Wingate at Beacon
September 25, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.10(f)(10)(iii):ACCOUNTING AND RECORDS OF PERSONAL FUNDS

REGULATION: §483.10(f)(10)(iii) Accounting and Records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: September 25, 2018
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure that residents consistently received quarterly statements in writing regarding their personal fund accounts. Specifically, 1 of 1 residents (#19) reviewed for personal funds did not receive a written statement of his personal funds account since his admission to the facility in 2013. The facility policy stated that the business office representative/designee will print the individual resident statements quarterly. Residents determined by the Social Worker as capable of receiving their statements will receive a copy of their quarterly statements. The finding is: Resident #19 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (a resident assessment tool) of 6/29/18 indicated the resident had no cognitive impairment with daily decision making. The resident was interviewed on 9/19/18 at 2:00 PM and was asked if he receives personal fund statements at least quarterly. The resident stated he had not received a statement since he was admitted in 2013. The facility administrator was interviewed on 9/24/18 at 12:00 PM and stated that the employee responsible for providing residents with quarterly statements was not available at that time and he would provide Resident #19 with a statement as soon as possible. The resident was interviewed on 9/24/18 at 2:00 PM and stated he had just received his first statement. The resident further stated the Administrator informed him that going forward he will receive a statement quarterly. 415.26(h)(5)(iii)

Plan of Correction: ApprovedOctober 10, 2018

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.
The facility Administrator will ensure that residents receive quarterly statements of their personal funds, and upon request.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation conducted during a recertification survey, the facility did not develop person-centered care plans with measurable objectives, time frames and interventions for 7 of 18 residents reviewed for care planning to address: - monitoring of daily weights for 1 of 1 resident (#52) reviewed for activities of daily living; - use of medication given for elevated cholesterol for 1 of 6 residents (#45) reviewed for unnecessary medications; - pressure ulcers for 1 of 4 residents (#86) reviewed for pressure Ulcer/Injury; - [MEDICAL CONDITION] and use of [MEDICAL CONDITION]-embolic deterrent (TED) stockings for 1 of 1 residents (#124) reviewed for positioning and mobility; - pain management for 1 of 1 residents (#108) reviewed for pain management; - the use of a restraint for 1 of 1 resident (#96) reviewed for physical restraints; and - accidents for 1 of 4 residents (#130) reviewed for accidents. The findings include, but are not limited to: 1. Resident # 86 has [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set; a resident assessment tool) dated 8/3/18 documented that the resident had a moderately impaired cognitive skills for daily decision making, required supervision of one person for most aspects of activities of daily living (ADL); was occasionally incontinent of bladder and bowel; was at risk for developing pressure ulcers; and had one Stage 3 pressure ulcer (sacral region) measuring 1.4 x 0.5 x 0.5 cm. There was no documented evidence that a person-centered care plan with measurable objectives, timeframes and interventions was initiated to address the resident's risk for developing pressure ulcer and the care of the resident's existing pressure ulcer. The resident was interviewed on 9/18/18 at 1:45 PM and stated that she has a sore on her 'behind for 5 months and it is uncomfortable but not painful. The physician's wound progress notes and the nursing notes revealed that the pressure ulcer was noted on 8/7/17 as a Stage II on the right inner buttock and was treated and healed as of 10/2/17. The wound reoccurred on 3/15/18 as a Stage II which deteriorated to a Stage III on 4/23/18. The physician's wound progress notes of 9/18/18 revealed that the pressure ulcer is currently a healing Stage III. The unit Registered Nurse Manager (RN #3) was interviewed on 9/25/18 at 12:25 PM and was unable to provide a care plan that addresses the existing pressure ulcer to include interventions to prevent development of further pressure ulcers.
2. Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS of 8/21/18 indicated the resident had severely impaired cognitive skill for daily decision making and required extensive assistance to being totally dependent on 1-2 person assistance for most activities of daily living. The Physician order [REDACTED]. The PO order of 9/6/18 included the use of venodynes (a device placed around the legs that inflates and deflates to keep blood circulating in the legs to help prevent the formation of blood clots) and a hematology consult for a [DIAGNOSES REDACTED]. The nursing progress note of 9/7/18 documented that the resident was positive for [MEDICAL CONDITION] of the RUE, venodynes for the legs were ordered, and to apply TEDs stockings until the venodynes arrive. There was no care plan with measurable objectives, time frames and interventions to address the Acute RUE [MEDICAL CONDITION], the use of venodynes, and the use of TED stockings. Observations were conducted on 9/20/18 at 12:30 PM, 9/21/18 at 9:30 AM and 9/21/18 at 12:39 PM. At the time of these observations, the resident was in bed and there were no TED stockings applied to the resident's lower extremities. During an interview on 9/21/18 at 10:56 AM with the Director of Nursing, she stated that the Physician Assistant requested TED stockings to be worn 12 hours on and 12 hours off, even when the resident was in bed. When asked who was responsible for initiating care plans, she said the nurse managers were responsible but since the nurse manager resigned, she was responsible. She said there did not appear to be a care plan in place to address the [MEDICAL CONDITION] and the use of the TED stockings, and she would put one in place. 3. Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS of 8/1/6/18 documented that the resident had severely impaired cognitive skills for daily decision making; required extensive assistance of one person for most aspects of activities of daily living; had a fall in the last 2-6 months prior to admission and was receiving 6 days of physical therapy and occupational therapy. This MDS further indicated the resident used a bed alarm daily and there were no physical restraints used. The Physician order [REDACTED]. The nursing progress notes (NPN) of 9/2/18 documented that the resident was non-compliant with transfers, and walking alone with shoes untied. The NPN of 9/5/18 indicated the resident was walking without assistance, frequently standing, chair alarm was put in place, and a self-release seatbelt was applied and the resident demonstrated ability to release the seat belt. Observations were conducted on 9/18/18 at 10:45 AM and 2:00 PM. The resident was standing in front of his wheelchair and was attempting to lift his right leg up and over the wheelchair seatbelt which was around his legs at knee level and clipped together (unopened). There was no documented evidence that the following were done: - a doctor's order to address the use of the seat belt including the reason(s) for its use was done, - an assessment to determine options prior to the use of the seat belt; - a care plan with measurable objectives, time frames and interventions to address its use. The 8/18/18 care plan initiated for at-risk for falls only addressed the use of bed and chair alarm. The Director of Nursing (DON) was interviewed on 9/25/18 at 11:20 AM and she stated there should have been a physician's orders [REDACTED]. Following surveyor intervention, physician orders [REDACTED]. The care plan was then initiated for the use of the self-release seatbelt and two quarter side rails with interventions including self-release seatbelt applied as ordered, encourage resident to self- release on command, monitor response to self-release seatbelt, assess for reduction quarterly and prn (as needed), and monitor for changes in behaviors and ADL (Activities of Daily Living). The resident's wife also initiated an Informed Consent for the Use of Physical Restraints Assistive Device for the use of an alarmed self-release seatbelt. 415.11(c)(1)


Plan of Correction: ApprovedOctober 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The RN Unit Manager/designee will develop and implement comprehensive person-centered care plans for resident #52(monitoring daily weights), #45(cholesterol medication), #86(pressure ulcer care and prevention), #124([MEDICAL CONDITION] and use of TED stockings), #108(pain management), #96(use of restraint/seat belt), and #130(accidents) to include measurable objectives, time frames, and appropriate interventions based on comprehensive assessments.
The RN Unit Managers/designee will develop comprehensive person-centered care plans with measurable objectives, time frames, and interventions based on comprehensive assessments for all residents on daily weights, on cholesterol medication, with pressure ulcers, with [DIAGNOSES REDACTED].
The ADON/designee will in-service all RN Unit Managers on developing comprehensive person-centered care plans with measurable objectives, time frames, and interventions based on comprehensive assessments.
The DON/designee will review 5 resident records per unit each month to ensure residents on daily weights, on cholesterol medication, with pressure ulcers, with [DIAGNOSES REDACTED]. The audit results will be presented at the monthly Quality Assurance/Performance Improvement meeting for three months after which time the QA/PI committee will determine the frequency of the audits.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure for 1 of 5 residents reviewed for unnecessary medications (#11) that monthly medication regimen reviews performed by the consultant pharmacist were consistently reviewed and acted upon by the attending physician or medical director. The finding is: Resident #11 was admitted with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set; a resident assessment tool) dated 6/22/18 revealed the resident's BIMS score (Brief Interview for Mental Status) was 3 out of 15 which indicated that her cognition was severely impaired. This MDS assessment further revealed the resident was prescribed an antipsychotic ([MEDICATION NAME]), an antidepressant ([MEDICATION NAME]), and a diuretic ([MEDICATION NAME]) during the last seven days of the assessment period. The monthly medication regimen reviews conducted by the consultant pharmacist for the last 6 months revealed irregularities were identified for the months of April, May, (MONTH) and (MONTH) (YEAR). Further record review revealed no documented evidence that the attending physician reviewed or acted upon these irregularities. The Director of Nursing was interviewed on 9/25/18 at 1:00 PM and had no response as to why these findings have not been addressed by the physician. She stated that she would notify the attending physician. A phone call was made to the attending physician and was not returned. 415.18(c)(2)

Plan of Correction: ApprovedOctober 15, 2018

The Attending Physician/designee will address all identified irregularities reported by the Consulting Pharmacist for resident #11.
All current resident irregularities identified by the Consulting Pharmacist in (MONTH) (YEAR) and forward will be addressed by the Attending Physician/designee.
All Attending Physicians and their physician extenders, DON, ADON, Unit Managers will be in-serviced by the Medical Director/designee on the drug regimen review policy and procedure and the requirement to address all Consulting Pharmacist irregularities.
Five residents on each of the four units will be audited monthly by the DON/designee to ensure any drug irregularities identified by the Pharmacy Consultant have been addressed by the Physician/designee. The results of the monthly audits will be presented at the monthly QA/PI meetings by the DON for the next three months at which time the QA/PI Committee will determine the frequency of the audits.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that foods brought in from outside sources were stored according to professional standards of food safety practice on 2 of 4 facility units (Putnam and Dutchess). Specifically, multiple containers of food brought in for residents by family members were observed to be out dated. The facility policy did not indicate how long the food could be kept in the refrigerators. The findings are: The refrigerators on the units were observed on 9/25/18 between 1:30 PM to 2:00 PM: 1. Putnam - Multiple outdated food items; - Plastic container of an unidentified food dated 9/6/18 - 19 days; - Plastic container of rotisserie chicken dated 9/16/18 - 9 days; - Sandwich and salad that came from the kitchen dated 9/18/18 - 7 days; - Two store bought cakes with no date; and - A bag of plums with an (MONTH) date. The refrigerator was sticky on the inside. The Registered Nurse present at the time of observation stated she would throw out all the outdated and undated food. When asked who was responsible for cleaning the refrigerators she stated she wasn't sure and thought it was the kitchen department. 2. Dutchess - A plastic bag of potato salad had no label and was undated. The Licensed Practical Nurse who was present at that time stated she would throw it away. There were no instructions indicating how long the foods can stay in the refrigerators before being discarded. The Food Service District Manager (the Food Service Manager was not available) was interviewed at 2:00PM on 9/25/18 and she stated that the kitchen was responsible for cleaning the unit refrigerators and discarding outdated food. When asked how long food can be kept in the unit refrigerators, she stated she thought it was 3 days. Review of the Policy and Procedure for Food from Outside Sources dated (MONTH) (YEAR) included the following statement: Perishable food should be sealed, labeled with the resident's name and room number, dated with a use by date and placed in the refrigerator. There is no indication in the policy of how long foods brought in from outside for the resident can be kept in the refrigerator. 415.14(h)

Plan of Correction: ApprovedOctober 15, 2018

The undated and outdated food items in the Putnam and Dutchess unit refrigerators were discarded.
The Orange unit and Ulster unit refrigerators were checked to ensure compliance.
The policy and procedure for Food from Outside Sources will be revised to include the dated items could be kept in the refrigerators for three days. All staff will be in-serviced on the policy and procedure by the ADON/designee. The Food Service Director added signage to each unit refrigerator indicating the food items must be labeled, dated and discarded in three days. The Food Service Director will assign a staff member to check the unit refrigerators and discard any undated or outdated food items daily.
The Food Service Director/designee will audit by observing the contents of each unit refrigerator weekly to ensure food items are dated and not retained in the refrigerator beyond three days. The Food Service Director/designee will report audit findings at the monthly QA/PI meetings for three months after which time the QA/PI committee will determine the frequency of the audits.

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(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; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview conducted during a recertification survey, the facility did not ensure that each resident's medication regimen was free from unnecessary medications for 1 of 5 resident (#11) reviewed for unnecessary medications. Specifically, the resident's behavior and response to the use of the antipsychotic medication ([MEDICATION NAME]) was not consistently monitored in order to justify the ongoing use of the medication. The finding is: Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set; a resident assessment tool) dated 6/22/18 revealed the resident's BIMS score (Brief Interview for Mental Status) was 3 out of 15 which indicated that her cognition was severely impaired. Review of the admission physician's orders [REDACTED]. The care plan for behaviors that was last updated on 1/25/18 documented the following behaviors were present - refusal of cares, refusal of medications and refusal to ambulate. The intervention to address these behaviors was to reapproach the resident at a later time. The Psychiatric evaluation of 9/10/18 documented a recommendation not to reduce the dose of [MEDICATION NAME] based on the high risk of decompensation. It further documented that the resident stated she does not need her medications and at times will not take them. The evaluation documented that when the resident was asked questions, she becomes irritable, angry and delusional. It further stated that the resident had no insight and her judgement was limited. Review of the monthly behavior notes revealed two notes dated (MONTH) (YEAR) and (MONTH) 20, (YEAR). The (MONTH) (YEAR) note documented no behaviors noted. The (MONTH) 20, (YEAR) note documented her behaviors were stable. Further review revealed no documented evidence of any other behavior in the medical record to justify the ongoing use of [MEDICATION NAME] at least with the current dose. The unit Registered Nurse manager was interviewed on 9/25/18 at 3:00 PM and stated that the above notes were the only behavior notes in the resident's record. 415.12(l)(2)(ii)

Plan of Correction: ApprovedOctober 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Attending Physician will review the medication regimen of resident #11 and revise medications as medically indicated.
The Attending Physicians will review the medication regimen of all residents on [MEDICAL CONDITION] medications to ensure that each resident's medication regimen is free from unnecessary medications.
The Assistant Director of Nursing/designee will educate the RN Unit Managers, Attending Physicians, Physician Extenders, and Psychiatrist of the requirement to review each resident's medication regimen for necessity and to document the justification for continued use of [MEDICAL CONDITION] medications or attempt a dose reduction. The RN Unit Managers will complete a Nursing Monthly Behavior Note to include behaviors, non-pharmaceutical interventions, and effectiveness of the [MEDICAL CONDITION] medication.
The DON/designee will audit 20 medical records of residents on a [MEDICAL CONDITION] medication each month for documentation that justifies the ongoing use of the medication or a dose reduction is attempted. The Director of Nursing will report the audit findings monthly at the Quality Assurance/Performance Improvement Committee for three months after which time the QA/PI committee will determine the frequency of the audits.

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure for 1 of 3 residents (#90) reviewed for hospitalization that the resident's representative was given a written notice of the facility bed hold policy upon transfer to the hospital. The finding is: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; an assessment tool) dated 5/11/18 documented that the resident has moderately impaired cognition for daily decision making and was able to participate in assessment and goal setting. The nurses' note dated 8/7/18 documented that the resident returned from [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] was not completed due to inability to access the fistula (a venous access device). The Medical Doctor (MD) was notified of the [MEDICAL TREATMENT] center's recommendation for the resident to have a fistulagram (an x-ray procedure to look at the blood flow and check for blood clots or other blockages in the fistula). A subsequent nurses' note dated 8/8/18 documented that the resident had not received [MEDICAL TREATMENT] since 8/4/18, the MD was made aware, and the resident was transferred to the hospital. The resident was subsequently re-admitted to the facility on [DATE]. Review of the resident's clinical record revealed no documented evidence that the facility provided a written notice to the resident or to the residents' representative which specified the facility's bed hold policy. The Social Worker (SW#1) was interviewed on 9/25/18 at 1:50 PM and stated that she does not send a written notice of the facility's bed hold policy to residents or families. 415.3(h)(4)(i)(a)

Plan of Correction: ApprovedOctober 15, 2018

Resident #90 returned to her same room on 8/15/18.
All residents transferred to the hospital will be audited for documentation that they and their responsible party received written notice of the bed hold upon transfer.
The licensed nursing staff will be in-serviced by the ADON/designee on the process to provide the bed hold notice to the resident at the time of transfer. The Social Workers will be in-serviced by the ADON/designee to mail the bed hold notice to the responsible party following all resident hospital transfers.
The Social Workers will audit all hospital transfers each month for documentation that the bed hold notice was provided to the resident and responsible party. The Social Workers will provide results of the audits at the monthly QA/PI meetings for three months after which time the QA/PI Committee will determine the frequency of the audits.

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a re-certification survey, it was determined for 1 of 1 resident (#124) reviewed for positioning and mobility that treatment and care was provided in accordance with professional standard of practice in order to meet the resident's physical, mental, and psychological needs. Specifically, the facility did not ensure that [MEDICAL CONDITION]-embolic deterrent (TED) compression stockings were applied per physician's orders [REDACTED]. The finding is: Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) of 8/21/18 indicated the resident had severely impaired cognitive skill for daily decision making and required extensive assistance to being totally dependent on 1-2 person assistance for most activities of daily living. The Physician order [REDACTED]. The PO order of 9/6/18 included the use of venodynes (a device placed around the legs that inflates and deflates to keep blood circulating in the legs to help prevent the formation of blood clots) and a hematology consult for a [DIAGNOSES REDACTED]. The nursing progress note of 9/7/18 documented that the resident was positive for [MEDICAL CONDITION] of the RUE, venodynes for the legs were ordered, and to apply TEDs stockings until the venodynes arrive. There was no care plan with measurable objectives, time frames and interventions to address the Acute RUE [MEDICAL CONDITION], the use of venodynes, and the use of TED stockings. Observations were conducted on 9/20/18 at 12:30 PM, 9/21/18 at 9:30 AM and 9/21/18 at 12:39 PM. At the time of these observations, the resident was in bed and there were no TED stockings applied to the resident's lower extremities. The (MONTH) (YEAR) Nursing Treatment flowsheet indicated that starting on 9/9/18 the resident was to have TED stockings applied in the morning and removed at hour of sleep daily at 6:00 AM and 9:00 PM, respectively. The Nursing Treatment flowsheet for these dates revealed that the TED stockings had been applied at 6:00 AM. The assigned Certified Nursing Aide (CNA #2) was interviewed on 9/21/18 at 10:22 AM and she stated she had put foam booties on the resident to protect her heels. When asked if the resident used TED stockings, she said she had seen them on the resident at times but she did not see them daily. She said the nurses were responsible for putting them on and taking them off. The unit Registered Nurse (RN #2) was interviewed on 9/21/18 at 10:27 AM and she stated there was some uncertainty regarding the times when the TED stockings should be applied and removed. She stated that the nurses were responsible for putting on and taking off the TED stockings. The Physician Assistant (PA) was interviewed on 9/21/18 at 10:06 AM and she stated that the TED stockings were supposed to be worn daily from 9 AM to 9 PM even when the resident was in bed. She said the TED stockings were the least they could do as the resident would spend most time in bed. The DON (Director of Nursing) was interviewed on 9/21/18 at 10:56 AM and stated the PA requested TED stockings to be worn 12 hours on and 12 hours off, even when the resident was in bed. When asked who was responsible for initiating care plans, she stated the nurse managers were responsible but since the unit nurse manager left she was responsible. She said there did not appear to be a care plan in place to address the [MEDICAL CONDITION] and the use of the TED stockings. 415.12

Plan of Correction: ApprovedOctober 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The care card and care plan of resident #124 was reviewed and revised by the DON to address the application of TED stockings as indicated by the physician order.
The RN Unit Managers/designee will audit all residents with physician orders [REDACTED].
The ADON/designee will in-service the licensed nursing staff on the application of TED stockings as ordered by a physician.
The RN unit managers will audit weekly all residents with physician orders [REDACTED]. The DON will present audit findings at the monthly QA/PI meetings for three months after which time the QA/PI Committee will determine the frequency of the audits.

FF11 483.10(e)(1); 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure that residents were free from physical restraints. It was determined for 1 of 1 resident (#96) reviewed for physical restraints that: (1) thorough assessment and re-evaluation were not conducted to address the use of a self-release seatbelt while in the wheelchair that may possibly restrict the resident's movement, and (2) the physician's orders [REDACTED]. The facility policy and procedure for Restraints, revised on 02/28/17, stated that the decision to apply a restraint required the collaborative opinion of the resident's physician, the resident/health care agent or responsible person, and appropriate interdisciplinary team members. For residents utilizing a Velcro Seatbelt or clip belt as a device that does not meet the definition of a restraint, the resident will be assessed weekly by the licensed nurse for the ability to remove the device upon request. The policy and procedure further stated that all restraints will have a specific physician's orders [REDACTED]. The findings are: Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (a resident assessment tool) of 8/1/6/18 documented that the resident had severely impaired cognitive skills for daily decision making; required extensive assistance of one person for most aspects of activities of daily living; had a fall in the last 2-6 months prior to admission; and was receiving 6 days of physical therapy and occupational therapy. This MDS further indicated the resident used a bed alarm daily and there were no physical restraints used. The Physician order [REDACTED]. There were no further orders that included the use of a self-release seatbelt. The Nursing Progress Notes (NPN) of 8/18/18 documented that resident attempted to stand up out of the wheel chair and sometimes toilets himself or just stands up, chair and bed alarms were in place. The NPN of 9/2/18 documented that the resident was non-compliant with transfers, and walking alone with shoes untied. The NPN of 9/5/18 indicated the resident was walking without assistance, frequently standing, chair alarm was put in place, and a self-release seatbelt was applied and the resident demonstrated ability to release the seat belt. An 8/18/18 care plan was initiated for at risk for falls with interventions including bed alarm/chair alarm, encourage the use of a walker when ambulating, provide call bell, provide low bed, monitor for changes in cognition. This care plan was not updated to include the use of self-release seatbelt that was initiated on 9/5/18. There was no documented evidence that a doctor's order was initiated to address the use of the seat belt including the reason(s) for its use; an assessment to determine options other the use of the seat belt and a care plan with measurable objectives, time frames and interventions to address its use. The 8/18/18 care plan initiated for at-risk for falls only addressed the use of bed and chair alarm. The 8/9/18 CNA (Certified Nursing Assistant) Care Guide was updated on 9/19/18 to include restraint/device and self-release seat belt, following review by the surveyor and after an incident of fall. The CNA guide did not include directions for monitoring the use of the seatbelt. Observations were conducted on 9/18/18 at 10:45 AM and 2:00 PM. The resident was standing in front of his wheelchair and was attempting to lift his right leg up and over the wheelchair seatbelt which was around his legs at knee level and clipped together (unopened). An interview was conducted on 9/18/18 at 10:30 AM with the wife of resident #96. When she was asked if she had been educated and informed about the use of the seatbelt, she said she was never informed about the use and had never signed a consent. She said it had just appeared one day. An interview was conducted on 9/25/18 at 11:28 AM with CNA #1 and she stated that the seatbelt was applied when the resident was in the wheelchair, was removed for toileting and when the resident went to bed. She stated that the seatbelt was not removed during meals and that the resident was not able to open the seatbelt at all times when directed. CNA #1 stated that she had witnessed the resident standing with the seatbelt around his legs with the clip unopened and that she felt the seatbelt could cause a fall. The Director of Nursing (DON) was interviewed on 9/25/18 at 11:20 AM and she stated there should have been a physician's orders [REDACTED]. The unit Registered Nurse (RN #1) was interviewed 9/25/18 at 11:33 AM and was asked if she had the wheelchair seatbelt placed on the resident's wheelchair. RN #1 stated she was instructed by a supervisor to have the seatbelt put on the resident's wheel chair and that she did not obtain a physician order's for the use of the seatbelt. RN #1 stated she had seen the resident stand at times with the seatbelt fastened (unopened) and resting around his legs. She said she had spoken with the other nurses and they were aware the resident was able to stand even when the seatbelt was fastened and that it posed a fall risk. The Director of Therapy was interviewed on 9/25/18 at 1:45 PM and he stated that physical therapy was not involved with the assessment and implementation of the seatbelt. He stated that the resident could ambulate with a rollator and staff supervision. Following surveyor intervention, physician orders [REDACTED]. The care plan was then initiated for the use of the self-release seatbelt and with two quarter side rails. Interventions included self-release seatbelt applied as ordered, encourage resident to self-release on command, monitor response to self-release seatbelt, assess for reduction quarterly and prn (as needed), and monitor for changes in behaviors and ADL (Activities of Daily Living). The resident's wife also initiated an Informed Consent for the Use of Physical Restraints Assistive Device on 9/25/18 for the use of an alarmed self-release seatbelt. 415.4(a)(2-7)

Plan of Correction: ApprovedOctober 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Under the direction of the Director of Nurses a physician order [REDACTED].#96.
All residents with a self release belt will be assessed by the RN Unit Manager/designee for ability to release upon request, that a consent exists, that an MD order is in place, and the self release belt is addressed in the plan of care.
All nursing staff will be in-serviced on the physical restraint policy and procedure, which addresses self release belts, by the ADON/designee.
The RN Unit Manager/designee will audit all residents with self release belts monthly for documentation of re-assessment of continued need and consideration of options other than the self-release seat belt, ability to release on request, MD order for belt with medical symptoms to warrant its use, consent for belt, and is observed properly applied and released per care.
The DON/designee will present the audit findings at the monthly QA/PI meeting for three months after which time the QA/PI Committee will determine the frequency of the audits.

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

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during a recertification survey, the facility did not provide the housekeeping and maintenance services necessary to maintain a clean, comfortable and homelike environment for multiple residents on 4 of 4 resident units. Examples of conditions observed included, but are not limited to soiled carpeting, walls were scuffed and dirty, peeling wall paper, multiple radiators needed repainting, stained and dirty bathroom floor, non-working call bell, and soiled privacy curtain. The findings include, but are not limited to: The following environmental conditions were observed during environmental tours of the facility on 09/19/18 and 09/20/18. On 9/19/19 between 10:00 AM and 2:00 PM, the following were observed: - carpeting on the east side of the Orange Unit was soiled and in room G 16 the vinyl covering of the base board was separated from the wall; - Room G 20 - the walls and radiator paint had peeled off; - room [ROOM NUMBER] - the walls were scuffed and stained with brownish material, and the radiator paint was scraped; - room [ROOM NUMBER] - the wall near the bed was heavily gouged; - room [ROOM NUMBER]- the walls were soiled with dirt, there was a 3-inch hole on the wall behind the door, broken floor tile near base board behind the door; - Room G 21- radiator paint had peeled off, the wall paper in some areas of the room was soiled; - room [ROOM NUMBER] - the call bell of resident #116 did not work; - room [ROOM NUMBER] - the room walls were scuffed, soiled privacy curtain, bathroom floor has large stain area, bathroom walls soiled, and radiator needed repainting. On 9/20/18 at 11:14 AM, in room [ROOM NUMBER], rust was noted on base board heating unit. On 9/24/18 at 2:30 PM, the facility administrator, the housekeeping director (HD) and the director of maintenance (DM) conducted a tour of the facility with a surveyor. At that time, they were informed and were able to observe the above conditions. The HD and the DM both stated that they would address these environmental concerns. 415.5(h)(2)

Plan of Correction: ApprovedOctober 10, 2018

Under the direction of the Director of Maintenance and the Director of Housekeeping the observed environmental conditions were corrected by the end of survey on 9/25/18.
The Director of Maintenance and the Director of Housekeeping will review the facility environment to identify and correct any additional environmental conditions not meeting the requirement.
All staff will be in-serviced on the requirement to provide a clean, comfortable, and homelike environment and how to report conditions not meeting the requirement for correction.
With the administrator/designee an interdisciplinary team will conduct an audit of one unit weekly (each unit monthly) to ensure a clean, comfortable, homelike environment. Results of the audits will be presented to the QA/PI committee monthly for three months after which time the QA/PI committee will determine the frequency of the audits.

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: December 4, 2018

Citation Details

Based on interviews and record review conducted during the most recent recertification survey, the facility did not ensure that sufficient staff was available to meet the needs of residents on all units and on all shifts. This was evidenced by (1.) multiple residents reporting during confidential interviews and the group meeting of lack of Certified Nurse Aides (CNAs) to respond to call bells and provide assistance with activities of daily living; (2.) multiple nursing staff members reporting lack of sufficient staffing on all units; and (3.) analysis of the actual staffing schedule showing that on multiple occasions the facility was below its required levels for CNAs on all units. The findings include: 1. Confidential interviews were held on 9/18/19, 9/19/19 and 9/20/18 and four residents reported the following: - There was not enough staff. Frequently, there were three CNAs on the unit and when this was the case, showers were not done; - When the call bell is pressed, it takes an hour to get a response, and that staff has to work a lot of overtime; - one of the residents stated she needed help to get off the toilet and it takes a long time for the staff to come, more than 20 minutes; - After having a bowel movement, another resident stated it takes a long time for the staff to respond to call for assistance, up to one and one-half hours. 2. There were five residents at the group meeting conducted by a surveyor on 9/19/18 at 11:00 AM. The residents stated that there should be four aides on each unit, which frequently does not happen. They stated that sometimes you have to wait a long time because the aides are with other residents. Two aides were needed for the use of a Hoyer lift and on the Putnam unit there were about 15 residents that needed to be transferred with this lift. Call bells were answered in about one-half hour. 3. Seven nursing staff members including 5 CNAs and 2 licensed nurses, were interviewed from all units (Putnam, Orange, Ulster and Dutchess) regarding staffing. Their responses included as follows: - CNA #1 assigned to the evening shift stated on 9/19/18 at 3:35 PM that frequently there are three CNAs on the shift. Sometimes scheduled showers are not done; - Two licensed nurses stated on 9/19/18 at 4: 00 PM that there are usually three CNAs on the evening shift and it is more difficult to complete assignments. Residents complained of lack of sufficient staff; - CNA #2 assigned to the evening shift stated on 9/19/18 at 4:00 PM that there were only three aides on the unit 6 out of 7 days. When this happens, call bells were not answered promptly and showers were not always done as scheduled; - CNA #3 assigned to the day shift stated on 9/21/18 at 2:07 PM that during orientation she was told there was supposed to be four CNAs on the day shift however there are usually three. She stated further she is usually assigned 13 residents, resulting in her missing breaks, rushing, not being able to respond to call bells timely, and some residents get upset when they missed their showers. While the Department of Health is here, CNA #3 stated they have been having four CNAs; - CNA #4 assigned to the day shift stated on 9/21/18 at 2:17 PM that when there are three CNAs on the shift she may not be able to take breaks and has difficulty responding to call bells. She is asked to work overtime a lot. She comes in and is afraid that she is going to be stuck, that is, she may be asked to work overtime). - CNA #5 assigned to the day shift stated on 9/24/18 at 2:29 PM that when there are three CNAs on the unit, which is usually the case, she is responsible for up to 14 residents. This is a big problem. CNA #5 stated she gets stressed, pressured and tense. Sometimes baths have to be given instead of showers and some residents have to stay in bed until 11: 00 AM. She stated she spoke to administration about it and they said they are doing their best. 4. Facility Assessment and Staffing Schedule The Facility Assessment (FA; an assessment that determines the needs of the residents and the amount of staff required to meet those needs) dated 11/3/17, actual nursing staff schedule, and a list of CNAs on the payroll were reviewed. The resident census and condition report was used as the basis for the staffing requirements in the FA. The resident census and condition report indicated that the number of residents who either needed assistance or were totally dependent on staff in the following areas included: - Bathing - 139 - Dressing - 139 - Transfer - 125 - Toilet use - 123 - Eating - 57 A review of the current Resident Census and Conditions dated 9/20/18 showed the conditions of the residents to be similar to those noted in the FA above and the current data showed: - Bathing - 140 - Dressing - 137 - Transfer - 129 - Toilet use - 125 - Eating - 144 According to the FA, the facility requires a ratio of one CNA to 10 residents (or four CNAs per unit) and a total of 80 CNAs. The actual nursing schedule for 8/22/18 to 9/20/18 showed that the average ratios per unit for this period based on 3 CNAs were as follows: Putnam - 12.9 (21 times with 3 CNAs) Ulster - 12.26 (19 times with 3 CNAs) Orange - 11.8 (23 times with 3 CNAs) Dutchess - 11.3 (22 times with 3 CNAs) The Administrator, Director of Nursing (DON), Director of Human Resources (DHR) and the staff member responsible for making up the schedule (scheduler) were interviewed on 9/25/18 between 2:30 PM and 4:30 PM. These interviews revealed that the facility did not have sufficient staff. - The Administrator stated that several CNAs were recently hired but changed their status to per diem after they completed their orientation. The Administrator also stated there is a radio campaign in progress to get more staff in. - The Director of Nursing (DON) stated that she knows that it is hard to work with three CNAs on a unit. The DON further stated that three CNAs on each unit is the minimum on the day and evening shifts and two on the night shift. Further review of the schedule during this interview with the DHR and the scheduler showed that the facility was below minimum staffing on five occasions. The scheduler stated that the following was due to a lack of sufficient staff. - 8/24/18 and 8/31/18, there was one CNA on Dutchess and Ulster respectively on the night shift, the census was 35. - 8/29/18, there were two CNAs on the day shift on Dutchess with a census of 36 - 9/09/18, there were two CNAs on the day shift on Putnam with a census of 37, and on 9/19/18 two CNAs on Dutchess. Additionally, the list of the CNAs on the payroll was reviewed with the DHR while she was being interviewed. This review showed that the facility currently employs 34 full time CNAs and 10 part time CNAs, which was below the number of CNAs the FA determined to be necessary to meet the needs of the residents. Twenty nine per diem CNAs were on the list. The scheduler stated that these CNAs are placed on the schedule based on their availability. 415.13(a)(1)(i-iii)

Plan of Correction: ApprovedOctober 16, 2018

The Facility Assessment will be reviewed and revised by the Administrator, DON, and Medical Director to reflect nursing staffing needs based on census and condition. Minimum staffing levels will be identified to ensure that the facility provides adequate care and services to the residents.
The Scheduler and the Nursing Supervisors will be in-serviced by the ADON/designee to schedule units based on the Facility Assessment, census, and resident conditions.
Weekly Staffing Meetings will be held attended by Administrator, DON, Scheduler, HR, with Regional Staffing Support to promote staff retention, develop strategies to fill open nursing positions, and implement staffing solutions. we The contact list will be reviewed and revised to include CNAs, LPNs, RNs, nurse supervisors, unit managers, and staffing agencies to ensure coverage for call outs. The Nursing Supervisors will be in-serviced regarding their requirement to conduct rounds to observe that appropriate care is being provided and to speak with staff, residents, and family members regarding care needs.
The Administrator/designee will audit daily scheduled hours and actual hours worked to ensure adequate staffing to meet the needs of the residents. The Resident Council and 10 residents per month will be asked if there are adequate staff to meet their needs timely. Each month the Administrator/designee will audit that showers were provided as scheduled for 10 residents. The Administrator/designee will conduct 10 call bell audits per month to ensure timely response rate. The audit findings will be reviewed at the monthly QA/PI meetings for three months after which time the QA/PI Committee will determine the frequency of the audits.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: November 24, 2018

Citation Details

Based on observation, interview, and record review, the facility did not ensure that all the patient care related electrical equipment (PCREE) used in the facility was tested and inspected, and that the service manuals for the equipment were on file, in accordance with NFPA 99. Reference is made to no documentation for the inspection and testing of the air mattress pumps, and the lack of service manuals for the PCREE equipment that was observed in use (i.e. suction machine, AED defibrillator, oxygen concentrators, nebulizers, air mattress pumps and feeding pumps). The findings are: During the recertification survey conducted on 9/18/18, 9/19/18 and 9/20/18 between 10:00 AM and 3:00 PM, the facility's PCREE inspection log book was reviewed. According to this log book, the vendor inspects most of the patient care related electrical equipment (i.e. suction machines, AED defibrillator, oxygen concentrators, nebulizers, and feeding pumps), except the air mattress pumps used in the facility. Manufacturer's specifications (service manuals) were requested, but not provided for, any of this patient care related electrical equipment. In an interview on 9/18/18 at 12:50 PM, the Maintenance Director stated that the air mattress pumps used by residents are checked in house by maintenance, but the checks are not documented. He further stated that he will reach out to the vendor to obtain the manufacturer's service manuals for the patient care related electrical equipment used in the facility. 2012 NFPA 99: 10.5.2.1.2, 10.5.3.1, 10.3.1.2 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 5, 2018

The Maintenance Director has arranged for all air mattress pumps to be inspected, with documentation.
The Maintenance Director has created a binder of service manuals for all PCREE equipment in use at the facility.
The Maintenance Director will audit 15 PCREEs per month to ensure they have been inspected.
The Administrator will educate the maintenance staff on the requirements of NFPA 99 related to PCREE and develop a policy and procedure with the Director of Maintenance which will address the responsibilities of PCREE equipment testing and maintenance as well as maintaining on file all service manuals for PCREE equipment used in the facility.
The Maintenance Director will audit that all service manuals for the PCREE equipment used at the facility are on file each month.
The Maintenance Director will report both audit findings at the monthly QA/PI meeting for three months after which time the QA/PI Committee will determine the frequency of the audits.

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: November 24, 2018

Citation Details

Based on documentation review and interview, the facility did not ensure that fire drills are held at varying times. This was evidenced by the fire drills for the Night shift that were not conducted at varying times. The findings are; Facility fire drill records for the past 12 month period were reviewed at 9:30 AM on 9/18/18. The quarterly fire drills for the night shift were not conducted at varying times, as required. Specifically, two of the quarterly drills were conducted at 12:30 am, and two had been conducted at 5:00 AM. In an interview at the time of findings, the Maintenance Director stated that he will ensure that the fire drills are conducted at varying times. 2012 NFPA 101: 19.7.1.26 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 5, 2018

The maintenance Director will conduct a night shift fire drill at a varied time from the past 12 months.
The Administrator will audit the times of fire drills monthly to ensure they are held at varying times over the previous twelve months.
The Administrator will report the results of the fire drill audits at the monthly QA/PI meetings for three months after which time the QA/PI Committee will determine the frequency of the audits.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: November 24, 2018

Citation Details

2010 NFPA 13: 8.15.3.2.1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. 2010 NFPA 13: 8.15.3.2.2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and interview, the facility did not ensure that sprinklers were installed in all required areas in accordance with NFPA 13. Reference is made to the lack of sprinkler coverage in the alcove area at the bottom landing within stairwell 5. This was noted in 1 of 5 stairwells. The findings are: On 9/18/18 at 2:05 PM, during the recertification survey, a tour of the stairwell 5 was conducted and revealed that, although a pendent style sprinkler was installed in the area between the base of the stairs and the emergency exit, sprinkler coverage was not provided to an alcove area near the exit door where the radiator is located. In an interview at the time of the finding, the Maintenance Director stated that he will contact the vendor to provide sprinkler coverage in this area. 2010 NFPA 13: 8.15.3.2.1, 8.15.3.2.2 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 5, 2018

The Maintenance Director will arrange for the addition of sprinkler coverage to the alcove area at the bottom landing, near the exit door, of stairwell #5.
The Director of Maintenance has inspected all similar areas and found all to have sprinkler coverage.
The Director of Maintenance will audit all stairwells monthly to ensure all areas such as alcoves have sprinkler coverage.
The Director of Maintenance will report audit findings at the monthly QA/PI meeting for three months after which time the QA/PI Committee will determine the frequency of the audits.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 25, 2018
Corrected date: November 24, 2018

Citation Details

2012 NFPA 101 7.2.2.5.5 Exit Stair Path Markings. Where exit stair path markings are required in Chapters 11 through 43, such markings shall be installed in accordance with 7.2.2.5.5.1 through 7.2.2.5.5.11. 7.2.2.5.5.1 Exit Stair Treads. Exit stair treads shall incorporate a marking stripe that is applied as a paint/coating or be a material that is integral with the nosing of each step. The marking stripe shall be installed along the horizontal leading edge of the step and shall extend the full width of the step. The marking stripe shall also meet all of the following requirements: (1) The marking stripe shall be not more than 1/2 in. (13 mm) from the leading edge of each step and shall not overlap the leading edge of the step by more than 1/2 in. (13 mm) down the vertical face of the step. (2) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm) and a maximum width of 2 in. (51 mm). (3) The dimensions and placement of the marking stripe shall be uniform and consistent on each step throughout the exit enclosure. (4) Surface-applied marking stripes using adhesive-backed tapes shall not be used. 7.2.2.5.5.2 Exit Stair Landings. The leading edge of exit stair landings shall be marked with a solid and continuous marking stripe consistent with the dimensional requirements for stair treads and shall be the same length as, and consistent with, the stripes on the steps. Based on observation, the facility did not ensure that the exit stairwells were provided with stair tread marking stripes on each step in accordance with NFPA 101. Reference is made to unapproved adhesive -backed tape that was noted in 5 of 5 stairwells and was applied on the top and bottom step only of each set of stairs. The findings are: During the recertification survey on 9/18/2018, 9/19/18 and 9/20/18 between 9:00 AM and 3:00 PM , a life safety tour of the stairs was conducted and revealed that the marking stripes on the leading edges at the top and bottom of the stairs were applied with a non-approved material, i.e. adhesive - backed tape. This was noted in 5 of 5 stairwells on resident units. In an interview at the time of the findings, the Maintenance Director stated that the adhesive - backed tape will be removed and each step in the stairwells will have a marking stripe with approved material. 2012 NFPA 101: 7.2.2.4.1.5, 7.2.2.4.1.6, 7.2.2.5.5, 7.2.2.5.5.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 5, 2018

Under the direction of the Maintenance Director, all adhesive backed tape will be removed from stairwell steps and all steps in the five stairwells in the facility will be painted with marking stripes.
The Maintenance Director will audit the five stairwells monthly to ensure the exit stairs are free of adhesive backed tape and that each step has a marking stripe.
The Director of Maintenance will present audit findings at the monthly QA/PI meeting for three months after which time the QA/PI Committee will determine the frequency of the audits.