Essex Center for Rehabilitation and Healthcare
November 5, 2018 Certification/complaint Survey

Standard Health Citations

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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, during a recertification survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident consistent with the resident rights set forth that include measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for seven (7) (Residents #'s 3, 5, 54, 63, 82, 91, and #543) of twenty-six (26) residents reviewed. Specifically; for Resident #543 the facility did not ensure that the Comprehensive Care Plan (CCP) for alteration in respiratory status accurately identified whether staff or the resident would provide [MEDICAL CONDITION] care, suctioning and regulate the use of and liter flow of oxyge, for Resident #'s 5 and 54, the facility did not develop a CCP for constipation, for Resident #91, the facility did not ensure that the CCP for behavior included the resident's significant behavior of yelling with interventions to address the behavior, for Resident #63, who had a history of [REDACTED]. This was evidenced by: Resident #543: This resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. During an observation on 10/30/18 at 2:17 PM, the resident was observed to be receiving 7.5 liters of oxygen [MEDICAL CONDITION]. The resident was observed in his room on several occasions throughout the day shift; on 10/30/18 at 02:17 PM the resident was receiving oxygen via [MEDICAL CONDITION] collar at 7.5 Liters / minute (L/min), on 10/31/18 03:09 PM at 9 L/min, on 11/01/2018 at 4:52 PM oxygen was at 4 L/min, and on 11/02/18 at 10:13 AM oxygen was at 9 L/min. Review of the resident's medical record, documented that the resident is alert, oriented x 3, oxygen and understood with the use of an assistive device. A consultation from a Respiratory therapist (RT) dated 10/26/2018, documented the resident stated he was able to self perform [MEDICAL CONDITION] care, suctioning and use of humidified oxygen. A physician's orders [REDACTED]. A care plan for alteration in respiratory status dated 10/29/18, documented the following interventions; provide [MEDICAL CONDITION] care daily and PRN using aseptic technique, suction secretions per MD (medical doctor) orders and as needed, and provide oxygen per MD orders. During an interview on 10/30/18 at 2:17 PM, the resident stated a nurse had adjusted his oxygen overnight. The resident was observed self-suctioning during this interview. The resident stated he has provided self-care for [MEDICAL CONDITION] since admission to facility. During an interview on 11/01/2018 at 4:52 PM, RN (registered nurse) #3 stated the resident was independent with oxygen, care of the [MEDICAL CONDITION] and self-suctioning. She stated she was unaware of the level of oxygen resident was receiving at that time. RN #3 stated she did not know what the MD orders or care plan was for oxygen, care of the [MEDICAL CONDITION] and for suctioning. RN #3 reviewed the care plan during the interview and stated the care plan did not include that the resident independently cares for his [MEDICAL CONDITION], suctioning and oxygen. During an interview on 11/2/18 at 10:13 AM, LPN (licensed practical nurse) #5 stated the resident self applies oxygen throughout the day, and provides his own [MEDICAL CONDITION] care. She stated there should be an MD order and the care plan should include MD order to include the resident is able to independently perform [MEDICAL CONDITION] care, suctioning and use of the oxygen. During an interview on 11/2/18 at 10:41 AM, RNUM (registered nurse unit manager) #4 stated the care plan should indicate if a resident provides self-care, and be resident specific. She stated resident was receiving oxygen at all times, stated care plan is not specific to the resident in regard to oxygen MD orders. She stated care plan should be revised to include resident specific diagnosis / needs and reflective of resident ability to provide self-care safely. During an interview on 11/2/18 at 03:48 PM, the DON (Director of nursing) stated the resident was evaluated by respiratory and able to care for his [MEDICAL CONDITION] and oxygen administration. The DON stated the expectation of staff was to communicate assessment findings regarding the resident's ability to self care for [MEDICAL CONDITION], suctioning and utilization of oxygen, obtain an MD order, add to the care plan, and monitor the resident for ability to manage these tasks independently. The DON reviewed the care plan and stated it is not resident specific and would need to be revised. Resident #91: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 10/6/18, assessed the resident usually understood, sometimes understands and had severely impaired cognitive ability. It documented no behaviors. On 11/02/18 at 1:55 PM, Resident #91 was observed being walked by Activity Aide (AA) #12 down the unit hallway calling out constantly. Fifteen minutes later the resident was still being walked by the same AA, and she was still calling out. The AA said you cannot tell what she is saying, but thought she was saying she was cold. The AA got her a sweater, but she continued to say the same thing. Licensed Practical Nurse (LPN) # 4, who was standing by the resident, stated the resident speaks French, she had married a serviceman during the war and came to this country from Paris. The LPN did not know if there were staff who spoke French. On 11/2/18 at 2:15 PM, AA #12 was still walking the resident at the end of the hallway. She was heard to say some words in French to the resident and the resident stopped yelling for a few seconds. The AA said the resident yells out daily. You can tell when she wants to walk, she will hold out her hands. Sometimes her holding onto something will help the yelling. On 11/2/18 at 3:47 PM, the resident was observed walking in the Unit hallway by herself. She was yelling out something that sounded like it might be a resident's name. No staff were walking with her or paying attention to her. The residents CCP for Behavior initiated 5/6/16, documented behaviors of; wandering, making negative statements, difficult to redirect, lays self on the floor, history of slapping others, sometimes combative with care, and unpredictable behavior. There was no mention of the repetitive yelling out. Interventions included: 1:1 as needed; psychiatric medication as ordered; assist resident in seeking a quiet area when having sensory overload; close monitoring due to exit seeking; distract from wandering; resident enjoys 1:1 visits; offer support and redirection; reapproach if combative with care. There was no Nurse Manager for the unit available for interview. During interview on 11/2/18 at 3:47 PM, LPN Manager #6 of Unit 1 stated she has covered the resident's Unit and knows the resident. She stated she had seen the resident yelling/calling out and saying different words. She looked at the resident's CCP. She said there was nothing in the behavior CCP or any other CCP about the repetitive yelling out. Maybe one of the interventions could address the yelling but there was nothing else. She looked at the resident's Kardex ( used by staff to provide care for the resident) and said there was nothing specific to address the yelling behavior. During interview on 11/02/18 at 5:02 PM, the Director of Nurses said the resident's yelling out behavior should be in a care plan with interventions specific to that behavior. Resident #5: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 10/20/18, assessed the resident understands, was understood, had no cognitive impairment and was frequently incontinent of urine and bowel. During interview on 10/30/18 at 2:43 PM, the resident stated she had very bad constipation. She only had a bowel movement (BM) once a week. She thought she received as needed (PRN) bowel medications. There was no Comprehensive Care Plan to address her constipation. The resident's Kardex (used by staff to provide needed care) documented under Toileting: toilet use, extensive assist of 2 staff. There were no other instructions. Bowel Records documented: October (YEAR): 9/30-10/4 6 days without a BM; 10/7-10/15 8 days without a BM; 10/17-10/22 6 days without a BM;10/25-10/30 6 days without a BM. September (YEAR): 9/7-9/13 7 days without a BM; 9/24-9/28 5 days without a BM. August (YEAR) 8/18-8/22 5 days without a BM; 8/23-8/27 5 days without a BM; 8/30-9/4 6 days without a BM. During interview on 11/02/18 at 7:24 AM, LPN #2 said the resident has problems with constipation. During interview on 11/02/18 at 8:59 AM, CNA #3, who cares for the resident, said the resident has constipation, it gets worse every time she comes back from the hospital. During interview on 11/02/18 at 10:51 AM, LPN Manager #6 said the resident has constipation occasionally. Constipation was not an issue she remembered discussing at care planning meetings, LPNM #6 said the resident does not like to get out of bed, when she gets up on the commode 90 % of the time she goes. She stated there was no plan in place to address putting the resident on the commode to have a BM. LPN #6 said they encourage the resident. She said she did not think it was on the Kardex to encourage the resident to use the commode for a BM. She stated she could see this resident should have had a CCP for constipation.

Plan of Correction: ApprovedNovember 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** How the corrective action will be accomplished for any resident affected by deficient practice:
Care plans for residents #3, 5, 54, 63, 82, 91, 543 were reviewed and updated to ensure an inclusive, person centered approach.
Residents # 3 and 82 had no specific problems identified with their care plans.
Residents # 5 & 54 had a care plan for constipation added.
Resident # 91 had the care plan had interventions to address the yelling behavior added.
Resident # 63 had a care plan for history of UTI?s with septic shock added.
Resident # 543 had the Respiratory care plan clarified to clearly indicate what the resident can do independently and what the staff have to do for the resident.

How we identified other residents/areas that could potentially be affected:
All residents have the potential to be affected.
An audit will be completed to ensure all residents have person centered goals and interventions added based on [DIAGNOSES REDACTED].

Measures to ensure were/will be put into place to assist this area of concern:
The policy titled ?Care Plans, Comprehensive Person-Centered?, has been reviewed and no changes were necessary.
Re-education for all RN?s regarding the comprehensive care plan policy and the need to ensure all diagnoses, needs are included and implemented will be completed.
All new admission and readmission's care plans will be audited by the Director of Nursing or designee weekly times 4 weeks, then biweekly x 4 weeks then 5 care plans to identify missed care plan opportunities will be done biweekly times 4 weeks.
The results of the audit will be brought to
the QA committee and will continue until
otherwise directed by the committee.
Responsible party:
Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash dumpsters had broken lids. This is evidenced as follows. The trash dumpster area was inspected on 11/02/2018 at 1:09 PM. The middle of 3 dumpsters had an 8-inch by 4-inch hole and was not pest-resistant. The side door left facing the dumpster was left open. Additionally, directions on the side of each dumpster state that the unit is to be placed on a level surface, and when the Director of Maintenance measured, the level was off by 1-inch per foot. The Assistant Administrator stated in an interview conducted on 11/02/2018 at 2:30 PM that he will the dumpster company should be able to replace the lid on Monday and he will investigate the dumpster surface being off-level. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
Middle dumpster with 8?x4? hole will be replaced.
Dumpsters will be placed on a level surface.

How we identified other residents/areas that could potentially be affected:
All other garbage bins were inspected to ensure they close and do not have holes.

Measures to ensure were/will be put into place to assist this area of concern:
Housekeeping & Maintenance will be educated on the regulations regarding waste disposal. An audit checklist will be added to the weekly environmental rounds to ensure the garbage bin is closed, level, & inaccessible to small animals.

How the concern will be monitored and title of person responsible for monitoring:
Maintenance personnel will audit the dumpster area weekly x10 weeks to ensure compliance with regulations.
Results of the audit will be presented to the QAPI committee.
Responsible Party:
Administrator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation, staff interview, and policy record review during the recertification survey, essential equipment was not maintained in safe operating condition. Specifically, the automatic dishwashing machine was improperly modified. This is evidenced as follows. The automatic dishwashing machine in the main kitchen was inspected on 10/29/2018 at 10:47 AM. The dishwashing machine was fed by a chlorinating concentrate for sanitizing during the final rinse. The information data plate located on the side of the machine lists the device as a(NAME)model AC-66EC. Record review of the dishwashing machine Installation/Operation & Technical Manual on 10/29/2018 revealed that only(NAME)models AJ-44, 66, and 80 CL, CS, or CSL are designed for low temperature chemical sanitizing. The Food Service Director stated in an interview conducted on 10/29/2018 at 12:22 PM that the dishwashing machine had been modified for low temperature chemical sanitizing, but as per survey observations, and new booster heater for hot water final rinse sanitizing will be purchased and installed. 10 NYCRR 415.5(e)(1)(2)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
A work order has been placed to add a new hot water booster for the final rinse sanitizing cycle to increase the temperature of the water to regulatory standards.

How we identified other residents/areas that could potentially be affected:
The installation/Operation & Technical Manual of the Dishwasher was reviewed to ensure the dishwasher is operated as per the manufacturers? recommendations.

Measures to ensure were/will be put into place to assist this area of concern:
The Administrator will educate the Food Service Director on the installation/Operation & Technical Manual of the Dishwasher, & not to use chemicals such as chlorine to sanitize the dishes.

How the concern will be monitored and title of person responsible for monitoring:
The FSD will check the rinse cycle temperature logs weekly for 4 weeks until 100% compliance.
Results of the audit will be reported to the QAPI Committee for review.
Responsible Party:
Administrator

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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Equipment in food preparation and serving areas and equipment are to be kept clean. Food is to be protected from contamination when distributed. Specifically, equipment in the main kitchen and 3 of 3 resident unit kitchenettes were not clean and in good repair, and meals were not covered when being distributed. This is evidenced as follows. The main kitchen and the unit kitchenettes were inspected on 10/29/2018 at 10:47 AM. In the main kitchen, the microwave oven, table mixers, shelving & drawers, measuring cups, slicer, stove drip pans, can opener holder, handwashing sink, wall fans, floor under equipment, and fire extinguisher were soiled with food particles or grime. Wall tiles in the dishwashing machine area were cracked and broken. In the Unit One, Unit Two, and Unit Three kitchenettes the microwave ovens, cabinetry, and freezer door gaskets were soiled. The Food Service Director stated in an interview on 10/29/2018 at 12:22 PM, that the he will devise a cleaning schedule for the kitchen and kitchenettes and the broken tiles will be replaced when the kitchen is remodeled. During observation on 11/02/2018 at 11:45 AM, desserts and poured beverages were not covered and protected from contamination while being distributed through resident Unit 1 and resident Unit 2 hallways. The Food Service Director stated in an interview on 11/02/2018 at 12:06 PM, that he was not aware open foods, such as desserts and beverages, had to be kept covered while being distributed. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.40, 14-1.110, 14-1.170

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
All areas identified in kitchen & 3 kitchenettes to include hand washing sink, wall fans, appliances, dishes, walls, fire extinguishers, & drip pans.
were cleaned immediately.
Broken tiles in the kitchen will be replaced.

How we identified other residents/areas that could potentially be affected:
All residents have the potential to be affected.
An initial food service sanitation audit was updated to identify areas of concern. Issues identified were immediately addressed.

Measures to ensure were/will be put into place to assist this area of concern:
Education will be provided to the Kitchen & Housekeeping staff on how to clean the kitchen & kitchenettes properly and also the need to keep food covered while it is being distributed to the nursing units.
The policy on Sanitization was reviewed.
The FSD revised cleaning schedules to incorporate daily cleaning checklist to ensure that all areas in the kitchen are free of soil, dust, food particles, & grime.

How the concern will be monitored and title of person responsible for monitoring:
The FSD or designee will conduct kitchen sanitation audits weekly x 4 weeks then monthly x 6 months to ensure 100% compliance is maintained.
Any issues will be immediately addressed.
Results of the audits will be forwarded to the QA committee monthly for review and input.
Responsible party
Administrator


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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview during a recertification survey the facility did not ensure that PRN orders for [MEDICAL CONDITION] 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 as needed (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 for one Resident #16 of five residents reviewed for unnecessary medications. Specifically: the facility did not ensure that the resident's PRN [MEDICATION NAME] order did not exceed 14 days without physician justification for continued use. This is evidenced by: Resident #16: The resident was admitted to the nursing home on 7/30/18 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 usually understood and was usually understood by others. A Physician (MD) Order dated [MEDICATION NAME] 1 milligram (mg); Give one by mouth every 4 hours as needed (PRN) for increased anxiety. The Comprehensive Care Plan (CCP) did not include a care plan to address anxiety or the use of an Antianxiety medication. During an interview on 11/02/18 at 05:24 PM, the DON stated that PRN medications should not be ordered for more that 14 days without physician justification for continued use. It was the nurse managers responsibility to ensure the medication was reviewed and that there was a CCP with non pharmological interventions and tell what symptoms the resident was having and what made it effective. 10NYCRR 514.12(l)(2)(i)

Plan of Correction: ApprovedNovember 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** How the corrective action will be accomplished for any resident affected by deficient practice:
Resident # 16 is no longer in the facility.

How we identified other residents/areas that could potentially be affected:
All residents with [MEDICAL CONDITION] medication orders have the potential to be affected.
All residents with PRN [MEDICAL CONDITION] medication orders have been reviewed to ensure medical records include justification for sure beyond 14 days.

Measures to ensure were/will be put into place to assist this area of concern:
Policy titled [MEDICAL CONDITION] medication use has been written.
All licensed nurses and medical practitioners will be educated on the policy.
Any PRN [MEDICAL CONDITION] medications ordered will have a duration of 14 days then will be reevaluated for review of need and medical justification if extended past 14 days.

How the concern will be monitored and title of person responsible for monitoring:
100% of PRN [MEDICAL CONDITION] medications will be audited to ensure medical justification is completed if need beyond the 14 days weekly x 12 weeks.
The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
Responsible Party:
The Director of nursing will be responsible for compliance.

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. Hot water temperatures are to be maintained between 90 degrees Fahrenheit (F) and 120 F. Specifically, resident room hot water temperatures were excessive and could cause skin damage in 11 of 61 resident rooms. This is evidenced as follows. The resident room handwashing sink hot water temperatures were checked on 10/29/2018 at 1:29 PM. The hot water temperature in room [ROOM NUMBER] was 126 F, room [ROOM NUMBER] was 124 F, room [ROOM NUMBER] was 123 F, room [ROOM NUMBER] was 137 F, room [ROOM NUMBER] was 137 F, room [ROOM NUMBER] was 123 F, room [ROOM NUMBER] was 124 F, room [ROOM NUMBER] was 136 F, room [ROOM NUMBER] was 132 F, room [ROOM NUMBER] was 135 F, and room [ROOM NUMBER] was 134 F. The Administrator and Director of Maintenance were interviewed on 10/29/2018 at 2:10 PM and again at 5:17 PM. They stated that based on verbal notices from staff, the hot water will randomly get very hot at certain times of the day either during mid-morning or mid-afternoon. The facility has contacted the corporate engineer and a plumber who speculate that the issues with the hot water may have to do with the water system mixing valves or recirculating pumps, but no work has been conducted to modify the system. Providing a dedicated hot water supply for the laundry may help regulate the water temperatures. The Administrator stated in an interview on 10/30/2018 at 9:00 AM, that since survey observations, the hot water system boilers were shut down last night, the boiler holding tanks were drained then allowed to refill, the boiler thermostat was re-set to 110 F, and the hot water temperatures in resident rooms have consistently not been above 110 F since. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
A mixing valve was repaired, which now gives a steady hot water temperature throughout the building. This fixed irregular temperatures in the affected rooms.

How we identified other residents/areas that could potentially be affected:
All rooms were in compliance when the mixing valve was replaced.

Measures to ensure were/will be put into place to assist this area of concern:
The facility will implement daily water temperature checks at different resident care areas of the building to monitor hot water throughout the day.

How the concern will be monitored and title of person responsible for monitoring:
An audit of 5 rooms per unit 5 days weekly (for a total of 60 rooms per week)will be completed to ensure that the hot water temperatures are maintained between 90 and 120 degrees F x 4 weeks, then 3 rooms per unit 5 days weekly x 4 weeks, then 1 room per unit 5 days weekly x 4 weeks.
Maintenance personnel will report any irregularities to the Administrator immediately. Results of the audit will be presented to the QAPI committee monthly x3 months.
Responsible Party:
Administrator


ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based employee health record review, staff interview, and the Legionella Sampling and Water Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.4 requires that by (MONTH) 1, (YEAR) initial Legionella sampling shall be at periods not exceeding 90 days prior to annual sampling. Specifically, the facility did not test for Legionella as required by New York State regulation and did not provide education on the risks and benefits of (education) the pneumococcal vaccine to all employees within the past 12 months. This is evidenced by the following. The potable water system Legionella testing reports were reviewed on 10/30/2018. The reports were dated 03/06/2017, 07/13/17, 10/16/2017 and 01/29/2018. The time frame between the 03/06/17 and 07/13/17 was greater than 90 days. The Administrator stated in an interview conducted on 10/30/2018 at 3:00 PM, that the water samples were taken before he was hired and does not know why the samples were not conducted in accordance with the regulations. The health records for the Director of Maintenance, Assistant Director of Maintenance, and Dietary Aide #1 were reviewed on 10/31/2018. No records were available for survey review documenting education within the past year on the risks and benefits of the pneumococcal vaccine for these employees. The health and time card records for Dietary Aide #2 reviewed on 10/31/2018. This review revealed that she worked during the winter and late spring months of (YEAR). No records were available for survey review documenting that she received the influenza vaccine and/or receive education on the risks and benefits of the influenza vaccine. The Assistant Director of Nursing stated in an interview conducted on 10/31/2018 at 9:45 AM, that she did not know education on the pneumococcal vaccine was necessary and does not know why Dietary Aide #2 did not receive education on the influenza vaccine. 415.19(a)

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
New legionella testing has begun. The first test was taken on 11/7/18, and was negative for legionella. The following tests will be taken within 90 days of the previous test.

How we identified other residents/areas that could potentially be affected:
The first round of testing was completed and the test returned negative on all areas for Legionella.

Measures to ensure were/will be put into place to assist this area of concern:
The policy titled Prevention and Control of Seasonal Influenza and Pneumococcal vaccine for employees were reviewed and revised to add the process for staff returning from a LOA.
The ADON will be educated regarding the above policies regarding flu and pneumonia vaccinations.
The maintenance department will be educated on the regulations of proper legionella testing, and legionella testing has been scheduled for the next year in February, May, & August, to bring the facility up to the yearly testing protocols.

How the concern will be monitored and title of person responsible for monitoring:
The results of the legionella test will be brought to the QAPI committee for review. The Maintenance Director will ensure that legionella testing is done within 90 days of the previous test 4x year.
Responsible Party:
Administrator

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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure written notice which specifies the duration of the bed-hold policy, was provided to the resident and the resident representative at the time of transfer for hospitalization . This was evident for 2 (Residents # 49 and 63) of 2 residents reviewed for hospitalization . Specifically, for Residents # 49 and 63, there was no documented evidence the resident and the resident's representative were notified in writing of the bed hold policy when the resident was admitted to the hospital. This is evidenced by the following: Resident #49: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident could understand, was understood, and had no cognitive impairment. A Nursing Progress Note dated 8/9/18, documented the resident was complaining of back and bilateral leg pain and made a request to go to the emergency room (ER). An order was obtained to send the resident to the ER for an evaluation. A Nursing Progress Note dated 8/13/18, documented the resident was readmitted to the facility from the hospital. Review of the Multidisciplinary Progress Notes did not include documentation that written notification of the bed hold policy was sent to the resident or the resident's representative at the time of discharge. During an interview on 11/01/18 04:28 PM, the Director of Social Work reported there is a Bed-hold notice that residents are given on admission, but it is not provided again when a resident is transferred to the hospital. During an interview on 11/01/18 04:30 PM, the Director of Nursing (DON) reported that Social Work should be sending the notices. Resident #63: The resident was admitted to the nursing home on 1/25/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. The Hospital Discharge Summary documented that the resident was admitted from the nursing home on 10/9/18. A Social Work (SW) Note dated 10/10/18, documented that the resident was transferred and later admitted to the hospital and therefore had been discharged from our facility at this time. During an interview on 11/2/18 at 2:40 PM, the SW stated that she had not given a notice of a bed hold policy when the resident went to the hospital, but would from this point. 10NYCRR415.3(h)(4(i)(a)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
Residents #49 and 63 were readmitted to their beds without incident.

How we identified other residents/areas that could potentially be affected:
All residents being transferred have the potential to be affected.

Measures to ensure were/will be put into place to assist this area of concern:
The ?Notice of Bed Hold Policy? form has been added to the transfer paperwork.
The Finance Manager has been educated

How the concern will be monitored and title of person responsible for monitoring.
All hospital transfers and therapeutic leaves will be audited monthly to ensure that the bed hold form was provided to the resident and/or representative prior the resident leaving the facility.
Results of the audit will be reported to the QAPI Committee for review and any appropriate action monthly x 3 months.
Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Responsible Party:
Administrator

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not ensure that notification was provided to the resident, the resident's representative, and a representative of the Office of the State Long-Term Care Ombudsman, of the resident's transfer or discharge and the reasons for the move for 2 (Residents #'s 49 and 63) of 2 residents reviewed for hospitalization . Specifically, for Resident #'s 49 and 63, there was no documented evidence the resident, the resident's representative, or the Ombudsman were notified by the facility when the residents were admitted to a hospital from the facility. This is evidenced by: Resident #49: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident could understand, was understood, and had no cognitive impairment. A Nursing Progress Note dated 8/9/18, documented the resident was complaining of back and bilateral leg pain and made a request to go to the emergency room (ER). An order was obtained to send the resident to the ER for an evaluation. A Nursing Progress Note dated 8/13/18, documented the resident was readmitted to the facility from the hospital. Review of the Multidisciplinary Progress Notes did not include documentation that written notification was sent to the resident, resident's representative, or the Ombudsman regarding the facility initiated resident discharge. During an interview on 11/01/18 at 04:28 PM, the Director of Social Work reported she was not aware that a letter had to be sent to resident, the resident representative and the Ombudsman when a resident was transferred to the hospital. She stated that she believed this would be her responsibility. During an interview on 11/01/18 04:30 PM, the Director of Nursing (DON) reported that Social Work should be sending the notices. The DON provided a Notice of Transfer/Discharge form, that she reports is not being used as it should be. Resident #63: The resident was admitted to the nursing home on 1/25/18, with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. The Hospital Discharge Summary documented that the resident was admitted from the nursing home on 10/9/18. A Social Work (SW) Note dated 10/10/18, documented that the resident was transferred and later admitted to the hospital and therefore discharged from our facility at this time. During an interview on 11/2/18 at 2:40 PM, the SW stated that she had not done discharge notices for unplanned discharges and did not do one for this resident. She stated from this point on she would. 10NYCRR415.3 (h)(1)(iii)(a-c)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
Residents # 49 and 63 were readmitted without incident.

How we identified other residents/areas that could potentially be affected:
All residents being transferred/discharged have the potential to be affected.

Measures to ensure were/will be put into place to assist this area of concern:
Nursing and Social Services has been educated regarding the Notice of Transfer / Discharge Policy.
The Transfer/Discharge form has been added to the transfer paperwork.

How the concern will be monitored and title of person responsible for monitoring:
All transfers and discharges will be audited monthly to ensure that the Notice of Transfer/Discharge form was provided to the resident, resident?s representative and Office of the State Long-Term Care Ombudsman.
Results of the audit will be reported to the QAPI Committee for review and any appropriate action monthly x 3 months.
Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations.
Responsible Party:
Director of Nursing

FF11 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(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 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation, and interview the facility did not provide food and drink that was palatable, attractive and at a safe and appetizing temperature on two of 3 units and in the Main Dining room during the recertification survey. Specifically, the food was not palatable and was not at appetizing temperatures. This is evidenced by: Finding #1 During interview on 10/30/18 at 10:33 AM, Resident #54 stated the food was cold when he gets it, he receives meals on trays and has told the nurses the food is cold. During interview on 10/30/18 at 10:54 AM, Resident #69 stated the food was not good. During interview on 10/31/18 at 9:19 AM, Resident #92 stated the food was repetitive, not hot when she got it, she did not get hot coffee and sometimes the soup was not hot. She said she received meals on trays. On 10/31/18 12:27 PM, Resident #'s 69 and 3 were observed sitting at a table in the back area of Unit 3. The residents said the beef stew was cold. This surveyor felt Resident #69's (with permission) bowl of stew. It was lukewarm. On 10/31/18 at 12:39 PM, this surveyor went into the Main Dining Room. Resident #'s 57, 15, 22, 92, 50, 23, and #10 said the stew was not hot. Resident #10 said the stew would have been better hot. Finding #2 On 11/1/18 a Test Tray was performed on Unit 1: The food cart of trays arrived on the unit at 12:00 pm and staff started to pass the room trays. Large containers of cold beverages were in a bin of ice. As the trays were prepared the milk and apple juice were taken out of the ice bin and left sitting on the cart (off ice). Staff continued to pour the cold beverages for each tray. At 12:19 PM, the last tray was served and test tray was sampled with the following results: potato soup- 90 degrees, tepid to taste and tasted like watered down potato soup; the bread dressing with gravy- 120 degrees and warm to taste; roast turkey- 92 degrees barely warm and bland; carrots - 100 degrees crunchy, barely warm; water for tea-116 degrees- lukewarm to taste; milk- 55 degrees- lukewarm; apple juice-58 degrees- cool, but not cold to taste. Finding #3 On 11/1/18, a Test Tray was performed on Unit 3: At 12:17 PM, the test tray was sampled with the following results: soup- 93.9 degrees, very thin, scant potato, bland and tepid; stuffing- 128.9 degrees tepid and mushy; turkey- 120 degrees tepid; carrots-116.6 degrees and hard, not fully cooked; hot water- 118.2 degrees; milk- 40.3 degrees; apple juice 55.2 degrees. During interview on 11/01/18 at 12:42 PM, Resident #78 said his meal at lunch was not hot, the food here is not hot. Resident #41 said the soup was not hot today. Resident #76 said lunch was not hot today, the carrots were frozen. Resident #69 said her food was not hot today, the turkey and stuffing were not hot. Finding 4 On 11/1/18, a Test Tray was performed on Unit 2 (Dementia Unit): At 12:15 AM, trays were being passed to residents. At 12:43 PM, the last tray was served and the test tray was sampled with the following results: potato soup- 106 degrees and watery looking; stuffing-122 degrees, carrots- 80 degrees; turkey- 116 degrees; water- 54 degrees. During interview on 11/01/18 at 2:37 PM, the Food Service Director (FSD) said isolated complaints of cold food from residents have been received. In Food Meeting this week(Monday 10/29/18) the residents thought trays were not being passed out quickly enough so the food was cold. In August, the residents complained of cold food. We tried to get trays passed more quickly which occurred for a while. The FSD said he does test trays once a week to test temperatures. They show the soup is an issue which he is trying to work on. He stated as soon as food leaves the tray line temperature starts to drop. He did not know why the temperatures today were so different from our test tray results, food is hot on the tray line. It usually takes about 15 minutes on the units to pass trays when he does the test trays. Food temperatures did not come up at the QA meeting last week. Monday was the last time resident's complained about cold food. During interview on 11/01/18 at 3:13 PM, Unit 1 CNA #10 said it takes on average 20 minutes to pass trays. Today they had an extra person helping so it was quicker passing trays. Sometimes it can take longer or go quicker depending on what is happening on the unit. During interview on 11/01/18 at 3:20 PM, Unit 3 CNA #11 said it can take up to 45 minutes to pass food trays in the morning, they have to pour beverages. Lunch time is about the same, they have to pour beverages and heat the soup, it is always cold. On weekends it is worse because there are only two CNAs, it takes at least 45 min to pass trays. Resident's do complain of cold food. We tell the kitchen about resident complaints of cold food. Last week end she told the kitchen the food was cold. CNA #11 stated she had told the FSD of the cold food complaint of residents and it takes more time for us to pour the beverages. 10NYCRR415.14(d)(1)(2)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The Director of Food Services will meet with Residents #54, 69, 92, 3, 78, 41, 76 to address their identified concerns regarding food temperatures and will meet with them at least weekly to assure resolution until all residents have stated satisfaction for 4 consecutive weeks.

How we identified other residents/areas that could potentially be affected:
All residents with outstanding concerns pertaining to food temperatures were addressed by the FSD.

Measures to ensure were/will be put into place to assist this area of concern:
A new induction warmer has been installed on 11/9/18 to increase the temperature of plates used to serve meals.
The process for documenting food temperatures has been revised to reflect monitoring and recording the food temperature of the food at the beginning of each meal service and repeated midway through the meal service at the point of service.
All Food Services staff will be in-serviced on the changes to the Temping process.

How the concern will be monitored and title of person responsible for monitoring:
The Director of Food Services/ designee will audit the Temperature Log on a daily basis until compliance with Food temps is 100% for 2 consecutive weeks
Audit results will be reported to the QAPI Committee for review and comment.
The Director of Food Services will report outcomes of Food Committee meetings monthly with identified interventions to the QAPI Committee on a monthly basis. The need for continued reporting will be determined by the QAPI Committee.
The individual responsible for correction of this deficient practice is the Director of Food Services.

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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the resident's choices for 3 ( Resident #'s 5, 16, and #54) of 26 residents reviewed during the recertification survey. Specifically: For Resident #'s 5, and 54 the facility did not ensure that the computerized process for bowel care was followed resulting in a lack of regular elinimation. For Resident #16, who was dependent for care, the facility did not ensure that Activities of Daily Living were provided, that food was offered, that drinks were available, that the resident's communication board was utilized to communicate with her, and that the Comprehensive Care Plan (CCP) was revised as the resident's condition changed. Additionally the facillity did not have a written policy or proceedure regarding bowel management for staff to follow. This is evidenced by: Resident #5: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 10/20/18, assessed the resident understands, was understood, and had no cognitive impairment. The resident was frequently incontinent of urine and bowel. Review of the Comprehensive Care Plan (CCP) did not include a care plan that addressed the resident's constipation. The resident's Kardex (used by staff to provide needed care) documented the resident required an extensive assist of 2 staff for toileting. There were no other instructions regarding constipation care on the Kardex. Review of the resident's bowel records from 8/18/18 through 10/30/18 revealed the resident did not have a bowel movement: for 5 days from 8/18 - 8/22/18, 8/23 - 8/27/18, 8/30 - 9/4/18, and 9/24-9/28/18; for 6 days from 9/30 - 10/4/18, 10/17 - 10/22/18, and from 10/25 - 10/30; for 7 days from 9/7- 9/13/18 ; and for 8 days from 10/7 - 10/15/18. Review of the Medication Administration Record (MAR) dated from (MONTH) through (MONTH) (YEAR) documented the following Physician ordered bowel medications for constipation; [MEDICATION NAME] 2 capsules at bedtime for constipation, [MEDICATION NAME] powder 17 grams one time a day for constipation, Senna-[MEDICATION NAME] Sodium 2 tablets at bedtime for constipation. Review of the MARs dated (MONTH) (YEAR) through (MONTH) (YEAR) documented the resident received an as needed bowel medication for constipation on 2 occasions during this time period. The resident received a [MEDICATION NAME] Suppository on 9/3/18 at 9:28 PM and on 10/15/18 at 7:30 PM. The suppsoitories were administered based on an as needed physician order [REDACTED]. The 24-Hour Report Sheets for October, September, and (MONTH) (YEAR) did not include documentation that the MD was notified that the resident did not have a bowel movement in 3 days. Nursing Progress Notes documented: On 8/22/18, the resident was on day 3 of not having a BM. The CNA (Certified Nurse Aide) would get the resident up to sit on the toilet today and that usually when the resident was placed on the toilet she is able to have a BM. If the resident was unable to have a BM the on call MD would be notified. On 10/3/18, the resident was on day 3 of not having a BM. The CNA's will get the resident up and on the commode. If no effect, will give MOM (Milk of Magnesia). The Nurse Practitioner was aware. During interview on 10/30/18 at 2:43 PM, the resident stated she had very bad constipation. The resident stated she only had a bowel movement (BM) once a week and thought she received as needed (PRN) bowel medications. During interview on 11/01/18 at 11:15 AM, the Director of Nurses (DON) stated that PRN bowel medications will not show up on the MAR unless they were given. She said the facility does not use standing orders for PRN bowel medications. If MOM, suppository or enema was needed they would have to call the doctor for an order. She stated the facility did not have a bowel protocol. The computer is set up to do an alert if a resident does not have a BM after 3 days. On day 4 staff has to call the doctor for orders. During interview on 11/02/18 at 7:24 AM, Licensed Practical Nurse (LPN) #2 stated the resident has problems with constipation. LPN #2 thought it was due to the resident's refusal to get up. The resident will have a BM when sitting on the toilet. During interview on 11/02/18 at 8:59 AM, CNA #3, stated the resident has constipation. The constipation gets worse every time she comes back from the hospital. CNA #3 thought the resident needed a laxative yesterday. The problem for her is she stays in bed. It is easier for her to go when sitting on the commode. On shower day we put her on the commode and she goes. She stated the resident's need to get up to have a BM was not documented in the Kardex. During interview on 11/02/18 at 10:51 AM, Licensed Practical Nurse Manager (LPNM) #6 stated the resident has constipation occasionally. Constipation was not an issue she remembered discussing at care planning meetings. LPNM #6 stated the resident does not like to get out of bed. When the resident gets up and on the commode she has a BM 90 % of the time. She stated there was no plan in place to address putting the resident on the commode to have a BM. LPN #6 stated they encourage the resident. If a resident goes 3 days without a BM it pops up as an alert on the computer's clinical dashboard. The medication nurses are supposed to check it every shift. They have to call the doctor or Nurse Practitioner (NP) for an order on day 4. If a nurse called the doctor or NP it should be documented in the progress notes or somewhere on the 24 hour report sheet. If a medication was ordered it should be documented on the MAR. LPN #6 stated she did not think the Kardex documented to encourage the resident to use the commode for a BM. She stated she could see this resident should have had a CCP for constipation. Resident #54: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 9/13/18, assessed the resident understands, was understood and had moderately impaired cognitive ability. The resident was extensive assist of 2 staff for toileting. Review of the Comprehensive Care Plans (CCPs) did not include a care plan to address constipation. Review of the resident's Bowel Records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that the resident did not have a BM; for 5 days from 8/29-9/2/18, for 5 days from 9/28-10/2/18, and for 6 days from 10/11-10/16/18. Physician's Medication orders documented: [MEDICATION NAME] 10 mg-one tablet 3 times a day for pain (started 7/31/18), [MEDICATION NAME] powder 17 gm one time a day for constipation (in Liquid) started 1/19/17; Senna-[MEDICATION NAME] Sodium 8.6-50 mg two tabs at bedtime for constipation, started 7/24/18. Review of the (MONTH) and (MONTH) MARs did not include documentation that the resident received as needed bowel medications. During interview on 10/30/18 at 10:59 AM, the resident stated he has problems with constipation, that he receives medications for constipation, but was not having boewel movements regularly. The resident stated he has gone 5-6 days without a BM. During interview on 11/01/18 at 11:15 AM, the Director Of Nurses (DON) stated that as needed bowel medications will not show up on the MAR unless they were given. She said the facility does not use standing orders for as needed bowel medications. If MOM, a suppository or an enema was needed they would have to call the doctor for an order. The DON stated the facility did not have a bowel protocol. The computer is set up to do an alert if a resident does not have a BM after 3 days. On day 4, staff have to call the doctor for orders. During interview on 11/02/18 at 7:07 AM, LPN #2 stated the computer lets us know if a resident does not have a BM in 3 days. Then we have to call the doctor. The evening nurse can call, but they don't call on nights. The resident goes well for a while, then he doesn't. During interview on 11/02/18 08:55 AM, CNA #3 stated she remembered one time the resident had a hard time the nurse gave the resident laxatives and he went. Residents get a laxative after 3 days of no BM. She stated they record BMs under tasks in the computer and it pops up as an alert for the nurses if there is no BM in 3 days. During interview on 11/02/18 11:10 AM, LPNM #6 stated the resident goes back and forth between loose stools and constipation. He is on medications that cause constipation. LPNM #6 stated the resident should have a care plan for constipation. LPNM #6 stated the computer looks at 3 full days of no BMs before the alert comes up. The alert stays until cleared. She thought the alert could be cleared without doing anything, but was not sure. Resident #16: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was usually understood by others. The resident was on comfort care. Finding #1: The facility did not ensure that the resident who was dependent for care was provided with ADLs. During observations on 10/29/18 at 11:30 AM and on 10/30/18 at 11:14 AM, the resident was lying in bed in the dark. She and her bed were disheveled and the resident smelled of urine. During an observation on 10/31/18 at 03:12 PM, the resident was in her bed with the lights out and had her head laying in a large amount of red liquid that was spilled in her bed. The bed was soiled with juice and water. The resident was trying to pull her chair to her, took her drink and tried to drink the water while laying down and spilled the water in the bed. LPN #3 took the drink away and continued to mop the floor. He the left room, and did not give the resident a drink or return to the room. During an observation on 10/31/18 at 03:15 PM, a Certified Nursing Assistant (CNA) went by the resident to put the room mate to bed. When she finished she left the room. LPN #3 came in with a mop and was mopping the floor around the bed. While he was doing this, the resident reached for the chair that was next to the bed, pulled the chair to her and took a drink that was sitting on the chair and attempted to drink it. LPN #3 took the drink away from the resident, moved the chair across the room and continued to mop the floor. The resident laid back down in the spilled liquid. When LPN #3 finished he left the room without giving the resident a drink or changing the bed. During an observation on 10/31/18 at 03:45 PM, the resident was lying in bed, in the dark, still laying on the soiled sheet. During an observation on 10/31/18 at 03:47 PM, this surveyor brought RNM #1 to the resident's room. The resident was laying on the soiled sheets. RNM #1 directed staff to change the resident. During an interview on 10/31/18 at 3:47 PM, RNM #1 stated that staff should have changed the resident and not left her on soiled bedding. During an interview on 11/01/18 at 09:24 AM, the Director of Nursing (DON) stated that based on what the surveyor was telling her it appeared the resident was not getting the ADL care she should have been getting. Finding #2: The facility did not ensure that food was offered and that drinks were available to the resident. During an observations on: 10/29/18 at 12:29 PM, CNA #9 took a full tray out of the food cart and took it into the room marked medical room. She came out a couple minutes later and placed the tray back on the food cart. 10/29/18 at 12:48 PM, this surveyor asked CNA #9 to show this surveyor the tray she put back on the cart. CNA #9 removed the resident's tray and opened it. There was no food on the plate, but remnants remained where the meal was scraped off the plate. When asked, CNA #9 stated she did not know where the food was. 10/30/18 at 07:56 AM, the resident was asleep in bed and the room was dark. There was a breakfast tray on a straight back chair next to bed. The tray had sausage and eggs and an unopened bowl of oatmeal. The silverware was not moved. 10/31/18 at 08:37 AM, the resident was asleep in bed and the room was dark. The tray was open on a chair at the bedside with no food consumed. 11/01/18 at 08:38 AM, while the surveyor was standing outside the resident's room, a CNA delivered the tray to the room. There was no interaction heard with the resident prior to the CNA exiting the room. The resident's tray was opened and left on the overbed table, the room was dark and the resident was asleep in the bed. 10/31/18 at 03:12 PM, while staff was in the room, the resident pulled her chair to her and removed a glass of water that was on the chair. The resident lifted her head and attempted to drink the water and spilled it in her bed. LPN #3 took the drink away, left the room, and did not give the resident her drink or return to room. 10/31/18 at 03:45 PM, the resident was lying in bed in the dark, there were no drinks in her reach. 11/01/18 at 08:49 AM and 09:05 AM, the resident had a glass of water in the room with no top on it and no straw. 11/01/18 at 03:43 PM, the resident was laying in bed with drinks across the room, out of her reach. The surveyor asked CNA #8 to offer the resident a drink, when the CNA did, the resident accepted it. During an interview on 10/29/18 at 12:42 PM, CNA #9 stated that the resident did not eat because she was on comfort care and that she was bringing her a glass of water. During an interview on 10/31/18 at 03:47 PM, the surveyor advised RNM #1 that the resident's drink was taken away. RNM #1 responded, she thought the resident was on supplements, but they were discontinued because she was comfort care. During an interview on 11/02/18 08:44 AM, the DON stated that they had done comfort care training with the staff and that she would expect them to check on the resident frequently and see if she wanted a drink. They do not want the table in her reach as she may attempt to use table to get up alone and get hurt. During an interview on 11/02/18 at 11:10 AM, the Speech Language Pathologist (SLP) stated that anyone could send a referral if they had a concern but no one had contacted him to address the resident's eating or drinking. During an interview on 11/02/18 11:14 AM, the Food Service Director (FSD) stated that staff would email or communicate verbally if they had concerns about a resident; he was not aware of any concerns. During an interview on 11/2/18 at 2:00 PM, the SLP stated he saw the resident after talking to Department of Health (DOH) and noticed that the resident was taking sips of liquids. She was end stage dementia and SLP did not feel there was an issue if drinks were in her reach, so he added a cup with a cover and a straw so the resident could have drinks available when she wanted them. Finding #3: The facility did not ensure that they used the resident's care planned communication board. A Comprehensive Care Plan dated 8/28/18, documented that hearing loss made communicating difficult and that she used a dry erase board to communicate with staff. During multiple observations from 10/29/-10/31/18, the resident was in bed with the lights out and two communication boards on her dresser. There was no marker available in the room to write on the board. During an interview on 10/30/18 at 11:19 AM, the Activity Aide (AA) #3 stated that the resident used a white board at times for communication. When surveyor checked the communication board there was no marker for it and the AA stated they had markers in activities. During an interview on 10/31/18 at 03:22 PM, RNM #1 stated that there should have been something in the room to write on the communication board with. During an interview on 11/01/18 at 08:39 AM, CNA #5, stated she did not use the communication board, that she talked loud. During an interview on 11/01/18 at 12:35 PM, the MDS Coordinator stated that she talked loudly to the resident and did not use the communication board. During an observation on 11/1/18 at 3:38 PM, the surveyor attempted to use the communication board and there was no marker in the room. The surveyor went out to staff and got a marker for the communication board. When the surveyor wrote on the board to ask the resident if she wanted a drink, the resident took the board from the surveyors hands, read it out loud and said yes. The surveyor went to get a staff member, who gave the resident a drink. Finding #4: The facility did not ensure that the Comprehensive Care Plan was updated to reflect the decline in the resident's condition. An undated Bedside Kardex (a guide to tell staff how to perform care) documented that the resident required an extensive assistance of one person for ambulation and toileting, was a supervision setup for meals, and to offer food and activities of interest while wandering to keep the resident occupied. The Comprehensive Care Plan documented that the resident exhibited behavior symptoms such as elopement, ambulate in the hall and corridor with an extensive assistance of one staff. During an interview on 10/29/18 at 12:00 PM, RNM #1 stated that the resident did not get up much anymore; she was comfort care and had lost a lot of weight. During an interview on 11/01/18 at 02:55 PM, CNA #7 stated that it had been at least 2 weeks since Resident #16 had walked. During an interview on 11/1/18 at 2:50 PM, the MDS RN stated that the resident has had declines in her ADLs, but that they did not need to do a significant change MDS because she was comfort care and end of life. During an interview on 11/02/18 08:44 AM, the DON stated that the resident's care plan should have been updated to reflect what was actually going on with the her. 10NYCRR415.12

Plan of Correction: ApprovedDecember 3, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** How the corrective action will be accomplished for any resident affected by deficient practice:
Resident # 16 is no longer in the facility.
Resident # 5 & 54 have had Bowel management protocols written.

How we identified other residents/areas that could potentially be affected:
All residents have the potential to be affected.
All residents who are on narcotic [MEDICATION NAME] will be reviewed for the need for routine bowel management protocols.
All residents found to be in need of bowel protocols will be reviewed to ensure that they have a current care plan in place for constipation.
All residents on comfort care will have their care plans reviewed to ensure that they are accurate based on the resident?s current abilities.
All residents that use devices to communicate will be reviewed to ensure that device is care planned and information is on Kardex for the aides to use also.

Measures to ensure were/will be put into place to assist this area of concern.
The Policy titled Bowel Management has been reviewed and revised.
The Policy titled Comfort Care has been reviewed and revised to include provision of food and fluids for those on Comfort Care.
All Nurses will be educated regarding the Bowel Management and Comfort Care Policies.

How the concern will be monitored and title of person responsible for monitoring:
All residents on comfort care will be audited weekly x 12 weeks to ensure that their care plans reflect their current needs.
All residents on comfort care will be audited 3 times weekly x 4 weeks, then 2 times weekly x 4 weeks then 1 time weekly x 4 weeks to ensure that they are being offered and assisted with food and fluids as they desire
10 residents will be reviewed 5 x weekly x 4 weeks, then 10 residents 3 x weekly x 4 weeks and then 10 residents weekly x 4 weeks to ensure that they have had regular bowel movements.
The results of all audits will be presented to the QAPI committee monthly. Audits will be continued as requested by the committee.
Responsible party:
Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification survey the facility did not ensure that in accordance with accepted professional standards and practices, it maintained medical records on each resident that were complete and accurately documented; Specifically, the Registered Nurse Manager signed for medications that she did not administer. During an observation at the Unit 2 medication cart on 10/31/18 at 09:01 AM, Registered Nursing Supervisor (RNS) #2 told RNM #1 that Licensed Practical Nurse (LPN) #3 had not documented the insulins as being administered. The Electronic Medication Administration Record [REDACTED]. The eMAR for 10/2018 for Resident #71, documented that on 10/30/18, the residents 8:00 AM [MEDICATION NAME]was administered by RNM #1. An eMAR for 10/2018 for Resident #293, documented that on 10/30/18, the residents 7:30 AM [MEDICATION NAME]was administered by RNM #1. During an interview on 10/31/18 at 09:11 AM, RNS #2 stated that he was the supervisor on during the 11:00 PM - 7:00 AM shift last night and relieved the Unit 2 LPN #3, at 7:45 AM. RNS #2 was relieved by RNM #1 at 9:00 AM. RNS #2 stated LPN #3 administered insulin injections on Resident #'s 63, 71, and 293 that morning before he left but did not sign for them. He guesses it could be considered a medication error. During an interview on 10/31/18 at 04:36 PM, Director of Nursing (DON) state there is a dashboard that the NM, ADON,DON have access to The NM is expected to check daily. If blanks are found should call nurse to see that it was given. Do not expect any nurse to document on a medication that they did not give themselves. 10NYCRR 514.22(b)

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The RNUM was terminated from employment at the time of the discovery of signing for medications which she did not administer.
Medication error reports were written up for all the insulin administered by LPN # 3 to residents # 63, 71 and 293 that he did not sign for at the time of administration. LPN # 3 also received education regarding the signing of medications immediately after administering them.

How we identified other residents/areas that could potentially be affected:
All residents receiving medications have the potential to be affected.
Measures to ensure were/will be put into place to assist this area of concern:
A Policy titled Medication Administration Documentation was written.
All licensed nurses will be educated regarding the new policy.

How the concern will be monitored and title of person responsible for monitoring:
Audits of medication administration will be completed to ensure that the medications are signed off right after administration by the nurse administering them. Ten nurses will be audited weekly x 4, then five nurses weekly x 4, then three nurse weekly x 4.
Results of the audits will be reported monthly to the QAPI committee. Audits will be continued based on recommendations from the committee.
The Director of Nursing will be responsible for continued compliance.

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey the facility did not ensure that residents who need respiratory care were provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #'s 82, #543) of 3 residents reviewed. Specifically; for Resident #82, the facility did not ensure that oxygen was administered per physician order, and for Resident #543, the facility did not ensure physician's orders [REDACTED]. This was evidenced by: Resident #82: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition. Observations: On 10/29/18 at 1:30 pm, Resident #82 was in his bed with his oxygen (02) concentrator (medical device used to deliver oxygen) on and set at 2.5 liters per minute and 02 administered via an oxygen cannula in his nose. On 10/30/18 at 2:00 pm, Resident #82 was sitting in his chair in his room with his oxygen concentrator on and set at 3 liters per minute and 02 being administered via an oxygen cannula in his nose. On 10/31/18 at 4:12 pm, the resident was sitting in his chair in room with his oxygen concentrator on and set at 2 liters per minute and 02 being administered via an oxygen cannula in his nose. The wife visiting and stated he uses the 02 when the staff thinks he needs it, he has it on most times when she visits. On 11/1/18 at 3:45 pm, the resident was in his bed in his room with his oxygen concentrator on and set at 3 liters per minute and 02 administered via an oxygen cannula in his nose. A nursing progress note dated 10/10/18, written by a Registered Nurse (RN), documented that the resident's wife stated the resident used 02 at home only as needed. The RN had removed the 02 from Resident #82 at 10:00 am and his SAT was 98%. The parameter for using the PRN 02 order was changed, to maintain SAT level at 90-95% per NP. The physician order [REDACTED]. Oxygen saturation ((the amount of oxygen bound to hemoglobin in the blood) before and after application of 02 and titrate LPM PRN. Maintain 02 saturation (SAT) level between 90-95%. 02 SAT daily when resident is on routine 02. If no improvement in 30 minutes notify MD. The Medication Administration Record [REDACTED]. Oxygen saturation before and after application of 02 and titrate LPM PRN. Maintain 02 SAT level between 90-95%. There was no initials documented to indicate the 02 had been administered. The treatment administration record (TAR) dated (MONTH) (YEAR) documented for 10/10/18, monitor oxygen saturation every shift and PRN. Document what the SAT is and the reason it was done every shift for dyspnea on exertion/SOB (short of breath) for 10 days. The SATs from 10/10/18 through 10/19/18 ranged from 93% to 99%. A review of the nursing progress notes dated 10/10/18 through 10/31/18, revealed there was no documentation that oxygen PRN was applied to Resident #82. During an interview on 11/01/18 at 4:00 PM, the Director of Nursing (DON) stated the nurses should have checked the SATs before putting the PRN 02 on, and should have checked the SAT after the 02 was applied, according to the MD (physician) order. The Nurses should have signed the MAR indicated [REDACTED]. If Resident #82 had used 02 continuous, the nurses should have called the MD for an order. During an interview on 11/1/18 at 3:50 PM, LPN #1 stated Resident #82 had an order for [REDACTED]. If Resident #82 was using the 02 the nurse should have checked to make sure they had an order. If she had taken care of Resident #82 and he had the 02 on she would have taken it off and checked his SATs. If the Resident was using 02 continuous and only had a PRN order, she would have let the MD know. During an interview on 11/1/18 at 3:30 PM, LPN #5 stated when she had worked on Resident #82's assignment she had checked his 02 SATs per the MD order. If the Resident's 02 had been on, it should have been signed for in the MAR, and a nurses note should have been written. Resident #543: Finding #1: This resident was admitted on [DATE], [DIAGNOSES REDACTED]. During an observation on 10/30/18 at 2:17 PM, the resident was observed on 7.5 liters of oxygen [MEDICAL CONDITION]. The resident was observed in his room on several occasions throughout the day shift, specifically; on 10/30/18 at 02:17 PM the resident was receiving oxygen via [MEDICAL CONDITION] collar at 7.5 Liters / minute (L/min) , on 10/31/18 03:09 PM at 9 L/min, on 11/01/2018 at 4:52 PM oxygen was at 4 L/min, 11/02/18 at 10:13 AM at 9 L/min. Review of the resident's medical record, documented that the resident is alert, oriented x 3, and understood with the use of an assistive device and understands. A physician's orders [REDACTED]. Review of the resident's medical record, documented a consultation from a Respiratory therapist (RT), indicating resident stated ability to complete [MEDICAL CONDITION] care, suctioning and use of humidified oxygen. Review of a consultation from RT dated 10/29/18, documented the resident was receiving 6 liters / minute of oxygen, provided nurse and resident education. Nurse reported resident self-adjusting oxygen. An alteration in respiratory status care plan dated 10/29/18, documented to provide oxygen per MD orders. A nursing progress note dated 10/31/2018 at 5:56 PM, documented an oxygen saturation of 98% on room air. All other progress notes dated 10/26/18- 11/1/18 reviewed and without note of resident oxygen usage, or self-administration. During an interview on 10/30/18 at 2:17 PM, the resident stated a nurse had adjusted his oxygen overnight. Finding #2 A nursing progress note dated 10/31/2018 documented not to administer the as needed dose (PRN) [MEDICATION NAME] ([MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME] sulfate) via inhalation: (these two medicines work together to help open the airways in your lungs) and schedule [MEDICATION NAME] every four hours as a scheduled dose for five days. A MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The nursing progress notes / assessments dated 10/31/18-11/1/18 did not include documentation of the effectiveness of the respiratory medication. During an interview on 11/02/18 at 10:41 AM, RNUM (Registered Nurse Unit Manager) #4, stated when a verbal order is obtained the nurse is expected to enter the order into the electronic medical record (EMR) and document the conversation with the MD in the nursing progress notes section of EMR. RNUM #4 reviewed orders during interview and was able to identify discrepancy in progress note and orders. During an interview on 11/2/18 at 03:48 PM, the DON stated she was aware of discrepancy identified with RNUM #4 and the MD will be contacted to obtain clarification of order. Finding #3 Review of a consultation from a Respiratory therapist (RT), documented that the resident stated he was able to self perform [MEDICAL CONDITION] care, suctioning and the use of humidified oxygen. A MD order dated 10/26/18 documented [MEDICAL CONDITION] care every shift and as needed. A treatment administration record dated from 10/26/18-11/1/18, documented [MEDICAL CONDITION] care every shift and as needed and was signed off each shift through 11/1/18 7-3 shift by a nurse. An alteration in respiratory status care plan dated 10/29/18, documented to provide tracheotomy care daily and as needed using aseptic technique. During an interview on 11/01/2018 at 4:52 PM, RN (registered nurse) #3 stated the resident was independent with oxygen, care of the [MEDICAL CONDITION] and self-suctions. She stated she was unaware of the level of oxygen resident was receiving at that time. RN #3 stated she did not know what the MD orders or care plan was for oxygen, care of the [MEDICAL CONDITION] and suctioning. RN #3 reviewed the care plan during the interview and stated the care plan did not include that the resident independently cares for his [MEDICAL CONDITION], suctioning and oxygen. During an interview on 11/2/18 at 10:13 AM, LPN (licensed practical nurse) #5 stated the resident self applies oxygen throughout the day, and provides his own [MEDICAL CONDITION] care. She stated there should be an MD order and the care plan should include MD order to include the resident is able to independently perform [MEDICAL CONDITION] care, suctioning and use of the oxygen. During an interview on 11/2/18 at 10:41 AM, RNUM (registered nurse unit manager) #4 stated the care plan should indicate if a resident provides self-care, and be resident specific. She stated resident received oxygen at all times, stated the care plan was not specific to the resident in regard to oxygen MD orders. She stated the care plan should be revised to include resident specific diagnosis / needs and reflective of resident ability to provide self-care safely. During an interview on 11/2/18 at 03:48 PM, the DON (Director of nursing) stated the resident was evaluated by respiratory and was able to care for his [MEDICAL CONDITION] and oxygen administration. The DON stated the expectation of staff is to communicate assessment findings in resident's ability to self care for [MEDICAL CONDITION], suctioning and utilization of oxygen, obtain an MD order, add to the care plan, and monitor the resident for ability to manage these tasks independently. The DON reviewed the care plan and stated it is not resident specific and would need to be revised. 10NYCRR415.12(k)(6)

Plan of Correction: ApprovedNovember 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** How the corrective action will be accomplished for any resident affected by deficient practice:
Resident # 82 has had the order for oxygen changed to 2 liters per minute continuous.
Resident # 543 has had his oxygen orders,[MEDICAL CONDITION], medication and suctioning orders clarified. The new orders have been added to the care plan and are reflected accurately on the MAR.

How we identified other residents/areas that could potentially be affected:
All residents with PRN oxygen orders have the potential to be affected.
All resident with PRN oxygen orders will be reviewed to be sure parameters have been followed. Error reports will be completed for any use found outside the parameters.
All residents who are independent with any of their respiratory care will be reviewed to ensure that their orders reflect what is being done.

Measures to ensure were/will be put into place to assist this area of concern:
Policy titled Oxygen use has been reviewed and revised.
All licensed staff will be reeducated.
All residents with PRN oxygen orders will be reviewed for frequency of use and provider will be updated for possible continuous oxygen orders.

How the concern will be monitored and title of person responsible for monitoring:
100% of residents with PRN oxygen will be audited for compliance of parameters 5 times a week times 4 weeks then weekly times 4 weeks then monthly times 4 weeks.
100% of the new admissions or readmissions who are independent with any of their respiratory care will be audited to ensure that the orders clearly state the residents independence 5 times a week for 4 weeks, then weekly times 4 weeks, then monthly times 4 weeks.
The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
The Director of nursing will be responsible for compliance.

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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services to maintain a clean and homelike environment. Specifically, the floors and walls on 2 of 3 resident units were not clean and/or in disrepair. This is evidenced by: The resident area floors and walls were inspected on 11/01/2018 at 2:30 PM. The walls in resident room #'s 13, 102, 104, 105, 108, 114, 116, 126, and #129 had scrapes and scuff marks. On Unit #1, the corridor floor was soiled with soiled wax buildup, and the corridor walls had scrapes and scuff marks. The Director of Maintenance stated in an interview conducted on 11/02/2018 at 9:15 AM, that he was aware that walls needed maintenance, stated he has not had the opportunity to repair them, and that he will notify the Housekeeping Department to have the floors cleaned.

Plan of Correction: ApprovedNovember 30, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

How the corrective action will be accomplished for any resident affected by deficient practice:
Unit 1 corridor floor & walls will be waxed, painted, & repaired.
Walls in rooms 13, 102, 104, 105, 108, 114, 116, 126, & 119 will be painted and repaired.

How we identified other residents/areas that could potentially be affected:
The corridor walls and floors on units 2 & 3 will be inspected and any nicks and chips identified will be repaired.
An inspection of all rooms will be completed and any found in disrepair will be fixed.

Measures to ensure were/will be put into place to assist this area of concern:
Housekeeping & Maintenance will be educated on proper cleaning and repairs of the floors & walls.
A new Director of Maintenance & Housekeeping Supervisor was hired to help resolve issues in a timelier fashion.

How the concern will be monitored and title of person responsible for monitoring:
The Director of Housekeeping will do a weekly audit of the resident rooms x4 weeks, then monthly x3 months to ensure walls & floors are in repair and are clean.
The results will be presented to the QAPI Committee for review.
Responsible Party:
Administrator

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store medical waste and soiled linens in accordance with adopted regulations. Medical waste storage areas must display signage indicating the space is used to store regulated medical waste, be designed or equipped to prevent unauthorized access, and be appropriately ventilated. Ventilating systems must be maintained and operated in such manner that air shall not be circulated from soiled utility rooms to other parts of the facility. Specifically, the medical waste storage room was not maintained as required and soiled linen rooms were not provided with mechanical ventilation. This is evidenced as follows. Observations revealed that on 10/31/2018 at 1:35 PM that the medical waste storage room was not labeled, the door was not locked, and lacked ventilation. The Director of Maintenance stated in an interview on 10/31/2018 at 3:15 PM that he did not know the medical waste storage room had to labeled, was unaware that the room was not locked and the vent was not working. Observations were made on 11/01/2018 at 4:45 PM that the soiled linen room in the Resident Unit 2 lacked mechanical ventilation. The Director of Maintenance stated in an interview conducted on 11/02/2018 at 9:00 AM that he was unaware that the soiled linen room was not ventilated. 10 NYCRR 415.29 (h), (j)(6)(ii); 10 NYCRR 70-2.2

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
All medical waste storage rooms will be inspected to ensure the doors locks, signage is present, and construction order has been put in to add ventilation to the room.

How we identified other residents/areas that could potentially be affected:
All storage rooms were inspected for compliance with standards for storing medical waste.

Measures to ensure were/will be put into place to assist this area of concern:
Housekeeping staff will be educated on proper storage & handling of medical waste including signage, locks, & the importance of ventilation. A new weekly checklist will be added to the supervisors? schedule to audit for compliance.

How the concern will be monitored and title of person responsible for monitoring:
The QAPI committee will monitor the new weekly audit implemented monthly x3 months to ensure that the medical waste storage rooms are compliant.
Responsible Party:
Administrator

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 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall when used to energize appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair. Specifically, power strips were not secured to the walls. This is evidenced as follows. Observations on 02/22/2018 at 9:30 AM, revealed power strips dangling loosely in mid-air in the following resident areas; activities room, Unit #1 nurse's station, resident room #'s 7 and 120, resident unit #3 electrical closet, and Unit #2 nurse's station. The Maintenance Director stated in an interview conducted on 11/02/2018 at 9:10 AM, that all the power strips were recently replaced and he has not had a chance to secure them. 42 CFR 483.70 (a) (1); 2011 NFPA 70 400.8, 400.7, 368.56(B); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 70

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
All power strips were fastened to the wall.

How we identified other residents/areas that could potentially be affected:
An audit of all rooms in the facility identified the locations of all power strips and if the power strip was secured to the wall, any that wasn?t secured was then secured safely.

Measures to ensure were/will be put into place to assist this area of concern:
Maintenance & Housekeeping staff will be educated of the requirement to ensure power strips are secure. An audit will be completed by the Administrator to ensure all power cords are compliant & secured.

How the concern will be monitored and title of person responsible for monitoring:
10 random rooms will be audited weekly x2, then monthly x3, to ensure power strips are secured to the wall.
The results will be presented to the QAPI Committee for review.
Responsible Party:
Administrator

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: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that PCREE is maintained with consideration of the owner's manual. Specifically, PCREE observed was not maintained as prescribed in the owner's manual. This is evidenced as follows. Observations on 11/01/2018 at 4:06 PM, revealed that the suction machines located on the crash carts on the nurse's stations on Units #1, #2, and #3 did not have bacteria filters between the collection canister and pump. On 11/02/2018, the suction machines inspection reports were reviewed revealing that the suction machines were checked by the unit's nursing staff and listed as ready to operate. The operation manual for the suction machine was reviewed 11/02/2018 and states that the bacteria filter must be attached between the collection canister and pump. Observations on 11/02/2018 at 2:45 PM, revealed that oxygen concentrators in operation in resident rooms #'s 1, 11, 15, and #115 were less than 12 inches from the wall. The nebulizers in resident room #'s 7 and 11 were not in use and were plugged into an electrical receptacle. Record review of the oxygen concentrators and nebulizers owner's manuals on 11/02/2018, revealed concentrators must be 12 from walls and furnishings when in operation and the nebulizers are to be unplugged after use. The Director of Nursing stated in an interview conducted on 11/02/2018 at 9:26 AM, that she unaware that nursing staff was not operating oxygen concentrators and nebulizers in accordance to the owner's manuals, and the suction machines were missing the bacteria filters. Furthermore, the staff will be in-serviced to operate suction machines, nebulizers, and oxygen concentrators in accordance to the owner's manuals. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedDecember 4, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The nebulizers were unplugged and inspected.
The concentrators were moved at least 6-inches from curtains & walls.
New suction machines will be ordered to replace the old ones with no filters for the crash cart on units 1, 2, & 3.
How we identified other residents/areas that could potentially be affected:
An audit of all patient care related electrical equipment currently assigned to residents will be conducted for the safe use in accordance with the owner's manual. Any found to not be used according to owner's manual will be corrected immediately.
Measures to ensure were/will be put into place to assist this area of concern:
A list of all residents with patient care electrical equipment will be created. New & current nursing, maintenance, recreation, & housekeeping staff will be educated on the equipment?s guidelines for safe use & handling.

How the concern will be monitored and title of person responsible for monitoring:
The new guidelines-for-use page prepared for any new equipment will be reviewed by the Director of Nursing & training completed for all appropriate staff prior to the new equipment being put into use.
Ten pieces of patient care related equipment will be audited for safe use in accordance with the owners manual daily x 5 days per week x 4 weeks, then 5 pieces of equipment 5 days per weeks x 4 weeks then 5 pieces of equipment 3 days per week x 4 weeks. Results of these audits will be presented to the QAPI committee for continuation if needed.
The Director of Nursing will report on the new equipment & training at the QAPI committee meeting.
Responsible Party:
Director of Nursing

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, analysis of drills and actual events that tested the efficacy of the Emergency Plan were not conducted. This is evidenced as follows. The documentation of the missing resident drill of (MONTH) 18, (YEAR) and loss of normal power actual event of (MONTH) 05, (YEAR) were reviewed on 10/30/2018. This review revealed that an after-action reports (analysis) was not conducted after these events to assess staff response, areas of improvement, or necessary changes to the Emergency Plan if required. The Administrator stated in an interview conducted on 06/26/2018 at 12:45 PM, that the after-action reports will now be conducted after every actual event and every Emergency Plan drill. 42 CFR: 483.73(d)(2)(iii)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The facility will schedule an initial test of the EP plan, and implement a documented analysis and outcome through an after-action report based on the drill and actual events that took place.

How we identified other residents/areas that could potentially be affected:
All residents, staff, volunteers, family, & visitors have the potential to be affected.

Measures to ensure were/will be put into place to assist this area of concern:
The results of the after-action report will be brought to the QAPI committee for performance review, and then to make necessary adjustments.
The facility will also review its results with the Essex County Office of Emergency Management as part of a collaborative attempt to ensure the emergency plan is effective.

How the concern will be monitored and title of person responsible for monitoring:
The emergency plan will be updated each year with the planning and coordination of the Essex County OEM which will include any necessary changes to the plan. Any changes in the plan will be practiced in drills.
Responsible Party: Administrator

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not provide initial training for all existing staff in emergency preparedness policies and procedures consistent with their expected roles. This is evidenced as follows. A review of the Emergency Plan, Training Program documentation of staff training on 10/30/2018 revealed that 66 of 99 staff members did not receive annual training in emergency preparedness policies and procedures. The Administrator stated in an interview conducted on 01/12/2018 at 10:40 am, that he cannot say all staff received training on the Emergency Plan. 42 CFR: 483.73(d)(1)(ii)

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
Annual training & testing for the emergency preparedness plan will be completed. Staff will demonstrate knowledge of Emergency Preparedness by completing the quiz that will be provided.

How we identified other residents/areas that could potentially be affected.
All residents, staff, volunteers, family, & visitors have the potential to be affected.

Measures to ensure were/will be put into place to assist this area of concern:
Emergency preparedness training will be added to orientation for new hires, and the whole facility will be getting a re-education to make sure there is 100% compliance. And EP training will be added to the list of annual in-services & educations.

How the concern will be monitored and title of person responsible for monitoring:
The staff development RN will ensure compliance by bringing a quarterly report to the QAPI committee to ensure the training is completed by 100% of the staff.
Responsible party:
Staff development RN & Administrator

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not conduct fire drills as required by adopted regulations. NFPA 101 Life Safety Code 2012 edition section 19.7.1.6 requires that fire drills shall be conducted quarterly on each shift. Specifically, 9 of the last 24 required fire drills were not conducted. This is evidenced as follows: The fire drill evaluation records were reviewed on 10/31/2018. The evaluations for the day, evening, and night shifts for the 4th quarter (YEAR); the day, evening, and night shifts of the first quarter of (YEAR); and the day, evening, night shifts of second quarter of (YEAR), were not available for review. The Administrator stated in an interview on 10/31/2018 at 10:15 AM that he did not know if the fire drill were conducted or not. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.1.6; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.1

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
Fire Drills will be scheduled at least once per shift per quarter at random times. The Facility Maintenance Director will be educated on how to run a fire drill and properly document scenario, response, & results for performance review and record keeping.

How we identified other residents/areas that could potentially be affected:
An audit was completed of all completed drills including drills missing a fire drill performance review &/or documentation have been identified.

Measures to ensure were/will be put into place to assist this area of concern:
All staff will be re-trained on fire drill procedures, which will include the proper way to document the results of a fire drill for performance review.

How the concern will be monitored and title of person responsible for monitoring:
Fire drills and documentation will be reviewed by members of the QAPI Committee monthly x6 months, to ensure successful drills and that the documentation provides results of the drill for performance review.
Responsible Party: Administrator

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide education on the safety guidelines and risks associated with the handling of medical oxygen cylinders to the maintenance staff. This is evidenced as follows. The Director of Maintenance stated in an interview conducted on 10/31/2018 at 12:45 PM, that maintenance staff transports oxygen cylinders from the outside storage shed to the resident units. When requested on 10/31/2018, records were not available for survey review that documented that the maintenance staff received training. The Assistant Director of Nursing stated in an interview conducted on 10/31/2018 at 3:30 PM, that she could not find a record that the maintenance staff was trained on the risks associated with handling of oxygen cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
All Nursing & Maintenance staff will be educated on handling and the risks involved in the use of Gas Equipment. The new education implemented will be documented and recorded.

How we identified other residents/areas that could potentially be affected:
All staff handling Gas Equipment will be trained.

Measures to ensure were/will be put into place to assist this area of concern:
All new Nursing & Maintenance employees will be trained upon hire and annually to ensure training of proper handling of gas equipment is completed to ensure safe practice.

How the concern will be monitored and title of person responsible for monitoring:
All nursing & maintenance employee education files will be audited to endure the facility staff is in 100% compliance with gas equipment training.
The responsible party:
Administrator

MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on record review staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.3.1 requires that door assemblies in exit enclosures be tested not less than annually in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition (NFPA 80). NFPA 80 section 5.1.5 requires that repairs shall be made, and defects that could interfere with operation shall be corrected without delay. Specifically, smoke barrier doors on 2 of 3 resident units were in disrepair and defects were not corrected. This is evidenced as follows. Record review of the (YEAR) Fire Rated Door Inspection Report on 10/31/2018, revealed the fire rated door separating the kitchen and the dining room was in disrepair. Observations were made on fire rated doors on 11/01/2018 at 3:15 PM. The Unit #1 smoke barrier door had 15 -inch holes in the door frame and the panic bar hardware caps were loose and unseated. The smoke barrier door on Unit #3 did not seat to the door frame, and hardware was missing on the latching mechanism. The kitchen door would not close and latch. The Director of Maintenance stated in an interview on 11/01/2018 at 10:22 AM, that he was aware that these doors were not closing properly and he will contact a door repair company to make the repairs. 42 CFR 483.70 (a)(1); 2012 NFPA 101 8.3.3.1; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The following doors will be repaired:
1. Fire rated door separating Kitchen & the Main Dining Room
2. Fire rated door separating Unit 1 & Unit 3
3. Smoke barrier door separating Unit 3 & Unit 1

How we identified other residents/areas that could potentially be affected:
All fire rated doors will be inspected and tested in accordance with Chapter 5 of the NFPA 80 Standard for Fire Doors and other protective openings. Any identified defects will be corrected without delay.

Measures to ensure were/will be put into place to assist this area of concern:
Maintenance & Housekeeping staff will be educated about ensuring there are no penetrations or screw holes, the doors should swing & latch on its own, & that all hardware on the door should be in good working order.

How the concern will be monitored and title of person responsible for monitoring:
All fire rated doors will be inspected monthly x3 months.
The Maintenance Director will report his findings with the QAPI committee. Any new outlets installed will also be reported to the QAPI committee for review.
Responsible Party:
Administrator

POLICIES/PROCEDURES FOR MEDICAL DOCUMENTATION

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, did not include a policy and procedure for maintaining medical record confidentiality when a resident is moved to an off-site location. This is evidenced as follows. A review of the Emergency Plan on 10/30/2018, did not include a policy and procedure to maintain the confidentiality of physical copies of resident medical records while a resident is being relocated. The Administrator and Director of Nursing stated in an interview conducted on 10/30/2018 at 9:30 AM, that when a resident is relocated, a hard copy of their medical records is produced, then placed in a manila envelope to maintain confidentiality, but this procedure is not yet written into policy. 42 CFR: 483.73(b)(4)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The Emergency Preparedness plan will be updated to include a policy & procedure that implements a system of medical documentation that preserves patient information & secures & maintains availability of records in the event of an emergency where evacuation is necessary.

How we identified other residents/areas that could potentially be affected:
The new policy implemented will cover all areas of secure medical record transfer during an emergency.

Measures to ensure were/will be put into place to assist this area of concern:
A policy & procedure will be developed called ?Preserving & Transferring Confidential Medical Records during an Emergency? which will address how staff will keep resident medical records available and secure during an emergency and when evacuation is needed. This policy & procedure will be added to the emergency plan policy and procedure list in the book.

How the concern will be monitored and title of person responsible for monitoring:
The emergency plan will be updated each year with the planning and coordination of the Essex County OEM which will include any necessary changes to the plan.
Responsible Party: Administrator

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include the use of volunteers, such as State and Federal health care professional to address surge needs, in an emergency. This is evidenced as follows. A review of the Emergency Plan on 10/30/2018, revealed the policies and procedures did not include the use of medical volunteers to address an emergency, such as an influx of patients or residents. The Administrator stated in an interview conducted on 10/30/2018 at 9:30 AM, that he will develop a procedure for the use and credentialing of medical volunteers to include in the Emergency Plan. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
Medical Volunteers who could assist in an emergency were identified as Red Cross Volunteers. A policy & procedure will be developed to address the use of medical volunteers in an emergency.

How we identified other residents/areas that could potentially be affected:
The policy was reviewed by the administrator and meets the regulatory requirements of 403.748(b).

Measures to ensure were/will be put into place to assist this area of concern:
A policy & procedure will be developed called ?the use of volunteers in an emergency? for the use of medical volunteers in an emergency. This policy & procedure will be added to the emergency plan policy and procedure list in the book.
The administrator, Assistant Administrator, DON, ADON, and Maintenance Director will be educated on the policy for using medical volunteers.

How the concern will be monitored and title of person responsible for monitoring:
The emergency plan will be updated each year with the planning and coordination of the Essex County OEM which will include any necessary changes to the plan.
Responsible Party: Administrator

ROLES UNDER A WAIVER DECLARED BY SECRETARY

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan did not include provisions detailing their role for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 10/30/2018, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator stated in an interview conducted on 10/30/2018 at 9:30 AM, that county emergency preparedness officials will be contacted and the Emergency Plan will be revised to include provisions outlining their role for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedNovember 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** How the corrective action will be accomplished for any resident affected by deficient practice:
The Emergency Plan is being updated to include provisions for our role at a non-medical site.

How we identified other residents/areas that could potentially be affected:
The policy was reviewed by the administrator for the care and treatment of [REDACTED].

Measures to ensure were/will be put into place to assist this area of concern:
The policy titled ?1135 waiver? will be updated to include provisions for our role at a non-medical site and will be added to the emergency plan policy and procedure list in the book.

How the concern will be monitored and title of person responsible for monitoring:
The emergency plan will be updated each year with the planning and coordination of the Essex County OEM which will include any necessary changes to the plan.
Responsible Party: Administrator

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 5, 2018
Corrected date: January 4, 2019

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 8.15.7 requires automatic sprinkler protection throughout the premises, including canopies and overhangs used for combustible storage. Specifically, automatic sprinkler protection was not provided in all areas. This is evidenced as follows. A spot check of the sprinkler system conducted on 10/30/2018 at 3:30 PM, revealed combustible materials stored under the building overhang in the courtyard. Automatic sprinkler protection was provided in this area. The Administrator stated in an interview on 10/30/2018 at 3:45 PM, that all the combustible materials under the overhang will be removed and he will in-service staff on storing combustible materials in proper locations. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.15.7

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
All combustible material under the canopy has been removed.
The facility will add a sprinkler head to the canopy and building overhangs in the courtyard.

How we identified other residents/areas that could potentially be affected:
All canopies were visually inspected to ensure all canopies requiring a sprinkler have a sprinkler.

Measures to ensure were/will be put into place to assist this area of concern:
Maintenance staff will be educated on the regulations regarding safely storing combustible materials.
A full building inspection will be completed to ensure all existing combustible materials are stored safely, and to make sure all canopies have sprinkler heads.

How the concern will be monitored and title of person responsible for monitoring:
A full facility inspection will be completed by the Director of Maintenance monthly for 4 months to ensure combustible materials are stored safely, & all canopies have sprinkler heads. The results of the inspection will be presented to the QAPI committee to ensure compliance.
Responsible party:
Administrator

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and staff interview during the recertification survey it was determined that the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows. An assessment of the sprinkler system was conducted on 11/01/2018 at 2:00 PM. Two sprinkler heads in the Resident Unit #1 Nurse's Office, 1 sprinkler head in the Admission Office, and one sprinkler head in the Administrator's Office were found with a coating of dust. The Director of Maintenance stated in an interview conducted on 11/02/2018 at 9:12 AM, that the Housekeeping Department will clean the dusty sprinkler heads as per direction from the contracted sprinkler inspection company. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The following sprinkler heads have been dusted & cleaned:
1. 2 sprinkler heads on Unit 1
2. 1 sprinkler head in the Administrator?s Office
3. 1 sprinkler head in the Admission?s Office

How we identified other residents/areas that could potentially be affected:
All sprinkler heads have the potential to be affected and will be cleaned.
All sprinkler will be audited to ensure that they are not dusty and free of other foreign materials.
Measures to ensure were/will be put into place to assist this area of concern:
Sprinkler heads will now be scheduled to be cleaned on a repeating schedule as a part of environmental rounds.

How the concern will be monitored and title of person responsible for monitoring:
Ten sprinkler heads will be audited weekly x2 weeks, then monthly x3 months.
Results of the audit will be reported to the QAPI committee for review
Responsible party:
Administrator

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 5, 2018
Corrected date: January 4, 2019

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 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Specifically, for 1 of 1 smoke barriers observed, the wall was not continuous, and the fire-resistance rating was not maintained. This is evidenced as follows. The Unit 2 smoke barrier wall was inspected on 11/01/2018 at 9:00 AM. All observations were above the suspended ceilings. In the corridor, one 6-inch unsealed penetration, in the dining room four 4-inch and two 2-inch unsealed holes, and in staff education room one 1-inch and a 2-foot by 1-foot unsealed area around a steel beam were found. The Director of Maintenance stated in an interview conducted on 10/09/2018 at 10:30 AM, that he was not aware of unsealed penetrations in the smoke barrier and he will ensure that the penetrations are sealed. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The following smoke barriers will be repaired with a UL-Approved fire stopping system designed to maintain smoke barriers in accordance with Life Safety Code:
1. 1 6-inch unsealed penetration in the Unit 2 corridor
2. 4 4-inch & 2 2-inch unsealed holes in the Dining room
3. 1 1-inch & a 2x1 foot unsealed area around a steel beam in the Staff education room

How we identified other residents/areas that could potentially be affected:
All smoke barrier walls will be inspected to ensure there are no more penetrations. Any penetrations found will be sealed with a UL-Approved fire stopping system.

Measures to ensure were/will be put into place to assist this area of concern:
Maintenance staff will be educated on sealing holes in smoke barriers

How the concern will be monitored and title of person responsible for monitoring:
All smoke barriers will be inspected by the Maintenance Director to ensure there are no penetrations monthly x3 months, results of the audit will be presented to the QAPI committee.
Responsible party:
Administrator

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not address the provision of subsistence needs; such as food, water, medical, and pharmacological supplies, for staff whether they evacuate or shelter in place. This is evidenced as follows. A review of the Emergency Plan on 10/30/2018, revealed the policies and procedures did not include the provision of subsistence needs for staff if the facility must shelter-in-place or evacuate. The Administrator stated in an interview conducted on 10/30/2018 at 9:30 AM, that no provisions of subsistence needs for staff were considered when the Emergency Plan was developed. 42 CFR: 483.73(b)(1)

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The Emergency Preparedness plan will be updated to include enough provisional & emergency supplies, & a plan to support staff & residents sheltering in place in the event of an emergency.

How we identified other residents/areas that could potentially be affected:
The new policy implemented will cover all areas of secure medical record transfer during an emergency.

Measures to ensure were/will be put into place to assist this area of concern:
A policy & procedure will be developed called ?Sheltering in place: Staff provisions? which will address food, water, sleeping arrangements, and supplies for staff sheltering in place during an emergency. This policy & procedure will be added to the emergency plan policy and procedure list in the book.

How the concern will be monitored and title of person responsible for monitoring:
The emergency plan will be updated each year with the planning and coordination of the Essex County OEM which will include any necessary changes to the plan.
Responsible Party: Administrator

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 5, 2018
Corrected date: January 4, 2019

Citation Details

Based on observation and staff interview during the recertification, the facility did not maintain electrical wiring and equipment in accordance with the adopted regulations. NFPA 70 National Electrical Code 2011 edition Article 210.8 requires that Ground Fault Circuit Interrupter protection (GFCI) be provided on electrical outlets within six-feet of a sink rim or water source. Specifically, electrical outlet GFCI protection was not provided near bathroom sinks and the aquarium. This is evidenced as follows. Observations on 11/01/2018 at 2:30 PM, revealed that the electrical outlets in the common bathrooms on Units #1 and #2, the aquarium on Unit #3, the water cooler in the staff lounge, and the bathroom in the Housekeeping Office did not have GFCI protection. The Director of Maintenance stated in an interview conducted on 11/01/2018 at 9:45 AM, that he will audit the building and install GFCI outlets in the areas that are required. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.2; 2011 NFPA 70 Article 210.8; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 70 Article 210.8

Plan of Correction: ApprovedNovember 30, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The following outlets have been identified and will be changed to meet the requirements of GFCI:
1. Outlets in Bathrooms on Units 1
2. Outlets in Bathrooms on Unit 2
3. Fish tank
4. Outlet by the Water Cooler in the Staff Lounge
5. Outlets in the Housekeeping bathroom

How we identified other residents/areas that could potentially be affected:
All outlets in the building will be inspected to ensure that an electrical outlet within 6-feet of a sink rim or water source has ground fault interrupter (GFCI) protection.

Measures to ensure were/will be put into place to assist this area of concern:
The Maintenance Director will inspect all electrical outlets at least annually to ensure GFCI protection if the electrical outlet is within 6-feet of a sink rim or water source. Any new outlet installed for any reason will be checked to ensure GFCI protection is warranted.

How the concern will be monitored and title of person responsible for monitoring:
The Maintenance Director will report his inspection findings to the QAPI committee. Any new outlets installed will also be reported to the QAPI committee for review.
Responsible Party:
Administrator

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 5, 2018
Corrected date: January 4, 2019

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 sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls, including rated ceiling assemblies, shall be fire-sealed to maintain a 1-hour fire resistance rating and be continuous from floor to roof. Specifically, rated vertical openings were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations of the basement rooms on 10/31/2018 at 1:10 PM, revealed the following unsealed penetrations in the fire-rated ceiling; three 3-inch penetrations in the Pump Room, two 3-inch and one 4-inch penetrations in the Central Storage Room, one 6-inch and three 4-inch in the Physical Therapy Storage Room, seven 3-inch in the Laundry Room, and three 4-inch in the Mechanical Room. Observations on 10/31/2018 at 11:00 AM, revealed that a 6-inch area at the top of the elevator shaft was missing insulation. Observations on 11/01/2018 at 9:45 AM, revealed eight 4-inch unsealed holes for piping in Stairwell #1. The Director of Maintenance stated in an interview conducted on 10/31/2018 at 1:30 PM, 11/01/2018 at 10:00 AM and 10:15 AM, that he did not know of the unsealed penetrations in the fire-rated basement ceiling, that fire insulation was missing in the elevator shaft, and that the construction company hired to remodel the Unit #2 dining room did not fire caulk penetrations in the stairwell. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.3, 8.5, 8.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1, 8.2

Plan of Correction: ApprovedDecember 3, 2018

How the corrective action will be accomplished for any resident affected by deficient practice:
The following openings will be repaired with UL-Approved fire stopping materials:
1. 3 3-inch penetrations in the Pump Room
2. 2 3-inch penetrations in the Central Storage Room
3. 1 6-inch & 3 4-inch penetrations in the PT Storage Room
4. 7 3-inch in the laundry room
5. 3 4-inch in the Mechanical Room
6. 6-inch area at the top of the elevator shaft (missing insulation)

How we identified other residents/areas that could potentially be affected:
All wall areas were inspected to ensure no additional penetrations exist.
Measures to ensure were/will be put into place to assist this area of concern:
Whenever work is being completed in the facility that requires wires to be run, wall to vertical openings will be inspected to ensure no penetrations are left unsealed. Maintenance staff will be educated on the regulation that requires sealing of penetrations and holes.
Any penetrations in vertical openings (stairwells, elevator shaft, and floor-ceiling assembly) will be sealed with a UL-Approved fire stopping system.
How the concern will be monitored and title of person responsible for monitoring:
All wall to vertical openings will be inspected by the Director of Maintenance to ensure there are no more penetrations monthly x3 months. Any changes will be reported to the Administrator for repair.
Responsible party:
Administrator