M.M. Ewing Continuing Care Center
November 16, 2017 Certification Survey

Standard Health Citations

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

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2017
Corrected date: January 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three observations of resident care and two of five dining room observations, proper infection control techniques were not followed. The issues involved improper incontinence care and lack of glove removal (Resident #100), and bare hand contact with food items (Gardens and Meadows units). This is evidenced by the following: 1. Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/16/17, revealed that the resident had severely impaired cognition, was frequently incontinent of urine, occasionally incontinent of bowel, and required physical assistance with bathing. The Comprehensive Care Plan, dated 7/11/16, for urinary incontinence and the current Certified Nursing Assistant (CNA) Care Guide revealed the resident was incontinent of urine and stool at times and needed assistance with incontinence products. During an observation on 11/15/17 at 10:47 a.m., the CNA donned gloves and washed the resident's rectal area in a back and forth scrubbing motion repeatedly using the same surface of the washcloth. She rinsed the washcloth in the water basin multiple times during cares. The CNA then applied barrier cream to the buttocks. Without removing her gloves, the CNA applied the resident's Attends Briefs and pants. The CNA was about to start to wash the resident's chest and arms with a new washcloth and the same contaminated water, when the surveyor intervened. Interviews conducted on 11/15/17 included the following: a. At 11:13 a.m., the CNA said she should have changed her gloves after washing the rectal area. The CNA said that she should not have put the soiled washcloth in the water basin because that contaminated the water. She said that half of the time she starts washing the resident's lower half and then the upper half. The CNA said she should change the water when she does it that way. b. At 11:39 a.m., the Registered Nurse Manager said she would expect staff to wash the resident from top to bottom, doing the perineal and rectal care at the end. She stated she expects staff to change gloves and wash hands after applying barrier cream and before touching anything else. c. At 3:23 p.m., the Director of Infection Prevention and Emergency Preparedness said she expects staff to change gloves moving from a dirty task to a clean task to prevent cross contamination. She said gloves should be removed after providing peri care and always changed after completing a dirty task. 2. During an observation of the lunch meal served in the second dining room of the Garden Unit on 11/13/17 at 12:20 p.m., a staff member was observed with bare hands, removed a slice of bread from the plastic wrapping, picked up a slice of tomato and placed it on the bread. She then removed the second slice of bread from the plastic wrapping and held it while putting mayonnaise on it, and then placed the slice of bread on the top of the sandwich. Interviews conducted on 11/16/17 included the following: a. At 9:53 a.m., the Director of Nursing stated that the facility does not have a policy regarding glove use during food handling. b. At 9:57 a.m., the Food Service Director said that staff should be washing their hands prior to handling food. He said staff should be wearing gloves with any direct food/hand contact. c. At 10:20 a.m., the staff person said that they should have worn gloves while making the resident's sandwich. 3. During an observation in the Meadows Unit dining room on 11/13/17 at 12:39 p.m., without washing their hands, a staff member was observed handling a resident's bread in order to butter it with their bare hands. When interviewed on 11/15/17 at 3:23 p.m., the Director of Infection Prevention stated that she would expect staff to wash their hands before providing assistance with meal set up. She said staff should wear gloves if actually touching a resident's food. When interviewed on 11/16/17 at 10:33 a.m., the Registered Nurse Manager stated that it is her expectations that staff use utensils to touch a resident's food or wash their hands and wear gloves. She said staff should not touch the resident's food with their bare hands. (10 NYCRR 415.19(b)(4), 415.14(h))

Plan of Correction: ApprovedDecember 11, 2017

The Certified Nurse Aide (CNA) responsible for incontinence care on Resident #100 has received counseling and education on the proper way to provide incontinence care which included infection control practices specifically not using the same washcloth during care and the need to change gloves by the Registered Nurse Manager (RNM) of the avenue-12/06/17
The Registered Nurse (RN) responsible for the touching of resident?s food in the Garden?s Dining room has received education and counseling by the RNM of the avenue- 12/07/17
The Licensed Practical Nurse (LPN) responsible for the touching of resident?s food in the Meadow?s Dining room has received education and counseling by the RNM of the avenue- 12/07/17

The facility has identified that all residents could be affected by the deficient practices. Dining observations were completed by RNM or designee on each Avenue specifically looking for staff touching Residents? food with bare hands. During the observations staff did not touch food with bare hands. Incontinence care observations were conducted on each Avenue by RNM or designee specifically observing proper infection prevention practices. Staff education provided immediately.

All CNA?s demonstrate competency in incontinence care upon hire. The Director of Nursing (DON) and Registered Nurse (RN) Educator reviewed the perineal/catheter care competency for CNA?s. The RN Educator will provide all CNA?s education on incontinence care which includes infection control practice while providing incontinence care based on the CNA perineal/catheter care competency.

The DON and Director of Nutrition Services and RN Educator reviewed and revised the MM(NAME)CCC Guidelines for Enhanced Dining. RN Educator or her designee will provide education to all registered, licensed and certified nursing staff the Guidelines for Enhanced Dining standards which includes utilizing a barrier when touching resident?s food.
The facility will perform dining room observations utilizing a standardize audit tool. The dining room observations will be completed by the registered dietician, diet technician, registered nurse or designee. The standardized audit tool will be utilized monthly for a period of three months and then quarterly. The results of the dining room observations will be reported to the Performance Improvement Committee for action if needed.
The facility will perform monthly incontinence care observations utilizing a standardized audit tool. The standardized observations will be completed by the RNM or designee. The audits will be conducted monthly for a period of three months and then quarterly. The results of the incontinence care observations will be reported to the Performance Improvement Committee for action if needed.

The Plan of Correction will be completed by 01/12/18 and is the responsibility of the Director of Nursing(NAME)A Cone RN

FF10 483.45(f)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: 483.45(f) Medication Errors. The facility must ensure that its- (f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2017
Corrected date: January 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #14) of nine residents reviewed for medication administration, the facility did not ensure that each resident was free of a significant medication error. Specifically, the wrong dose of an anti-[MEDICAL CONDITION] medication was poured and about to be administered prior to surveyor intervention. This is evidenced by the following: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of current physician orders [REDACTED]. During an observation of medication pass on 11/15/17 at 12:09 p.m., the Licensed Practical Nurse (LPN) poured 5 ml (250 mg) of [MEDICATION NAME] Acid into a cup and mixed several other medications into the cup with the [MEDICATION NAME] Acid and some water. The LPN set up the supplies at the resident's bedside and began to administer the medication via the feeding tube when the surveyor intervened and asked the LPN to recheck the [MEDICATION NAME] Acid dose in the Medication Administration Record [REDACTED]. When interviewed at that time, the LPN stated she was not sure how she missed pouring the correct dose. The LPN said she was looking at the dose per ml as opposed to the actual dose to be administered. When interviewed on 11/16/17 at 10:33 a.m., the Registered Nurse Manager stated that it is her expectations that staff use the five rights of medication administration, right resident, right medication, right dose, right times and right route to avoid errors. The current facility policy, Techniques for Medication Administration, directed under techniques that nurses must observe the five rights of medication administration: right patient, right medication, right dose, right time and right route. (10 NYCRR 415.12(m)(2))

Plan of Correction: ApprovedDecember 11, 2017

For Resident #14 the Licensed Professional Nurse (LPN) involved has received counseling and education by the Registered Nurse Manager (RNM) for the incorrect dose of medication that was prepared to be administered to Resident #14 and has been educated on the Techniques of Medication Administration policy and procedure- Completed 12/07/17.The LPN demonstrated medication pass competency during consultant observation the week of (MONTH) 9, (YEAR).
The facility has identified that all residents could be affected by the deficient practice. Observations were conducted by RNM of medication administration on each Avenue; if deficient practices were identified, they were addressed immediately- Completed 12/07/17.

The Director of Nursing (DON) reviewed and revised procedure CC.13.001 MMECCC Techniques for Medication Administration and policy CC.13.001 General Medication Administration (12/06/17). The Registered Nurse (RN) Educator will provide in-service education to all licensed and registered nurses responsible for the administration of medications on the revised policy and procedure for Techniques of Medication Administration.

Medication observations will be completed by an outside consultant, RNM or designee utilizing a standardized audit tool. The standardized medication observations will be performed monthly for a period of three months and then quarterly. The results of the medication observations will be reported quarterly to the Performance Improvement Committee for action if necessary.

The Plan of Correction will be completed by 01/12/2018 and is the responsibility of the Director of Nursing(NAME)A Cone RN

Standard Life Safety Code Citations

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2017
Corrected date: January 12, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for one (Meadows) of five residential units, the facility did not properly maintain smoke barrier doors. Specifically, a smoke barrier door was obstructed from closing. This is evidenced by the following: Observations on 11/15/17 at approximately 8:50 a.m. revealed the smoke barrier door to kitchenette ( -Meadows) was obstructed from closing by a cart with a toaster oven and milkshake machine on top. Additionally at that time, the fire alarm system had been activated and the door would have automatically closed had the cart not been there. When interviewed at that time, the Recreation Therapist said the door was not supposed to be propped open. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.2.2.2.7, 7.2.1.8.2)

Plan of Correction: ApprovedDecember 8, 2017

K223 NFPA 101 Doors with self-closing devices
? The cart blocking the self-closing door in(NAME)Kitchenette off the dining room was immediately removed, leaving the door unobstructed.
? Maintenance personnel have conducted a visual inspection of all other fire doors in the facility none were observed to be obstructed( 11/14/2017). All staff will be educated, by Director of Facilities or his designee, to keep all fire doors unobstructed, this will be done upon hire, and annually during fire training.
? Visual inspection of fire doors is added to Nursing Supervisor rounds checklist to ensure that the doors remain unobstructed.
? Using a standard audit tool, the Director of Nursing or her designee will audit the Nursing Supervisor rounds checklist specifically to determine if the fire doors are unobstructed, monthly for 3 months, then quarterly. The results of the audit will be presented to the Performance Improvement Committee for action as necessary.
Person Responsible: Director of Nursing

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2017
Corrected date: January 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations conducted during the Life Safety Code Survey, it was determined that for two (Gardens and Pines) of five residential units, the facility did not properly maintain medical gases. Specifically, oxygen cylinders were stored less than 5-feet from combustible materials and flammable liquids. This is evidenced by the following: 1. Observations on 11/14/17 at 9:55 a.m. revealed two E-sized oxygen tanks stored in the Clean Holding Room (# -Gardens) less than 5-feet from a cardboard box with towels and pads, and approximately 18-inches from two containers of 70 percent ethyl alcohol Purell Hand Sanitizer. 2. Observations on 11/14/17 at 10:47 a.m. revealed five E-sized oxygen tanks stored in the resident lounge (# -Pines) less than 5-feet from a shelf containing books and magazines. The 2012 edition of NFPA 99, Standard for Health Care Facilities, directs that Oxidizing gases, such as oxygen and [MEDICATION NAME] oxide, shall not be stored with any flammable gas, liquid, or vapor. Oxidizing gases such as oxygen and [MEDICATION NAME] oxide shall be separated from combustibles or materials by one of the following: (1) minimum distance of 6.1 meters (20 feet); (2) minimum distance of 1.5 meters (5-feet) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems; (3) enclosed cabinet of noncombustible construction having a minimum fire protection rating of 0.5 hour. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.2.4, 2012 NFPA 99:11.3.2.2, 11.3.2.3)

Plan of Correction: ApprovedDecember 8, 2017

K923 NFPA 101 Gas Equipment- Cylinder and Container Storage
? The 2 E-tanks were immediately removed from the Clean Holding room (# Gardens) by the Nurse Manager. 11/14/2017
The shelf containing the books and magazines within 5 feet of the 5 E-tanks in the resident lounge (# Pines) was moved by Maintenance personnel and the floor was marked with yellow tape and signage indicating oxygen area. 11/14/2017
? Maintenance personnel, Director of Facilities, and Nurse Managers reviewed all other Avenues for oxygen storage to ensure they meet the NFPA101 storage requirements, oxygen E-tanks that were stored improperly were immediately removed. 11/14/2017
? The Director of Facilities will designate space for oxygen tanks in the Continuing Care Center that are in compliance with NFPA 101 Gas Equipment ?Cylinder and Container Storage requirements. All staff will receive education from the Director of Facilities or his designee about oxygen storage locations. Oxygen tank storage has been added to the Nursing Supervisor rounds checklist to ensure that oxygen tanks are in designated locations within the Continuing Care Center.
? Using a standard audit tool, the Director of Nursing or her designee will conduct audits of Nursing Supervisor rounds records to ensure that oxygen is observed for proper placement within the Continuing Care Center. The audits will be conducted monthly for three months, then quarterly thereafter. The results of the audits will be presented to the Performance Improvement Committee for action as necessary.
Person Responsible: Director of Nursing

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 16, 2017
Corrected date: January 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview conducted during the Life Safety Code Survey, it was determined that for two (Gardens and Meadows) of five residential units, the facility did not properly maintain smoke barrier walls. Specifically, there were improperly sealed openings in smoke barrier walls. This is evidenced by the following: Observations of smoke barrier walls above the suspended ceilings on 11/14/17 from 1:20 p.m. to 2:00 p.m. revealed the following: a. In the shower alcove of Bathing Suite # (Gardens), there were several sections of corrugated decking that were filled with mineral wool only. The section of the smoke barrier was approximately 5-feet long. b. Above the smoke barrier doors across from Bathing Suite # (Gardens) there was an approximately 1.25 inch unsealed opening extending through the wall around a yellow cable. In an interview at that time, Maintenance Mechanic #3 stated that it looks like they sealed the other side of the wall but not this side. c. In the Recreation Therapy Manager's Office # (Meadows), there was a 1.5 inch square unsealed penetration, a circular 1-inch unsealed penetration, and a two 1inch uncapped [MEDICATION NAME] pipes. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.3.7.3, 8.5.2.2)

Plan of Correction: ApprovedDecember 8, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K372 NFPA 101 Subdivision of building spaces- Smoke Barriers
? Maintenance mechanic properly sealed all the openings observed in the shower alcove in Bathing Suite # (Gardens), above the smoke barrier doors across from Bathing Suite # (Gardens), and in the Recreation therapy Manager?s office # (Meadows). In addition the 2 [MEDICATION NAME] pipes in the Recreation Manger?s Office # (Meadows) were capped. (1/12/2017)
? Maintenance Mechanics visually inspected all other smoke barrier walls for unsealed or improperly sealed penetrations and uncapped un-capped pipes finding none. (1/12/2017)
? The Director of Facilities will educate all Maintenance personnel on the proper materials to use to seal smoke barrier wall penetrations. After completion of construction projects that involve fire wall penetrations Maintenance Personnel will inspect the firewall to ensure that all penetrations are properly sealed.
? Using a standard audit tool, the Director of Facilities or his designee will conduct visual inspection of smoke barrier walls to ensure that all penetrations are sealed and pipes are capped monthly for 3 months and anytime work is performed above the ceiling. The results of the audit will be presented to the Performance Improvement Committee for action as necessary.
Person Responsible: Director of Facilities