Warren Center for Rehabilitation and Nursing
September 26, 2018 Certification/complaint Survey

Standard Health Citations

E3BP 402.6(d):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (d) A provider may temporarily approve a prospective employee while the results of the criminal history record check are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on record review and staff interview during the recertification survey, it was determined that the facility did not maintain the appropriate records while awaiting the results of a criminal history record check (CHRC). Supervision of temporary must be documented in writing on a weekly basis and maintained in the temporary employee's personnel folder. Specifically, for 2 of 4 prospective employee records reviewed, the provider did not ensure that supervision was documented in writing. This is evidenced as follows. The employee records for Certified Nursing Aide (CNA) #1 were reviewed on 09/20/2018. This review revealed that CNA #1 was hired on 06/27/2017 and the CHRC determination was dated 08/18/2018. The timesheet records document that CNA #1 worked 30 days within this period with no supervision records available for survey review documenting supervision on these dates. The employee records for Receptionist#1 were reviewed on 09/20/2018. This review revealed that Receptionist #1 was hired on 07/11/2018 and the CHRC determination is dated 08/14/2018. The timesheet records document that Receptionist #1 worked 12 days within this period with no supervision records available for survey review documenting supervision on these dates. The Human Resource Director stated in an interview conducted on 09/20/2018 at 3:00 PM, that she did not conduct the background check on these employees and cannot account as to why there was no supervision records available for review. 10 NYCRR 402.7(a) (2) (i)

Plan of Correction: ApprovedOctober 22, 2018

1. No residents were identified as being
affected. The criminal history background check
has been completed for the employees affected.
2. All residents have the potential to be
affected. The human resources director
that was responsible at that time has been terminated.
3. A new human resource Director was hired and Education provided regarding the criminal
history background check / fingerprinting policy relating to supervision of employees prior to results of CHRC. The CHRC policy has been revised to include ensuring supervision records of temporary employees will be retained.
4. Audits will be conducted to ensure supervision was completed by the
Administrator or designee for all new hires for
30 days then five new hires a month for 6
months.
The results of the audits will be presented
to the QA committee and will continue until
otherwise directed by the committee.
5. The administrator will be responsible for
Compliance.

E3BP 402.6(a):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. (a) The provider shall ensure the submission of a request for a criminal history record check for each prospective employee. If a permanent record does not exist for the prospective employee, the Department shall be authorized to request and receive criminal history information from the Division concerning the prospective employee in accordance with the provisions of section 845-b of the Executive Law. Access to and the use of such information shall be governed by the provisions of such section of the Executive Law. The Division is authorized to submit fingerprints to the FBI for a national criminal history record check.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on record review and staff interview during the recertification survey, it was determined that the facility did not adhere to the basic requirements when conducting criminal history record checks (CHRC). Providers shall ensure the submission of a request for a criminal history record check for each prospective employee. Specifically, for 2 of 4 prospective employee records reviewed, the provider did not maintain a record of the submission of a request for a CHRC. This is evidenced by: The employee records for Certified Nursing Aide (CNA) #1 were reviewed on 09/20/2018. Records documenting the request for a CHRC were not available for survey review The employee records for Receptionist #1 were reviewed on 09/20/2018. Records documenting the request for a CHRC were not available for survey review. The Human Resource Director stated in an interview conducted on 09/20/2018 at 3:00 PM, that she did not conduct the background check on these employees and cannot account as to why records requesting CHRC information were not available for review. 10 NYCRR 402.7(a) (2) (i)

Plan of Correction: ApprovedOctober 22, 2018

1. No residents were identified as being
affected. The criminal history background check
has been completed for the employees affected.
2. All residents have the potential to be
affected. The human resources director
that was responsible at that time has been terminated. The CHRC procedure has been updated to ensure CHRC records are retained.
3. A new human resource Director was hired and Education provided regarding the criminal
history background check/ fingerprinting policy.
4. Audits will be conducted by the
Administrator or designee for all new hires for
30 days then five new hires a month for 6
months.
The results of the audits will be presented
to the QA committee and will continue until
otherwise directed by the committee.
5. The administrator will be responsible for
Compliance.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure it developed and implemented comprehensive person centered care plans for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing and mental and psychosocial needs for 10 (Resident #'s 11, 24, 39, 48, 50, 58, 112, 213, 214, and #263) of 21 sampled residents during the recertification survey. Specifically, the facility did not ensure: Resident #24's Comprehensive Care Plan (CCP) for bed mobilty's directive for 2 staff members to assist with bed mobility was implemented when one staff member was observed assisting the resident with mobility while in bed; Resident #112's CCP for the risk for an actual/potential fluid deficit included interventions related to the resident's specific fluid needs; Resident #214's CCP for Activities of Daily Living's directive for the resident to receive supervision and set up during meals was implemented; Resident #50's CCP's for [MEDICAL CONDITION] medications and for pain management included person centered interventions; Resident #48's CCP for anxiety included resident specific non-pharmacological interventions for the resident's behavioral symptoms and included what behavioral symptoms the resident exhibited; Resident #213's CCP for pain included non-pharmacological interventions for use prior to the administration of as needed (PRN) narcotic pain medications; For Resident #11, that a person-centered care plan was developed for the resident's abdominal pain/gastrointestinal complaints; For Resident #39, that a Care Plan was developed to address the resident's needs following a tooth extraction. Also, the facility did not ensure that CCP's for the resident's urinary tract and tooth infections, and gingivitis were person-centered and included appropriate interventions; Resident #58's CCP for pain was person centered; and for Resident #263, that a CCP to address Comfort Care was developed. This is evidenced by: Resident #214 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 9/5/18, assessed the resident usually understands, was sometimes understood and had no cognitive impairment. It documented the resident needed set up help and supervision to eat. The CCP for Activities of Daily Living, initiated on 8/29/18 documented an intervention for eating of: supervision with set up help; All meals in the dining room; Out of bed for all meals. The resident's Kardex Report (used by staff to provide needed care) documented the same interventions as above. During interview on 9/21/18 at 09:11 AM, the resident stated she eats in her room all the time now. No one ever sits with her when she eats in her room. She had her breakfast tray in front of her at the time. There were eggs and toast on the tray. There were no staff in the room. During interview on 9/24/18 at 9:35 AM, the Assistant Director of Nurses (ADON) stated the resident choked on a gumball (on the 21st) and the Kardex has been changed. She was always supervision to eat which means she could not eat in her room alone. The resident should not have a food tray in her room without someone else there. Supervision started 8/29/18 and has been in effect since then. During interview on 9/24/18 at 10:15 AM, the Speech Language Therapist (SLP) stated since admission we did not want the resident to eat in her room alone due to [MEDICAL CONDITION], dysarthria and cognitive decline. We wanted her to eat in the Main Dining Room (MDR), but the resident did not want to eat there. Nursing then wanted the resident to sit at a table in the hall where she could be seen. The doctor ordered the resident could eat at the table at the end of the hallway. The resident should not have a tray of food in her room without staff there, someone needs to be in the vicinity . During interview on 9/24/18 at 2:18 PM, Licensed Practical Nurse (LPN) #4 stated the resident ate in the MDR or her room before she choked, it was ok for her to eat in her room prior to the choking incident. She did not need supervision prior to the choking episode. During interview on 9/25/18 at 10:56 AM, Certified Nurse Aide (CNA) #2 stated the resident likes to eat in her room, but needs supervision. We try to get her to eat at the table in the hall or the MDR. She does eat in her room at times. We try to peek in on her when she is in her room, but we cannot be in the room, it is hard. Resident #50 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident was understood and understands others. It documented the resident received antipsychotic, antianxiety, antidepressant and opioid medications 7 out of 7 days. Finding 1: A [MEDICAL CONDITION] care plan initiated on 8/11/18, documented the resident uses [MEDICAL CONDITION] medications related to [DIAGNOSES REDACTED]. Interventions documented on the care plan are as follows: AIMS scale assessment as scheduled; Educate resident on comfort measures, sleep promoting techniques, and lifestyle changes that can contribute to optimal sleep; Give medications ordered by physician. Monitor/document side effects and effectiveness; Monitor/record occurrence of target behaviors symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol. During interview on 09/26/18 at 10:35 AM, the Assistant Director of Nurses (ADON) stated the interventions on the [MEDICAL CONDITION] care plan do not apply to Resident #50. The care plan is not person centered and the interventions for the care plans were pulled out of a library. Finding 2: Resident #50's pain management care plan initiated on 8/11/18, documented alteration in comfort related to (potential/actual) aging process, diabetic [MEDICAL CONDITION], and immobility. On pain medication. The interventions documented; Administer medications as ordered; Evaluate the effectiveness of pain interventions as needed. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; Identify and record previous pain history and management of that pain and impact on function. Identify previous response to [MEDICATION NAME] including pain relief, side effects and impact on function; Report to nurse resident complaints of pain or requests for pain treatment. Utilize non-pharmacological pain interventions to promote comfort. During interview on 09/26/18 at 10:35 AM, the ADON stated there were no specific non-pharmacological interventions on the pain care plan for Resident #50. Resident #11 The facility did not ensure a person-centered care plan was developed for abdominal pain/gastrointestinal complaints. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with severe cognitive impairment. It documented the resident received scheduled and as need pain medication. On 9/24/18 & 9/25/18, the resident was observed in his room requesting medication for abdominal pain. Staff administered the medication. Doctor orders included: [MEDICATION NAME] before meals, Linzess once daily, [MEDICATION NAME] as needed, [MEDICATION NAME] twice daily, TUMS 3 x daily, and Tylenol four times daily and as needed. The Medication Administration Record [REDACTED]. The resident's Comprehensive Care Plan (CCP) does not address the resident's GI complaints. During an interview on 09/24/18 at 11:36 AM, Licensed Practical Nurse (LPN) #1, Unit Manager, stated abdominal pain has been present for greater than 1 year. LPN #1 stated non-pharmacological interventions would include offering toast and crackers / ginger ale, one on one for activities, and one on one with certified nurse assistants (CNA). LPN #1 stated the resident's CCP should include management of abdominal pain/ GI complaints During an interview on 09/26/18 at 10:33 AM, Certified Nursing Assistant (CNA) #11, stated she has worked with this resident for approximately one year. During an interview on 09/26/18 at 01:00 PM, LPN #5 stated she has worked with the resident for at least 2 years. The resident has complained of stomach pain at least daily. LPN #5 stated the care plan should include interventions for GI complaints. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedOctober 19, 2018

1. Residents #213 and 263 have been discharged . Care plans for residents # 11,24,39,48,50,58,112 ,214 were reviewed and updated to ensure. Resident #24 care plan for bed mobility has been updated. Resident # 112 care plan for actual potential fluid deficit has been enhanced. Resident #214 care plan was revised regarding supervision for meals. Resident #50,48 and 11 were reviewed and updated to ensure inclusive person centered non-pharmacological measurable interventions. Resident #39 and 58 care plans were reviewed and updated to ensure inclusive person-centered interventions.
2. all residents have the potential to be affected. An audit of all care plans will be completed to ensure they have patient centered goals and interventions.
3. Policy reviewed for Care plans comprehensive person centered and has been revised to include person centered non-pharmacological interventions. All RN?s will be educated on the revised policy. All nursing staff will be educated on the importance of following the care plans as written.
4. 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.
5. The Director of nursing will be responsible for compliance.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash dumpster was not insect and rodent proof and was not clean. This is evidenced as follows. The trash dumpster was inspected on 09/20/2018 at 9:04 AM. Trash was found in the dumpster, the lid could not be closed due to an overhang above, the 2-inch drain hole near the bottom did not have a plug, and the front and sides were soiled with a black build-up. Fly activity was noted in and around the dumpster. The Supervisor of Maintenance stated in an interview conducted on 09/20/2018 at 1:00 PM, that the dumpster vendor placed the dumpster in a wrong location, no staff are here when the dumpster is emptied and moved, and he will contact the vendor for a drain plug and cleaning. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedOctober 22, 2018

1. The lid of the dumpster was closed, a plug was ordered, the dumpster was pressure washed and the exterminator was called.
2. There are no other dumpsters that can be affected.
3. ACE trash removal was contacted to educate their staff on resetting of the dumpster after trash removal and they replaced the plug. The outside of the dumpster was added to a preventive maintenance schedule to be done weekly. BUG-U pest control sprayed the area for flies. Flies will be monitored weekly when the dumpster is pressure washed. The administrator will complete monthly audits to ensure the lid is closed, the plug is in place, the lid is closed and the outside of the dumpster is clean.
4. The audits will be reviewed by the QAPI committee monthly for 3 months and quarterly thereafter. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not adhere to adopted food safety regulations. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, food temperature thermometers are to be calibrated, food contact surfaces are to be cleaned after each use, and plumbing is to be maintained in a manner that does not contaminate the premises. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications required to sanitize food surfaces, food temperature thermometers were not in calibration, food surfaces were not clean, and sinks did not drain properly. This is evidenced as follows. The main kitchen and unit kitchenettes were inspected on 09/20/2018 at 9:04 AM. When checked, the automatic dishwashing machine wash temperature was 140 degrees Fahrenheit (F), the final rinse was 140 F at 15 pounds per square inch (psi) water pressure and 0 parts per million (ppm) of available chlorine. The automatic dishwashing machine information date plate states that the minimal wash water temperature is to be 160F, and the minimal final rinse water temperature is to be 180 F at 20 psi. No information on the label of the chemical sanitizer used in the automatic dishwashing machine provided directions for use in automatic dishwashing machines. Standing flooded water was found in an 8 square foot area around and below the 3-compartment sink. When checked for calibration utilizing the standard ice-bath method, one of 2 thermometers read 0 F and not a calibrated temperature of 32 F. The interior of the microwave oven was soiled with food particles, and the refrigerator and floor in the Northeast Unit Kitchenette were soiled with food drippings. The Food Service Director (FSD) stated in an interview conducted on 09/20/2018 at 9:04 AM, that the automatic dishwashing machine had not been consistently working properly for the past several weeks. When the 3-compartment sink is drained, water overflows unless just one compartment at a time is drained. The FSD will discuss thermometer calibration and cleaning with staff 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.85, 14-1.110, 14-1.113, 14-1.140

Plan of Correction: ApprovedOctober 22, 2018

1. The automatic dishwasher was repaired.
The food temperature thermometer was calibrated.
The microwave in the kitchen and floor and refrigerator in the kitchenette were cleaned.
The sink was drained.
2. An outside contractor was called to identify what was causing the temperatures to be below manufacturers recommendations.
All food temperature thermometers were audited for calibration.
An outside contractor was called to fix the sink so that there is no overflow when all compartments drain.
All food contact surfaces were audited for cleanliness.
All sinks in the kitchen and kitchenette areas were audited to ensure there is no overflow when draining.
3. A new booster was installed for the automatic dishwasher. The dietary staff was educated on proper temperatures for the automatic dishwasher. Temperatures for the wash and rinse cycle will be recorded daily. The administrator will do monthly spot checks to ensure the temperatures are within manufactures specifications.
The dietary staff was educated on how to calibrate thermometers and cleaning, and monitoring the dish washing machine temperatures and cleaning food contact surfaces after use .
The sink in the kitchen was repaired and a part replaced to allow for proper drainage. The dietary staff was educated on reporting sinks if they do not drain properly.
4. The temperature records, food temperature thermometers and food surface cleanliness audits will be reviewed by the QAPI committee monthly Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations. and quarterly thereafter.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that residents do not receive [MEDICAL CONDITION] 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 that PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician (MD) 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 for three (Resident #'s 10, 48, and #50) of five residents reviewed for unnecessary medications. Specifically: For Resident #48, the facility did not ensure that an as needed (PRN) antianxiety medication was not given for more that 14 days without a MD rationale and that there was documentation in the chart as to why the medication was administered or that non-pharmacological interventions were attempted prior to administration; For Resident #50, the facility did not ensure adequate monitoring and adequate indications for PRN (as needed) [MEDICATION NAME] ([MEDICATION NAME]) use; and for Resident #10, the facility did not ensure behavior monitoring was done after a GDR(Gradual Dose Reduction) for [MEDICATION NAME] ([MEDICATION NAME]) (an antipsychotic medication) and that monitoring was done to justify the continued use of [MEDICATION NAME] (an antianxiety medication). This is evidenced by: Resident #10: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During multiple observations on 09/25/2018 & 09/26/2018, the resident was noted to be in the common area moaning/ making incomprehensible sounds regularly at intermittent times throughout the daytime hours. A Comprehensive Care Plan (CCP) for behavioral symptoms dated 4/26/16 and last revised on 9/20/18, documented: Document all behaviors; Attempt to identify pattern to target interventions; evaluate side effects of medications; and notify Physician (MD) of negative behavior or activity. An MD Progress Note dated 11/1/2017, documented: [MEDICATION NAME] ([MEDICATION NAME]) (an antipsychotic medication) to be started to improve quality of life; resident has been frequently moaning, despite behavioral interventions, anti-anxiety and pain meds. The medical record did not include a psychiatry evaluation. A MD Progress Note dated 1/19/18, documented the resident is receiving [MEDICATION NAME] 1 milligrams (mg) every hour of sleep (hs) and [MEDICATION NAME] 0.5 mg twice daily. The resident was slightly less agitated/tearful with [MEDICATION NAME]. A Pharmacy Medication Review for 6/2018, recommended a GDR of [MEDICATION NAME]. A MD Order dated 6/15/18 documented [MEDICATION NAME] 0.25 MG every hs. A Pharmacy Medication Review for 8/2018, recommended a GDR of [MEDICATION NAME]. A Progress Note dated 8/16/18, documented the MD reviewed GDR recommendations and agrees to discontinue (d/c) [MEDICATION NAME] as she has had a successful GDR without ill effect in June. The Nursing Progress notes dated from 5/1/ (YEAR) - 9/25/18, did not include documentation of behaviors before or after the GDR of the [MEDICATION NAME] or episodes of anxiety to justify the continued use of the [MEDICATION NAME]. A Care planning meeting note dated 7/3/18, documented the resident was on [MEDICATION NAME] and [MEDICATION NAME] and symptoms were under adequate control. During interview on 9/25/18 at 11:26 AM, Licensed Practical Nurse (LPN) #1, Unit Manager (UM) stated the resident had been on [MEDICATION NAME] twice daily for years because she tended to yell and cry out. Staff should be completing behavior assessments on this resident, and when asked, could not find them in the medical record and stated they may not have done behavior charting on this resident. During an interview on 9/26/18 10:18 AM, Certified Nursing Assistant (CNA) # 9, who had worked with resident for greater than 1 year, stated the resident screamed and hollered daily. Resident #48: The resident was admitted to the nursing home on 7/4/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Finding #1: The facility did not ensure that an as needed (PRN) antianxiety medication was not given for more that 14 days without a MD rationale. A MD order dated 7/6/18 and discontinued on 8/7/18, documented [MEDICATION NAME] 0.5 milligram (mg) tablet; give 0.25 mg every 6 hours PRN for anxiety. The Medical Record did not include medical justification for keeping the resident on PRN [MEDICATION NAME] for over 14 days. During an interview on 09/26/18 at 08:33 AM, the MD stated there should have been a note in the chart addressing why the resident required the prn [MEDICATION NAME] more that 14 days. Finding #2: The facility did not ensure there was documentation in the chart regarding the reason medication was administered or that non-pharmacological interventions were attempted prior to administration The facility did not ensure that there was documentation in the chart as to why the medication was administered or that non-pharmacological interventions were attempted prior to administration; The Electronic Medication Administration Record [REDACTED]. The Progress notes dated from 7/6/18 - 8/6/18, did not include documentation regarding what symptoms the resident was exhibiting or if non-pharmaceutical interventions were attempting prior to using the [MEDICAL CONDITION] medication on nine of 18 times that the medication was administered. During an interview on 09/25/18 at 11:08 AM, Licensed Practical Nurse (LPN) #3 stated when some one gets a PRN antianxiety medication staff should be trying non-pharmacological interventions first and if unsuccessful would give the medication. They should be documenting those interventions and the outcome of the interventions or medication by writing what symptoms were relieved. During an interview on 09/25/18 on 01:16 PM, the Director of Nursing (DON) stated if PRN [MEDICAL CONDITION] are ordered, staff are supposed to attempt non-pharmacological interventions first. They should also document what symptoms the resident was exhibiting and the effectiveness of the interventions in chart, not just writing effective or ineffective, but what made it that way i.e the resident is asleep. During an interview on 09/26/18 at 08:33 AM, the MD stated staff should have been trying non-pharmacological interventions before giving [MEDICATION NAME] and the interventions and symptoms the resident was presenting with should be documented in the chart. Resident #50: The facility did not ensure adequate monitoring was provided and that there were adequate indications for PRN (as needed) [MEDICATION NAME] ([MEDICATION NAME]) use. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident was understood, understands others, and is cognitively intact. It documented the resident received antianxiety medication 7 out of 7 days. A physician order [REDACTED]. A physician note dated 8/31/18 documented the resident had a change in mental status, was lethargic and hypoxic, and was sent to hospital for evaluation. The Hospital Discharge Summary dated 9/4/18, documented [MEDICATION NAME] 0.5mg every 8 hours PRN for anxiety on the discharge medication list. This was a decrease in PRN frequency. A physician note dated 9/5/18 documented the resident was status [REDACTED]. The physician documented the resident's psychiatric status was much better and she continued on [MEDICATION NAME]. Nurses Progress Notes dated 9/4/18 - 9/10/18, documented the resident continued with an order for [REDACTED]. Between 9/4/18 - 9/10/18, the resident received PRN [MEDICATION NAME] 13 times. Nursing documentation did not include signs or symptoms the resident was exhibiting prior to administering PRN [MEDICATION NAME] and did not describe how the medication was effective for this resident 9 of the 13 times; 9/4 at 1403, 9/5 at 1256, 9/6 at 1200, 9/7 at 1400, 9/8 at 1255, 1830, 2353, 9/9 at 1548, and 9/10 at 0735. Nurses Progress Notes dated 9/11/18 did not contain mood or behavior monitoring after the PRN [MEDICATION NAME] order completed on 9/10/18. Comprehensive Care Path notes dated 9/11/18 at 00:00 and 9/11/18 at 20:00 did not include documentation for mood or behavior monitoring. On 9/12/18, a physician order [REDACTED]. Nurses Progress Notes dated 9/12/18 did not include a reason for the initiation of PRN [MEDICATION NAME]. A physician note on 9/14/18 did not include a rationale for ordering the PRN [MEDICATION NAME] on 9/12/18. During an interview on 09/25/18 at 02:17PM, Licensed Practical Nurse (LPN) #2 stated he administers Resident #50 PRN [MEDICATION NAME] when she asks for it. He stated he does not try other interventions prior to administering the PRN. He said he does not know why the resident receives an antianxiety because she doesn't really seem anxious. During an interview on 09/26/18 at 10:35AM, the Assistant Director of Nursing (ADON) stated she did not know why the PRN [MEDICATION NAME] was re-started on 9/12/18 or why the frequency of the PRN order changed. She did not find documentation by the doctor for the [MEDICATION NAME] order. She said the reason for the order should be documented in a doctor's note or nurses note. She said the nurses don't report normalized behaviors and have overlooked the monitoring of behaviors. During a telephone interview on 09/26/18 at 11:54AM, the Medical Doctor (MD) stated she would have to think the PRN order was re-started a day after it was completed because the resident used it frequently. The MD stated the resident has severe anxiety. The MD stated the PRN [MEDICATION NAME] order was likely decreased in frequency secondary to a recommendation from the hospital. MD is aware of the regulation for [MEDICAL CONDITION] PRN orders. She stated a PRN [MEDICAL CONDITION] is ordered for 14 days and then needs to be renewed after 14 days. 10NYCRR 415.12(1)(2)(ii)

Plan of Correction: ApprovedOctober 19, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident # 50 PRN antianxiety medication has been discontinued. Resident #10 the provider documented the reason for continued use of the [MEDICATION NAME]. Resident #48 The PRN [MEDICATION NAME] has now been scheduled as a routine dose.
2. All resident on [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. Resident with recent GDRs in the last two months have had their medical records reviewed to be sure behavioral documentation has been completed. If behavioral notes are not found those staff will be educated on behavioral documentation.
3. Any residents with a GDR will have a behavioral user defined assessment triggered to be completed daily times 14 days. Policy titled [MEDICAL CONDITION] medication use has been written. 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. All licensed nurses and medical practitioners will be educated on the policy.
4. 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. 100% of GDR?s implemented by provider will be audited weekly times 12 weeks. The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
5. The Director of nursing will be responsible for compliance.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on staff interview and the cooling tower maintenance program (cooling tower plan) and plan and the potable water Sampling and Management Plan (SMP) 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, requires that a cooling tower plan be developed specific to the facility, and that as of (MONTH) 01, (YEAR), potable water sampling be conducted at not greater than 90-day intervals for one year. Specifically, the cooling tower plan was not facility-specific, and water sampling was not conducted as required. This is evidenced by the following. The cooling tower plan, SMP, and potable water testing records were reviewed on 09/21/2018. The cooling tower plan documentation provided was a generic template and not facility-specific. The potable water Legionella testing records were dated 03/17/2017, 04/27/2017, 08/25/2017, and 11/29/2017. The Administrator stated in a telephone interview conducted on 09/26/2018 at 8:45 AM, that the cooling tower plan will be revised to be facility-specific and the required water testing will be restarted and conducted at not greater than 90-day intervals for one year. 415.19(a)

Plan of Correction: ApprovedOctober 22, 2018

1. The cooling tower plan was updated to be facility specific. Potable water legionella testing will be restarted and done at not less than 90 day intervals.
2. No other cooling towers at the facility.
3. Maintenance supervisor and administrator will be educated on SMP requirements regarding intervals of testing.
4. The findings of the potable water legionella testing will be submitted to the QAPI committee after each result is obtained for the next year.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: 483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. 483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that they had evidence that all alleged violations were thoroughly investigated for two Residents (Resident #'s 21 & 264) of five residents reviewed for abuse. Specifically, the facility did not ensure that an investigation was done when Resident 21 complained that a staff member was rough with her, and when a staff member made disparaging remarks about Resident # 264's genitals. This is evidenced by: Resident #21: The resident was admitted to the nursing home on 4/4/16, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an interview on 09/20/18 at 09:37 AM, Resident #21 stated that other day she had a Certified Nursing Assistant (CNA) put her to bed and was so rough, that her ribs are still tender. The worker grabbed me tight and hauled me out of the wheelchair and put me to bed. The resident stated she thinks it was about 3-4 days ago and she has not seen the person since but she does not have good sight. Her room mate told her the CNA will not be back. A Comprehensive Care Plan dated 6/8/18, documented the resident required the extensive assistance of two persons for transfers with a gait belt. A Grievance Form filled out by RN #3 on 9/24/18, documented that on 9/18/18, the residents daughter complained that CNA #10 was mean and rough with the resident when she was being toileted, stood her without using a gait belt and that she spoke to her in a harsh tone. The daughter requested that the CNA not care for the resident in the future. RN #3 documented that she spoke to the CNA after the incident and counseled her. During an interview on 09/24/18 at 01:45 PM, Resident #16, stated that CNA #10 was rough. She pushed me over to change me and almost pushed me out of the bed. She was rough with Resident #21 and Resident #21 reported it to the nurse, but no one came to talk to her. Resident #21's son came in and said their room was off limits to the CNA. CNA #10 came in last night to take care of her. During an interview on 09/24/18 at 02:34 PM, the Assistant Director of Nursing (ADON), who was covering as Nurse Manager for the unit, stated that she was not aware of an any issues or complaints between Resident #21 and any of the CNAs. On 09/26/18 at 09:57 AM, the ADON stated that she contacted the evening supervisor and was told that the resident's daughter reported that CNA #10 was rough but after RN #3 talked to the CNA, she thought it was more of a customer service issue and educated her. During an interview on 09/26/18 at 12:39 PM, the DON stated she assessed the resident for injury when we brought it to her attention and no injury was noted. She should have been made aware of the incident and an investigation should have been started. Both the RN and CNA have since received disciplinary action. Resident #264: The resident was admitted to the nursing home on 7/3/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an interview on 09/20/18 at 11:06 AM, Resident #213 stated that a couple weeks ago Resident #264 was upset after LPN #2 made some disparaging remarks about the size of Resident #264's penis. He did not hear the remark because he was half asleep but he did hear the resident report it and heard staff come in to talk to him about it. During an interview on 9/26/18 At 12:40 PM, the Director of Nursing (DON) stated she was not aware of any incidents between Resident #264 and LPN #2. During an interview on 09/26/18 on 01:20 PM, Registered Nurse (RN) #2 stated she worked on 9/1/18 and that Resident #264 approached her and reported the incident that occurred the previous evening with LPN #2. The resident was upset and did not want LPN #2 caring for him anymore. RN #2 sent an email to the DON as she usually does, when something occurs, with the specifics of what occurred, She then waits for the DON to get back to her about what to do. The DON did not get back to her so she thought it was handled. Additionally, the RN stated that the incident was highly inappropriate and could be borderline abuse. An copy of an E-Mail sent to the DON from RN #2, dated 9/1/18 at 8:21 PM, documented that the resident had several complaints about LPN #2. He reported that the other night, LPN #2 left him naked and uncovered for almost two hours before someone came to check on him and a couple nights ago when LPN #2 was assisting to put a condom catheter on the resident, LPN #2 made some inappropriate comments regarding the size of the resident's penis. He requested to no longer have any male care givers. During an interview on 09/26/18 on 01:38 PM, the DON stated she may have received an email, but did not recall. When she located the email, she stated the incident should have been investigated and the grievance process should have been started by the RN. 10NYCRR 415.4 (b)(1)(ii)

Plan of Correction: ApprovedOctober 19, 2018

1. Residents #21 and #264 had thorough investigations completed and no findings of abuse neglect or mistreatment were identified. The supervisor was reeducated on proper procedures to follow when an allegation of abuse, neglect or mistreatment occurs. LPN #2 was reeducated on customer service. CNA #10 was reeducated on customer service and safe patient handling.
2. All residents have the potential to be affected. All supervisors have been interviewed regarding possible allegations of abuse neglect or mistreatment. There were no other problems were identified.
3. The policy for Analyzing Occurrences of Abuse, Neglect, Mistreatment, and
Theft/Misappropriation of Resident Property and Exploitation and Residents grievance process policy have been reviewed and no changes were necessary. All staff to be educated on the above policies.
4. Audits will be conducted on all grievances and incident and accident reports 5 days weekly x 4 weeks to look for potential allegations of abuse, neglect or mistreatment. If allegation is found investigation will be completed. Twice weekly times 4 weeks then once weekly times 4 weeks. The results of the audit will be brought to
the QA committee and will continue until
otherwise directed by the committee.
5. The Director of nursing will be responsible for compliance.

FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: 483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section. 483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS- . This was evident for one (1) out of three (3) sampled residents reviewed for Beneficiary Protection Notification (resident #55). The findings are: 1) Review of the medical record for resident #55 on 09/20/2018, revealed that the resident last received rehabilitative services on 08/31/2018 and was provided the NOMNC to inform the resident of their right to an expedited review of a service termination on 08/30/2018, one day prior to the termination of services. The MDS Coordinator stated in an interview conducted on 09/20/2018 at 3:18 PM that she notified the resident's representative on 08/29/2018, but did not make a record. 10 NYCRR 415.3 (g)

Plan of Correction: ApprovedOctober 22, 2018

1. Resident number #55 has been
discharged from the facility.
2. All resident's with Medicare coverage
have the potential to be affected.
3. All residents that have had services terminated and are on
Medicare part A since (MONTH) will be reviewed to ensure
they have received the appropriate day notification of the termination of services with the notice to
Medicare provider non-coverage. The administrator will be provided the utilization review tracker for residents that will have services terminated in the near future. MDS coordinator was educated
and designated to issue all two-day notices
moving forward.
4. Audits of timely cut letters will be conducted by the
Administrator or designee five days a week
for four weeks then weekly x4 then monthly
x2. The results of the audit will be brought to
the QA committee and will continue until
otherwise directed by the committee.
5. The administrator will be responsible for
continued compliance.

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure it provided treatment and care in accordance with professional standards of practice, the comprehensive careplan and the resident's choices for one (Resident #112) of four residents reviewed for accidents during the recertification survey. Specifically, for Resident #112, the facility was unable to provide evidence that monitoring/neurological checks were done following a fall where the resident hit his head. This is evidenced by: Resident #112 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 9/11/18, assessed the resident was sometimes understood, sometimes understands, and had severe cognitive impairment. The facility policy titled Accidents and Incidents, last updated (MONTH) (YEAR), documented that when a resident sustains an accident with injury to the head (blow to the head, fall hitting head) or there has been an unwitnessed fall, neurological checks will be initiated in accordance with the facility policy. The facility policy titled Neurological Assessment, undated (revised (MONTH) 2010) at the bottom of the page. It documented that Neurological assessments are indicated a.) upon physician order; b.) following an unwitnessed fall; c.) following a fall or other accident/injury involving head trauma; d.) when indicated by the resident's condition. The facility provided the Form Neuro Vital Signs Worksheet (revised 2/4/16) when asked for the policy on performing the neurological assessments. This worksheet documented the following times to perform the neurological assessments: every 15 minutes for 2 hours; every 30 minutes for 2 hours; every hour for 4 hours and every shift for 48 hours. Nursing progress notes on 9/15/18 at 0:23 am, written by the Registered Nurse Supervisor documented that the writer responded to a chair alarm near the southwest nursing station. The resident was observed standing from the wheelchair and trying to take a step forward, lost his balance and fell back onto his buttocks and back, striking the back of his head on the wheel of an overbed table. He had a 2.5 cm (centimeter) skin tear on the left elbow. No loss of consciousness . The resident was assisted off the floor and range of motion of all extremities were within normal limits. Neurological assessment intact. Responds to verbal commands and answers questions appropriately. Skin tear cleaned and dressing applied. There were no further nursing notes until 9/15/18 at 8:36 am. The Incident and Accident Report for the resident's fall, dated 9/15/18 documented the resident was observed standing in the wheelchair when the writer responded to the alarm. The resident went to step forward, lost his balance and fell back onto the floor. There was a 2.5 cm skin tear on the left elbow. On 9/25/18 the the medical record for this resident was reviewed and there were no neurological assessments in the medical record. The neurological assessments for this resident were requested from the facility. On 9/25/18 at 2:00 PM the Director of Nurses stated they could not provide neurological assessments for the resident after his fall on 9/15/18. During interview on 9/26/18 at 11:45 am the resident's physician said she did not think she was on call the evening of the fall. She did not know of the fall until after the fact. She would have recommended neurological checks be done if the resident hit his head. During interview on 9/26/18 at 1:25 PM the Registered Nurse Supervisor (RNS) the night of 9/14/18 said she saw the resident fall. She heard the alarm, went to look and saw the resident standing and reaching. He got wobbly and quickly sat and fell on his buttocks. He hit part of his head on the overbed table wheel. She then called for help, got him up and there was no visible injury, he had a skin tear which she dressed. They put him back in the wheelchair. She gave the resident Tylenol for achiness. She asked him if he had any pain and he said no. His initial neurological assessment was normal, the rest of the assessments would be on the neuro sheet. She thought the neuro sheet was kept in the resident's chart. She would have done a neuro check within the hour before she left. Then the neuro sheet would have gone to the oncoming LPN. She told the doctor the resident hit his head, he said to keep monitoring the resident. The RNS stated she would not document anything in progress notes unless there was a change. 10NYCRR415.12

Plan of Correction: ApprovedOctober 19, 2018

1. Resident #112 was sent to the emergency room for a thorough evaluation following the incident. The supervisor was educated regarding the need to implement and continue neuros for all unwitnessed falls.
2. All residents with unwitnessed falls have the potential to be affected. An audit of all incident and accident reports on unwitnessed falls will conducted to ensure that neurological vital signs have been completed as indicated per policy. If neuro vital signs were omitted staff involved with be educated on the policy and procedure.

3. The policy accidents and incidents was reviewed and no revisions were necessary. All licensed staff will be educated on the policy as it pertains to unwitnessed falls.
4. 100% of All unwitnessed falls will be audited 5 times weekly times 4 weeks then three times weekly times 4 weeks then once weekly times 4 weeks to ensure that neuro vital signs have been completed per policy. The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
5. The Director of nursing will be responsible for compliance.

E3BP 402.5(c):REQUIREMENTS BEFORE SUBMITTING A REQUEST FOR

REGULATION: Section 402.5 Requirements Before Submitting a Request for a Criminal History Record Check. ...... (c) The provider shall obtain the signed, informed consent of the subject individual in the form and format specified by the Department which indicates that the subject individual has: (1) been informed of the right and procedures necessary to obtain, review and seek correction of his or her criminal history information; (2) been informed of the reason for the request for his or her criminal history information; (3) consented to the request for a criminal history record check; and (4) supplied on the form a current mailing or home address.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on record review and staff interview, it was determined that the facility did not obtain the minimum required permissions before submitting a request for criminal history information on a new employee. Providers shall obtain the signed, informed consent in the form and format specified by the New York State Department of Health (DOH) of the subject individual. Specifically, for 2 of 4 unlicensed prospective employee records reviewed, the provider did not obtain the required and signed the DOH Criminal History Record Check (CHRC) form 102 prior to requesting criminal history information on the prospective employee. This is evidenced by: The employee records for Certified Nursing Aide (CNA) #1 were reviewed on 09/20/2018. A DOH CHRC form 102 for CNA #1 was not available for survey review. The employee records for Receptionist #1 were reviewed on 09/20/2018. A DOH CHRC form 102 for Receptionist #1 was not available for survey review. The Human Resource Director stated in an interview conducted on 09/20/2018 at 3:00 PM, that she did not conduct the background check on these employees and cannot account as to why 102 forms were not available for review. 10 NYCRR 402.7(a) (2) (i)

Plan of Correction: ApprovedOctober 22, 2018

1. No residents were identified as being
affected. The criminal history background check
has been completed for the employees affected. CHRC policy has been reviewed and revised to include ensuring a CHRC form 102 will be signed prior to conducting a CHRC.
2. All residents have the potential to be
affected. The human resources director
that was responsible at that time has been terminated.
3. A new human resource Director was hired and has been
educated on ensuring a CHRC form 102 will be signed
prior to conducting a CHRC.
4. Audits will be conducted by the
Administrator or designee for all new hires for
30 days then five new hires a month for 6
months.
The results of the audits will be presented
to the QA committee and will continue until
otherwise directed by the committee.
5. The administrator will be responsible for
Compliance.

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: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure medical records were maintained in accordance with acceptable standards of practice for 1 (Resident #39) of 18 residents reviewed. Specifically, there was no documentation of monitoring following a tooth extraction. Resident #39 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 8/16/18 assessed the resident could understand, be understood and scored 13/15 on the Brief Interview for Mental Status, indicating no cognitive impairment. Three Physician orders [REDACTED]. One Progress Note written on 9/13/18 at 2:44pm, documented: Resident recently had tooth extraction, pain appears to be under control at this time. This was the only note regarding the tooth extraction. During an interview on 9/25/18 at 11:26 am, Nurse Manager (NM) #1 reported documentation at this facility is by exception, so if there is no notes that means there was nothing out of the ordinary during that shift. During an interview on 09/26/18 at12:30 PM, NM #1 reported she recalls the tooth extraction was done on the evening shift, after she left for the day. The Supervisor should have put a note in explaining why the orders were put in. The medication nurses that signed the Medication Administration Record [REDACTED]. During an interview on 09/26/18 at 1:12 PM, the Director of Nursing (DON) reported, there should have been notes documented by nursing showing that they had monitored his condition following the tooth extraction. 10NYCRR 415.22(qa)(1-4)

Plan of Correction: ApprovedOctober 23, 2018

1. Resident #39 was evaluated for discomfort following a tooth extraction with no complaints identified.
2. All residents that have teeth extracted have the potential to be affected. All other residents that have had teeth extractions in the last 30 days have been reviewed for proper documentation following a tooth extraction.
3. Policy titled charting and documentation has been reviewed with no changes warranted. All licensed staff will be educated on proper documentation following a dental procedure based on the charting and documentation policy. All dental consult reports will be reviewed at the time of consult to identify if a tooth extraction was completed and review any recommendations for follow up.
4. 100% of all dental extractions will be audited for proper documentation 5 times a week until area is healed. The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
5. The Director of nursing will be responsible for 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: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure a resident who needs respiratory care was provided care in accordance with professional standards of practice and the comprehensive care plan (CCP) for one (Resident #24) of one resident reviewed receiving oxygen therapy. Specifically, for Resident #24, the facility did not ensure that oxygen was provided in accordance with the CCP titled Alteration in Respiratory System that documented to provide oxygen per physician's orders [REDACTED].) This is evidenced by: Resident #24 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 7/26/18, assessed the resident understands, was understood and had no cognitive impairment. It documented the resident received oxygen therapy. A physician order [REDACTED]. The resident's Comprehensive Care Plan, initiated 10/25/16 for Alteration in Respiratory System related to [MEDICAL CONDITIONS] infarction and [MEDICAL CONDITION] documented a goal that the resident would exhibit no signs of respiratory distress through the review date. Interventions included: Administer treatments and medications per MD (medical doctor) orders; provide oxygen per MD orders. On 9/21/18 at 8:52 AM, the resident was in her room in bed with oxygen running via nasal canula and the oxygen concentrator. The resident was breathing heavily and very anxious. She said she had [MEDICAL CONDITION]. On 9/24/18 at 2:21 PM, the resident was sitting in her lounge chair in her room, coughing and sounded congested. The oxygen concentrator was running at 2.5 liters. On 9/26/18 at 10:10 AM, the resident was sitting in her lounge chair in her room, with the oxygen concentrator running between 2 and 2.5 liters. The resident's Medication Administration Record for (MONTH) documented to monitor oxygen every 4 hours for [MEDICAL CONDITION]. It documented the resident's oxygen liter flow rate was not provided at 2 liters per minute for 9 days. Oxygen was provided at 3 liters per minute for one day (9/12/18) and fluctuated at 2-3 liters per minute for 8 days (9/2, 9/11, 9/13, 9/14, 9/17, 9/18, 9/22, 9/23/18). During interview on 9/26/18 at 10:17 AM, LPN #3 said the resident uses the oxygen concentrator all the time, she spends almost all her time in her room. LPN #3 went to the resident's room, looked at the concentrator and said the oxygen indicator ball was on top of the 2 liter line. She thought the ball should be in the middle of the 2 indicator line. LPN #3 looked at the physician order [REDACTED]. LPN #3 looked at the MAR and said the flow rate was not always at 2 liters. She did not know why since LPNs cannot change the flow rate without an order from the doctor. She said the resident could not change the flow rate on her own. During interview on 9/26/18 at 11:11 AM, the Assistant Director of Nursing (ADON)/Acting Registered Nurse Manager of the unit looked at the resident's oxygen order in the computer. She said it was for 2 liters per minute prn to keep saturation above 90%. The ADON stated the resident uses the oxygen all the time, even if it was not needed. She looked at the MAR and said there were times the oxygen was at 3 liters. An LPN cannot change the oxygen flow rate. The ADON did not know if the resident was able to change the flow rate herself. If a nurse saw the wrong liters that nurse should have reported it. No one reported the wrong flow rate for this resident to her. 10NYCRR415.12(k)(7)

Plan of Correction: ApprovedOctober 25, 2018

1. Resident #24 has had her oxygen order changed to 2 liters per minute continuous.
2. 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.
3. Policy titled oxygen use has been reviewed and no revisions were necessary. 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.
4. 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. The results of the audit will be brought to the QA committee and will continue until otherwise directed by the committee.
5. The Director of nursing will be responsible for compliance.

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not protect the cooking facilities in in accordance with the adopted regulations. NFPA 17A Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2009 Edition section 7.5.1 requires that wet chemical extinguishing systems (kitchen fire extinguishing system) are to be subjected to a hydrostatic pressure test at intervals not exceeding [AGE] years. Section 7.2 requires monthly owner's inspections. Specifically, the kitchen fire extinguishing system hydrostatic test and monthly owner's inspections were not conducted. This is evidenced as follows. The kitchen fire extinguishing system tests reports were reviewed on 09/ 8. The reports dated 07/26/2018 and 01/30/2018 both state that a hydrostatic test is due. Records documenting that the hydrostatic test was conducted were not available for survey review Records documenting a monthly owner's inspection were not available for survey review The Maintenance Supervisor stated in an interview conducted on 09/21/2018 at 8:45 AM, that he thought the inspection company had conducted all required tests, and a monthly owner's inspection is not conducted. 42 CFR 483.70 (a) (1); 2011 NFPA 96 10.2.6; 2009 NFPA 17A 7.2, 7.5; 10 NYCRR 415.29, 711.2(a)(1) and (25); 1998 NFPA 96 1-3.1; 1998 NFPA 17A 5-2, 5-5

Plan of Correction: ApprovedOctober 22, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The hydrostatic pressure test was completed on (MONTH) 8, (YEAR) which is within [AGE] years of the last test.
2. There are no other Ansul systems in the cooking area that require testing or monthly owner?s inspection.
3. The hydrostatic pressure test has been added to a preventive maintenance schedule to be completed every [AGE] years or less. The monthly owner?s inspection has been added to a preventive maintenance schedule to be completed monthly and will also include a review of the date of the last hydrostatic pressure test.
The administrator, food service director and maintenance supervisor have been educated on the NFPA 17A section 7.5.1 requirement that wet chemical extinguishing systems/Ansul system are to receive hydrostatic pressure test every [AGE] years.
The administrator, food service director and maintenance supervisor have been educated on NFPA 17A section 7.2 requirement of monthly owner?s inspection of the kitchen fire extinguishing system.
4. The findings of the monthly owner?s inspection will be reported to the QAPI committee monthly times 3 months and quarterly thereafter. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

K307 NFPA 101:DISCHARGE FROM EXITS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the exit discharges to the public way were not free of all impediments for full instant use. NFPA 101 Life Safety Code 2012 edition section 7.1.10.1 requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, the resident escape walkways (exit discharges) were not available for full instant use. This is evidenced as follows. The Director of Nursing was present during survey observations. The exit discharges around the perimeter of the building were inspected on 09/24/2018 at 7:30 AM. Sections of the pavement were bumpy (4-inch to 6-inch bumps) from root growth underneath, and vegetation was overgrown in the gaps between paved sections. The Director of Nursing stated in an interview conducted on 09/24/2018 at 7:30 AM, that the overgrown vegetation and bumps in the egress pathway can make egress difficult with a wheelchair. 42 CFR 483.70 (a) (1); 2012 NFPA 101 7.1.10.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedOctober 22, 2018

1. The area identified around the perimeter of the building that had vegetation overgrowth was corrected. The administrator had the bumpy pavement caused by root growth underneath inspected by an outside contractor and obtained a quote to repair. The repair will be completed.
2. The administrator and maintenance supervisor will inspect all exit discharges to ensure pavement is not bumpy and is free form vegetation overgrowth. Any identified areas will be corrected.
3. The maintenance supervisor will be educated on the NFPA 101 Life Safety Code section 7.1.10.1 that requires that means of egress shall be continuously maintained and free of all obstructions or impediments in case of emergency.
Exit discharge areas will be inspected by the maintenance supervisor/designee monthly as part of preventive maintenance program to ensure the means of egress is free from obstructions and impediments.
4. The findings from the monthly inspection of exit discharges will be submitted to the QAPI committee monthly times 3 months and quarterly thereafter. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on employee interview and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that patient care-related electrical equipment (PCREE) is tested and inspected prior to being placed in service and is maintained in with consideration of the owner's manual. Specifically, nebulizers were not inspected prior to being placed in service and were not maintained as prescribed in the owner's manual. This is evidenced as follows. Observations on 09/21/2018 at 2:50 PM, revealed that the nebulizer assigned to the resident in room N-01 was not in use and was plugged into an electrical outlet. The resident was in their room. Review of the owner's manual for the nebulizer assigned to the resident in room N-01 on 09/21/2018, revealed that to reduce the risk for electrocution, the unit is to be unplugged immediately after using. When requested on 09/21/2018, no records were available for survey review documenting that the nebulizers were inspected within the past year. The Maintenance Supervisor stated in an interview conducted on 09/21/2018 at 2:30 PM, that he could not find any records of the nebulizers being inspected. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedOctober 22, 2018

1. The nebulizer in room N-01 was unplugged and inspected.
2. All nebulizers will be audited to ensure they have been inspected prior to being put in service.
3. All staff will be educated to ensure that nebulizers are unplugged when not in use in accordance with the owner?s manual.All staff assigned in the application of patient care-related electrical equipment (PCREE) will be in-serviced on the safe use as per the owner's manuals. All PCREE will be audited to ensure compliance with the owner's manuals.
The maintenance supervisor was educated regarding the need to have nebulizers tested prior to being placed in service in compliance with NFPA 99 section 10.3.5.4 testing requirements for PCREE. An audit will be conducted to ensure all PCREE has been inspected.
The administrator will review nebulizer testing documentation monthly to ensure testing was completed prior to being put in service.
4. The findings of the nebulizer audit will be reported to the QAPI committee. The administrator review of nebulizer testing documentation will be reported to the QAPI committee monthly times 3 months and quarterly thereafter. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide emergency power as required by adopted regulations. NFPA 99 Health Care Facilities Code 2012 edition section 6.4.1.1.17 requires that the emergency power source (emergency generator) is to include a remote annunciator that is storage battery powered and provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. Specifically, the emergency generator did not include a remote annunciator at a regular work station. This is evidenced as follows. Observations on 09/20/2018 at 10:31 AM, revealed that the emergency generator remote annunciator is in the basement. The Maintenance Supervisor stated in an interview conducted on at 09/20/2018 11:35 AM, that the emergency generator remote annunciator is located on a computer in his office that is not a regular work station. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1.1.15

Plan of Correction: ApprovedOctober 22, 2018

1. An emergency generator annunciator will be added to a regular work station.
2. There is no other generator that can be affected.
3. The maintenance staff was educated on the NFPA 99 section 6.4.1.1.17 requirements to include a remote annunciator that is storage battery powered and provided to be operated outside of the generating room in a regular work station.
4. The location of the additional annunciator will be reviewed by the QAPI committee.
5. The administrator is responsible for compliance.

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation, and employee interview during the recertification survey, the facility did not inspect electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Sections 6.3.3.2 and 6.3.4.1 requires that receptacles not listed as hospital-grade, at patient bed locations shall be tested at intervals not exceeding 12 months; the testing shall include: the physical integrity shall be confirmed by visual inspection; the continuity of the grounding circuit shall be verified; correct polarity of the hot and neutral connections shall be confirmed; the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Specifically, the facility did not ensure receptacles not listed as hospital-grade, were tested as required on 2 of 2 units. This is evidenced as follows. Observations on 09/20/2018 at 1:25 PM, revealed non-hospital grade receptacles in resident rooms on the Northeast and Southwest resident units. The Maintenance Supervisor stated in an interview conducted on 09/21/2018 at 8:50 AM, that he was not aware that non-hospital grade receptacles should be tested annually. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.3.3.2, 6.3.4.1

Plan of Correction: ApprovedOctober 22, 2018

1. The non-hospital grade receptacles have been tested .
2. All non-hospital grade receptacles located at patient bed locations have been tested .
3. The maintenance staff was educated in accordance with the NFPA requirement in sections 6.3.3.2 and 6.3.4.1 requiring that all non-hospital grade receptacles at patient bed locations are tested at least annually.
The testing of all non-hospital grade receptacles at patient bed locations will be added to a preventive maintenance schedule.
4. The findings from the initial testing of all non-hospital grade receptacles located at patient bed locations will be reviewed by the QAPI committee. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

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: September 26, 2018
Corrected date: November 25, 2018

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 (drills) shall be conducted quarterly on each shift. Specifically, fire drills were not conducted quarterly on each shift. This is evidenced as follows. The fire drill evaluations were reviewed on 09/24/2018. No fire drill evaluations were provided for survey review documenting that fire drills were conducted on the 7 AM to 3 PM shift during the first and fourth quarters of (YEAR) and second quarter of (YEAR). No fire drill evaluations were provided for survey review documenting that fire drills were conducted on the 11 PM to 7 AM shift during the first, second, and fourth quarters of (YEAR) and the second quarter of (YEAR). No fire drill evaluations were provided for survey review documenting that a fire drill was conducted on the 3 PM to 11 PM shift during the second quarter of (YEAR). The Administrator and Maintenance Supervisor stated in a telephone interview conducted on 09/26/2018 at 8:45 AM that a staff person that has since been fired, was assigned the responsibility to conduct fire drills simply did not conduct all the required drills. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.1.6; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.1.2

Plan of Correction: ApprovedOctober 22, 2018

1. No corrective action can be taken for past missed fire drills.
2. There are no other missed fire drills that were not identified during survey.
3. The maintenance supervisor will be educated on the NFPA 101 Life Safety Code section19.7.1.6 requirement to complete quarterly fire drills on each shift. Fire drills will be scheduled for the upcoming 4 quarters and reviewed to ensure compliance.
Fire drills will be completed by maintenance supervisor/designee on each shift in (MONTH) (YEAR).
Fire drill sign in sheets that include dates and times will be audited quarterly by the administrator.
4. The fire drill audits will be reviewed by the QAPI committee quarterly. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

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: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on record review and 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, defective fire-rated doors were not corrected after the required inspections were conducted. This is evidenced as follows. The fire-rated door inspection reports were reviewed on 09/21/2018. Four doors were documented as having defects: service wing door, oxygen storage room door, Co-gen electrical double door, double door adjacent to maintenance. No report was available for survey review documenting an inspection on the stairwell door. A spot visual check of the fire rated doors was conducted on 09/21/2018 at 8:50 AM. This visual check and record review revealed that defects such as missing closing devices, broken door handles, or hardware that is not listed were not corrected. The Maintenance Supervisor stated in an interview conducted on 09/21/2018 at 3:30 PM, that he was assigned to inspect the fire-rated doors without specific training and does not know why the door repairs were not completed and the stairwell door was not inspected. 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: ApprovedOctober 22, 2018

1. The service wing door, oxygen storage room door, Co-gen electrical double door, double door adjacent to maintenance closing devices, handles and hardware have been repaired or replaced. The stairwell door was tested .
2. All fire rated doors will be tested and any identified defects will be corrected without delay.
3. Maintenance staff will be educated to ensure that door assemblies in exit enclosures are tested annually and that all identified repairs are corrected without delay.
The administrator will audit fire rated door inspection reports monthly to ensure tests are completed annually and repairs are made without delay.
All assemblies in exit enclosures will be added to preventive maintenance schedule to be tested annually.
4. The findings from the audit will be reviewed by QAPI committee monthly times 3 months and quarterly thereafter. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include the use of volunteers, such as State and Federal health care professional to address surge needs, in an emergency. This is evidenced as follows. A review of the Emergency Plan on 09/21/2018, 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 and Director of Nursing stated in an interview conducted on 09/21/2018 at 9:00 AM, that the facility Emergency Plan will be revised to include the use of medical volunteers. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedOctober 22, 2018

1. Administrator has obtained the Centers policy for use of medical volunteers which includes the use of medical volunteers during an influx of patients
2. The policy was reviewed by the administrator and meets the regulatory requirements of 403.748(b).
3. The Centers policy for the use of medical volunteers has been added to the facility?s emergency management plan.
The administrator, DON and maintenance supervisor will be educated on the policy for using medical volunteers.
4. The emergency management plan will be audited yearly by the administrator to ensure it includes the policy to use of medical volunteers.
The review of the policy for use of medical volunteers will be submitted to the QAPI committee by the administrator yearly when the emergency management plan is reviewed and/or updated.
5. The administrator is responsible for compliance.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan 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 09/21/, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator and Director of Nursing stated in an interview conducted on 09/21/2018 at 9:00 AM, that though the county emergency preparedness officials have been contacted, the Emergency Plan has not yet been revised to include provisions outlining their role for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedOctober 22, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Administrator has obtained the Centers policy for care and treatment of [REDACTED].
2. The policy was reviewed by the administrator for the care and treatment of [REDACTED].
3. The policy for care and treatment of [REDACTED].
The county will be contacted by the administrator to assist the coordination of planning for the care and treatment of [REDACTED].
The administrator, DON and maintenance director will be educated on the policy for care and treatment of [REDACTED].
4. The emergency management plan will be audited yearly by the administrator to ensure it includes the policy for the care and treatment of [REDACTED].
5. The review of the policy for care and treatment of [REDACTED].
6. The administrator is responsible for compliance.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Section 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Specifically, in 1 of 1 smoke barriers observed, metal electrical boxes were not fire protected, the wall was not continuous, and the fire-resistance rating was not maintained. This is evidenced as follows. The Northeast Resident Unit smoke barrier wall was inspected on 09/20/2018 at 10:00 AM. The following items were observed: In resident room E-03 there was one unsealed 1-inch penetration; in resident room E-02 there was one metal electrical box over 16 squared inches was not fired protected; in the corridor there were 8 penetrations, two metal electrical boxes within 24-inches vertically, and a 10 foot by -inch space where the wall meets the underside of the roof were not fire protected; in the medication room there were two 4-inch penetrations, 8 one-inch penetrations for water piping and three holes above the suspended ceiling were not fire-sealed. The Maintenance Supervisor stated in an interview conducted on 09/20/2018 at 11:40 AM, that he was not aware of unsealed penetrations in the smoke barrier. He stated he will ensure that the metal electrical boxes are fire protected and 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: ApprovedOctober 22, 2018

1. Penetrations identified in the Northeast resident unit smoke barrier wall specifically in room E-03, the northeast corridor and medication room were sealed with fire caulking designed to maintain smoke barriers in accordance with Life Safety Code.
The electrical boxes identified in room E-02, the northeast corridor will be fire protected by packing with Fire Barrier Putty Pad, rated up to 4 hours, and specifically designed and approved for an electrical box.
2. All smoke barrier walls will be inspected to ensure metal electrical boxes are fire protected and free from penetrations in order to ensure fire resistance rating is maintained.
3. A monthly audit of all smoke barrier walls will be completed by maintenance supervisor/designee to identify penetrations and other areas that compromise the fire resistance rating in accordance with NFPA regulations.
4. The findings of the monthly audits will be reported to the QAPI committee monthly times 3 months and quarterly thereafter. Modification, discontinuation or continuation of audits will be based on QAPI committee recommendations.
5. The administrator is responsible for compliance.

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 26, 2018
Corrected date: November 25, 2018

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain equipment using gas or related gas piping in accordance with adopted regulations. NFPA 54, National Fuel Gas Code 2011 Edition Section 9.3 requires that Type II gas dryers specifically provide outside air for fuel combustion (make-up air). Specifically, adequate make-up air was not provided for gas dryers. This is evidenced as follows. Observations of the laundry room on 09/20/2018 at 11:50 AM, revealed 3 fuel fired gas clothes dryers and one duct for make-up air approximately 16-inches by 30-inches each, a total of 480 square inches of free ducting area. Record review of the clothes dryer installation manual on 09/20/2018 revealed that a total 585 square inches of free openings for make-up air be provided for fuel combustion. The Director of Maintenance stated in an interview conducted on 09/20/2018 at 1:45 PM, that the current vent for the make-up air is undersized and he will install an additional vent. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.1, 9.1.2; 2011 NFPA 54 9.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 54

Plan of Correction: ApprovedOctober 22, 2018

1. The ducting area in the laundry room will be increased in accordance with the owners manually.
2. No other area of the facility has the potential to be impacted.
3. The administrator and maintenance supervisor will be educated on NFPA 54 section 9.3 requirements for adequate make-up air.
4. Review of the increase of ducting area in the laundry room will be reviewed by the QAPI committee.
5. The administrator is responsible for compliance.