal electronics in resident room [ROOM NUMBER]. Multi-plug extension cords were used to power personal electronics in resident rooms [ROOM NUMBERS]. A multi-plug adapter was used to power electronics in the physical therapy room. The Maintenance Supervisor stated in an interview conducted on 11/15/2017 at 11:00 am, that removing extension cords and power strips from resident rooms is non-stop to the point where he cannot keep on top of it. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.4; 2011 NFPA 70 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedJanuary 9, 2018

The facility will adhere to the specific codes that govern the use of power strips in the facility.
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 -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
The non-compliant power strips and multi-plug adapters identified in the Life Safety Inspection Report (rooms 225, 131, 119, 128 and the physical therapy room) were replaced with ones that meet the proper UL standards for the proper condition.
Facility staff will notify current residents of the use of power strips, multi-plug adapters and extension cords at resident council and inform all new admissions of these standards. This information will also be included in the Family Council Newsletter.
Maintenance, housekeeping and nursing staff will be in-serviced on these standards and will be responsible for ensuring non-compliant power strips and multi-plug adapters are not used in the facility.
A complete facility audit was conducted in all resident and non-resident areas to ensure that no extension cords, multi-plug adapters and non-compliant power strips were in use. With the exceptions of the items identified in this citation, no others were found to be in use.
Housekeeping staff will conduct daily rounds during their normal work day to ensure that non-compliant power strips and multi-plug adapters have not been brought in from the prior day.
These rounds will be conducted daily for 4 weeks then weekly for 4 weeks then monthly for 3 months.
The Housekeeping Director will be responsible for this. Corrective action to be completed by 1/11/18

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 17, 2017
Corrected date: January 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.1.1 requires automatic sprinkler protection throughout the premises. Specifically, automatic sprinkler protection was encumbered with unacceptable obstructions and was not provided in all areas. This is evidenced as follows. Observations on 11/14/2017 at 9:00 am and again on 11/15/2017 at 7:30 am, revealed that automatic sprinkler protection was missing in the loading dock canopy under which combustible materials, such as plastic crates and racks and cardboard, are stored. Observations of the sprinkler system on 11/15/2017 at 8:15 am, revealed that light fixtures obstructed the automatic sprinkler protection in the 1-South and 2-North soiled utility rooms and the maintenance shop and restroom. The Maintenance Supervisor stated in an interview on 11/15/2017 at 11:00 am, that combustible materials should not have been stored under the loading dock canopy and the light will be moved to remove the obstructions. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.1.1, 8.15.7.5

Plan of Correction: ApprovedDecember 18, 2017

The facility will continuously maintain the automatic sprinkler system in reliable operating conditions and assure they are inspected and tested periodically. The facility will assure sprinkler heads are maintained in reliable operating conditions allowing them to give full coverage.
Maintenance will remove the obstructions from the sprinkler system in the maintenance shop restroom, the 2-North and 1-South soiled utility rooms and in the maintenance shop.
Dietary staff were in-serviced on not storing items under the loading dock canopy and all combustible items were removed from the area. The area will be checked daily by the Food Service Director/designee to ensure no combustible items are stored there.
The Sr. Maintenance Mechanic will audit the facility to assure that all sprinkler heads are unobstructed and that they provide full coverage to the intended areas. When removing items that are obstructing sprinkler heads, a re-evaluation of the sprinkler head will be completed to assure there are not additional obstructions.
The facility will institute the following measures to assure the deficient practice does not recur;
? The Sr. Maintenance Mechanic will meet with all contractors prior to them performing work in the building. He will review the pertinent NFPA 101 Life Safety Code Standard.
? Upon completion of work performed by a contractor, the Sr. Maintenance Mechanic will perform a walk through with contractor(s) to assure the work complies with the NFPA 101 Life Safety Code Standards, and specifically, that there are no obstructions to the sprinkler heads.
The corrective action will be monitored as follows:
? Sr. Maintenance Mechanic will audit the facility to assure sprinkler heads are not obstructed and provide full coverage to the intended area. Audits will be completed 1x per month for 3-months.
All findings will be reported to the Quality Assurance Committee who will determine a monitoring schedule thereafter.
The Senior Maintenance Mechanic is responsible for the correction of this deficiency and continued compliance.
All measures will be completed by 1/11/18.

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: November 17, 2017
Corrected date: January 18, 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 8.5.2 requires that smoke barriers be continuous from floor to floor and outside wall to outside wall, and section 8.5.6 requires that penetrations and miscellaneous openings in smoke barrier walls be sealed with materials capable of maintaining the smoke rating of the smoke barrier wall. Specifically, openings in 1 of 1 smoke barriers observed were not continuous and penetrations were not sealed with the appropriate materials. This is evidenced as follows. The 1st floor smoke barrier wall (wall) was inspected on 11/15/2017 at 8:30 am. All observations were from above the suspended ceiling. Throughout the length of the wall small spaces were sealed with non-fire rated materials, such as joint compound and insulating foam. In resident room 125 a 10-inch by 6-inch hole, a 4-inch hole, and a 1-inch hole were found. In resident room 122 two 4-inch holes were found. The Maintenance Supervisor stated in an interview conducted on 11/15/2017 at 11:00 am, that the joint compound and foam were applied before he was hired and that the holes found were from recent construction. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedJanuary 2, 2018

The facility will assure that smoke barriers are constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3.
Maintenance staff will repair penetrations identified during the standard recertification survey on the 1st floor smoke barrier wall; Room 125 and Room 122.
The Maintenance staff will audit the entire facility to assure that all smoke barrier walls are intact and contain no penetrations.
The policy regarding smoke barrier walls was reviewed on (MONTH) 12, (YEAR). The policy will be reviewed with the maintenance staff.
The Senior Maintenance Mechanic will conduct semi-annual audits of all smoke barrier walls as identified in the facility?s fire plan for 1 year. All findings will be reported to the Quality Assurance Committee who will determine a monitoring schedule thereafter.
The Senior Maintenance Mechanic is responsible for the correction of this deficiency and continued compliance.
All measures will be completed by 1/11/18.

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: November 17, 2017
Corrected date: January 18, 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 8.6.2 requires that the walls to vertical openings, such as stairwells, be continuous from floor to floor or floor to roof. Specifically, the walls of stairwell #3 were not continuous from floor to the underside of the roof and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. The maintenance stairwell was inspected on 11/15/2017 at 11:10 am. Viewing above the suspended ceiling in the corridor, a 7.5-foot by 6-inch section was found where the stairwell wall did not meet the underside of the floor-ceiling assembly. The Maintenance Supervisor stated in an interview conducted on 11/15/2017 at 11:10 am, that what was found was from original construction, and the area will be repaired. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedDecember 18, 2017

The facility will assure that all vertical openings are constructed to provide at least a two hour fire resistance rating and constructed in accordance with 8.6.2. It should be noted that this opening was part of the original construction in 1975
Maintenance staff will enclose the vertical opening, extending it to the underside of the roof identified during the standard recertification survey in stairwell #3. The enclosure will be constructed in the manner described to facility staff by the NYS DOH Surveyor.
The Maintenance staff will audit the entire facility to assure that all stairwell walls are continuous extending to the underside of the roof.
As this is a onetime correction, further follow up is not required after the vertical openings are properly enclosed.
The Senior Maintenance Mechanic is responsible for the correction of this deficiency and continued compliance.
All measures will be completed by 1/11/18.