Meadowbrook Healthcare
June 29, 2017 Certification Survey

Standard Health Citations

FF10 483.24(c)(1):ACTIVITIES MEET INTERESTS/NEEDS OF EACH RES

REGULATION: (c) Activities. (1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during the recertification survey, the facility did not ensure the provision of an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental and psychological well-being of each resident; encouraging both independence and interaction in the community. Specifically: The facility did not ensure activity programs were provided after 2:30 pm, Monday through Friday, did not ensure there were regularly scheduled activities on Saturdays and that activities other than Communion and church service were provided on Sundays, and did not ensure morning activities included scheduled times. For Resident #122, the facility did not provide care planned daily activities; and activities were not consistently provided on weekends. This was evidenced by: Finding #1: The facility did not ensure activity programs were provided Monday through Friday after 2:30 pm, that activities were regularly provided on Saturdays, and activities other than Communion and church service were provided on Sundays; as reported by residents and verified by the facility's monthly activity calendar, and interviews. Review of the March, April, (MONTH) and (MONTH) (YEAR) activities calendars documented AM unit programs with no times specified. Review of above calendars documented Sunday activities as Communion and church service. Review of the above calendars, documented a Saturday activity on (MONTH) 20, (YEAR) and a Saturday activity on (MONTH) 25, (YEAR) and one evening activity program on (MONTH) 10, (YEAR). During Group Interview on 6/27/17 from 10 am to 10:45 am, attended by 6 alert and oriented residents, all residents verbalized that there were no evening activity programs or weekend activities. Two (Resident #'s 86 and 199) of the 6 residents further verbalized that the evenings are too long and would like evening activities. During an interview on 6/27/17 at 2:05 pm, the Activities Director(AD) stated there is a once a month activity on Saturdays. For Saturday Activity programming the Activity staff will offer one program per month with the remaining activity programming being arranged by nursing. The AD stated there is one quarterly evening event for the facility. The AD stated that evening activities do not usually work out due to meal times. The AD stated residents are made aware of the time of a program, when activities' staff go and get them. The Activities Director (AD) stated that the Activity staff will go from room to room to invite residents to activity programming during the day. The AD stated that there are no times on the AM unit programs on the activities calendars because the times vary so much. The AD stated that for evening activity programming the nursing staff on the units will have the activities programming for the residents on respective units. For Sunday activities, the Activities staff will arrange for communion and religious services and the same will be announced on the monthly calendar for attendance by residents. The AD stated there are 5 full time employees; one staff member works Saturday and Sunday on the day shift and the staff during the week can be anywhere from 2 to 5 staff members. During interview on 6/29/17 at 4:00 pm, a Certified Nursing Assistant (CNA) stated there were no formal activities scheduled in the evening and very little on the weekend. She also said some residents get visitors, but wasn't sure if anyone came to see the resident. She said during the day if an activity is off the floor and resident's need to be transferred by staff it can't always be accomplished depending on staffing. During interview on 6/29/17 at 4:30 pm, a Licensed Practical Nurse (LPN) stated that the Activity staff takes care of the activity programming during the day. The LPN stated the nursing staff on the units don't have time for a formal activities program for the residents on the unit, but if materials or supplies are needed for evening activity that a resident requests, the nursing staff can get these from the activity cart. She stated nights are busy and if they are short staffed the resident's that require care come first. The LPN wasn't sure how Saturdays and Sundays were handled, but did know the activies staff handled the church services and coordinated the transporting of residents for off the floor activities. Resident #122: The resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident could understand and was understood with a Brief Interview for Mental Status (BIMS) of 10/15 or moderately impaired for decision making. It is documented that the resident received [MEDICAL CONDITION] medication 6/23-6/27 for depression. Physicians order dated 5/18/17, documented activities as tolerated and further document Resident may leave the facility to go out on supervised outings. Residents Comprehensive Care Plan (CCP) documented the resident is an active participant in group and independent activities, likes to be involved in all activities. Measurable goals: Resident will continue to actively participate in a variety of group an independent activities of choice daily x 3. Updated 6/2/17; Interventions: Post calendar in room each month and remind resident of activities she enjoys. Provide resident with independent supplies for coloring, arts and crafts and puzzles. Offer social visits, In vitae and escort resident to programs of choice (outings, bingo, special events, live entertainment, socials, trivia, residents council, arts and crafts, and exercise program. During record review, the activities program documented the following on the residents activity card: The residents activity card for (MONTH) (YEAR) documented no activity program for 3 Saturdays and 2 Sundays and there were no evening activities. Sundays activities documented Church Service only. No documented evening activities were evident. The residents activity card for (MONTH) (YEAR) - no activities documented included for 5 Saturdays and 1 Sunday. Sundays activities documented Church Service only. No documented evening activities were evident. The residents activity card for (MONTH) (YEAR) -documented no activities for 3 Saturdays and 1 Sunday. Sundays activities documented Church Service only. No documented evening activities were evident. The residents activity card for (MONTH) (YEAR) - documented no activities for 4 Saturdays and 1 Sunday. Sundays activities documented Communion blessing only. No documented evening activities were evident. During an interview on 6/29/17 at 3:15 pm, the resident stated she would like to have more things to do on the weekend and in the evening. She said she likes to go to all activities but can't go if there is nothing going on. She said she likes coloring and does this most of the time. She stated she likes to go to Bingo, but has to have someone bring her and sometimes there isn't enough help. During interview on 6/29/17 at 4:00 pm, a Certified Nursing Assistant (CNA) stated there were no formal activities scheduled in the evening and very little on the weekend. She also said some residents get visitors, but wasn't sure if anyone came to see the resident. She said during the day if an activity is off the floor and residents need to be transferred by staff it can't always be accomplished depending on staffing. During interview on 6/29/17 at 4:30 am, a Licensed Practical Nurse stated that the Activity staff takes care of the activity programming during the day. The LPN stated the nursing staff on the units don't have time for a formal activities program for the residents on the unit, but if residents request materials or supplies for an evening activity, the nursing staff can get these from the activity cart. She stated nights are busy and if they are short staffed the residents that require care come first. The LPN wasn't sure how Saturdays and Sundays were handled, but did know the activies staff handled the church services and coordinated the transporting of residents for off the floor activities. 10NYCRR 415.5(h)(1)

Plan of Correction: ApprovedJuly 20, 2017

F 248 - 483.24 Activities Meet Interests/Needs of Each Resident
1. The following corrective action was taken for the deficient practice that was cited in the sample:
a. For the residents identified during the time of survey that were found to not have been provided activities (resident #122, #86, #199) the facility reviewed their care plan and leisure time resident specific preferences per the interdisciplinary assessment.
b. Staff were instructed/inserviced at that time about the observed deficient practice patterns indicated above.
Completion Date 6/29/17

2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Resident surveys will be conducted with residents for preferred activity options/diversity and times of programs. The residents will be interviewed and the suggested outcomes will be reviewed and the activity calendars and care plans will be developed to reflect the residents individualized preferences.
b. All residents with moderate to good cognition will be interviewed throughout the
facility. Findings will be reflected in their leisure time activity preferences in the care plan. Inter-disciplinary staff will be trained in performing leisure time programs on a variety of times and days of the week. The calendar will continue to reflect residents? suggestions and preferences.
c. Continued resident satisfaction surveys will be completed through the residents? council each month to ensure the leisure time needs are being met.
Completion Date 8/7/17
3. The following measures will be put into place to prevent future residents from being
affected by the same deficient practice:
a. The Activities Director will be held responsible to ensure evening and weekend
activity programming frequency will be increased. Training and documentation tools will be given to the inter-disciplinary team and the education and training will be ongoing by the Activity Director and/or designated assistant.
b. Programs will be designated to a specific time on each household calendar and on the posted page of daily events. Each program will be conducted in a certain time per the policy. Morning programs will be designated to a certain time after the breakfast meal. Afternoon programs will be designated to a certain time after the lunch meal. Evening programs will be designated to a time that reflects the resident neighborhood?s preferences.
c. Ongoing training will be provided for the interdisciplinary team to assist in organizing and implementing a variety of group and independent leisure time activities.
Completion Date - 8/25/17
4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Activity Director or her designee, will audit all weekly calendars to ensure activities are properly recorded and provided according to resident preferences.
b. The Activity Director will submit weekly audit calendars to the Administrator as well as resident activity satisfaction surveys for review.
c. The Activity Director will follow up on audits and findings will be evaluated and additional corrective actions will be implemented if indicated.
d. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits and surveys will be presented to the Corporate Compliance committee and the Quality Assurance Performance Improvement committee where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date - 8/25/17

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

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined during the recertification survey that the facility did not ensure a comprehensive care plan (CCP) was developed for each resident to meet medical, nursing, and psychosocial needs as identified in the comprehensive assessment for 3 (Resident #'s 186, 198, and #218) residents of 30 residents reviewed. Specifically: For Resident #186, the clinical record did not include a care plan for activities; For Resident #198, the clinical record did not include a CCP for [MEDICAL CONDITION]; and for Resident #218, the clinical record did not include a CCP for pain. This was evidenced by the following: Resident #186: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident could understand and was understood with a Brief Interview for Mental Status (BIMS) of 6/15 or severely impaired for decision making. It documented the resident received [MEDICAL CONDITION] medication from 6/23-6/27 for depression. Physician order [REDACTED]. A review of the resident's activity card documented: May (YEAR) - The resident attended activities programs twice in the 31 days of the month. June (YEAR) - The resident attended activities programs 3 times out of the 28 days in the month. During an interview on 6/30/17 at 10:00 am, the Activities Director (AD) stated she would look for the CCP as well as the Activity log for the resident. She stated she wasn't sure if a CCP had been completed. She also said she uses information from an activity assessment to develop the care plan along with review of patient related concerns by staff and family. She stated no activity assessment was found in the residents records. During an interview on 6/30/17 at 11:00 am, the Director of Nursing (DON) stated the resident did not have a careplan for activities. The DON stated Comprehensive Care Plans (CCP) are started on the day of admission and are gradually developed according to the residents [DIAGNOSES REDACTED]. She stated the Social Worker (SW) does an intake on the the resident's preferences either with the family or resident, depending on cognition. After team meetings with staff, when reviewing the need to adjust a plan of care that is patient centered, according to problem areas, the AD should enter a CCP for activity into the system to address problems, goals, approaches and interventions for staff to follow. The DON stated she had reviewed the residents chart and was unable to find a CCP for activities and was completing the activity assessment so it could be put in place. She stated she wasn't sure how this got missed, but would be reeducating staff on reviewing CCP and the need for completing these in a timely manner. Resident #198: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a severe cognitive impairment. The MDS also assessed the resident with usually able to be understood by others and sometimes understands simple, direct communication. physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Review of the clinical record did not include a CCP for [MEDICAL CONDITION]. During interview on 6/29/17 at 9:00 am, the Director of Nursing (DON) stated that after a review of the resident's problem list, no CCP for [MEDICAL CONDITION] was completed. The DON stated that a CCP for [MEDICAL CONDITION] should have been completed and available for review. Resident #218 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating a severe cognitive impairment. The resident is usually able to be understood by others and is usually able to understand others. The Pain Section of the MDS indicated has a scheduled pain medication and has non-medication interventions for pain. The pain assessment documented: the presence of pain; frequent pain; pain limits daily activities; and the the verbal descriptor of the pain scale indicated the pain is mild. Physician orders [REDACTED]. Physician orders [REDACTED]. The Medication Administration Record [REDACTED] - [MEDICATION NAME]- [MEDICATION NAME] 5-325 ([MEDICATION NAME] 5-325) one tablet three times daily by mouth for pain at 8:00 am, 2:00 pm, and 8:00 pm. - Tylenol 325 mg tablet ([MEDICATION NAME]) stock one tablet three times daily by mouth for pain/anxiety at 8:00 am, 2:00 pm, and 8:00 pm. The clinical record did not include a CCP for pain. During interview on 6/29/17 at 9:00 am, the Director of Nursing (DON) stated she could not find a current CCP for pain in the active care plan documentation. The DON stated that a current CCP needs to be activated for the CCP for pain to be current. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedJuly 17, 2017

F279 ? Develop Comprehensive Care Plans
1. The following corrective action was taken for the residents identified in the sample:
a. The staff directly responsible for the care plan development of residents #186, #198 and #218 were inserviced by the Director of Nursing on the policies and procedures of comprehensive care plan development. Appropriate care plans were developed for the identified areas.
Completion Date: 7/17/2017
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Nursing Administration will review all residents comprehensive care plans to ensure all resident care areas and needs are addressed in the record. Further education will be provided to staff as necessary to develop appropriate care plans.
Completion Date: 7/30/17
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Medical Director, Interdisciplinary Team and the Director of Nursing will review the policy and procedure on comprehensive care plan development. The policies will be revised as necessary.
b. The Director of Nursing will monitor compliance of comprehensive care plan development documentation by conducting weekly care plan audits. Corrective action will be taken if indicated.
Completion Date: 8/25/2017
4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Nursing, or her designee, will audit 5% of all resident care plans weekly to ensure timely and comprehensive care plan development is completed.
b. The Director of Nursing will review the care plan audit findings weekly. Audit findings will be evaluated and additional corrective actions will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits will be presented to the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 8/25/17
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Compliance: 08/25/17

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

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that the temperature of potentially hazardous foods may not be above 41 degrees Fahrenheit (F) except for a period not exceeding two hours during food preparation; food packages shall be in good condition and protect the integrity of the contents; packaged frozen food shall be date-marked; and food temperature thermometers shall be calibrated. Specifically, food was not maintained at a safe temperature during preparation, the hermetic seals of canned foods were compromised, frozen foods were not date-marked, and the two kitchen food temperature thermometers were not calibrated when checked. This is evidenced as follows. The main kitchen was inspected on 06/26/2017 at 10:35 am. Pureed pre-cooked ham was found to be 56 F at 11:05 am and 48 F at 1:00 pm. The hermetic seal of one #10 can of tropical fruit, found in the common stock, was compromised with a creasing dent on the top seal of the can. In the walk-in freezer, hamburger buns were not marked with the date provided by the manufacturer. And the calibration of the two kitchen food temperature thermometers was 38 degrees F and 25 F when checked by standard method in an ice bath. The Food Service Director stated in an interview conducted on 06/26/2017 at 11:05 am, that the dented can should not have been stored with the common stock, she will institute dated-marking all frozen food in the walk-in freezer, and she will re-educate her staff on correct thermometer calibration. The Food Service Director stated in an interview conducted on 06/26/2017 at 1:00 pm, that the ham was not prepared and cooled properly and will be discarded. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.32, 14-1.40, 14-1.85

Plan of Correction: ApprovedJuly 17, 2017

F371 ? Food Procure/Store/Prepare - Sanitary
1. The following corrective action was taken for the deficient practice that was cited in the sample:
a. The Director of Food Service immediately discarded the food item into the garbage that was found to be improperly cooled/prepared, removed the dented food can from the storage room, dated the food items that were not dated, and recalibrated the food temperature thermometers.
b. Staff were instructed/inserviced at that time about the observed deficient practice patterns indicated above.

Completion Date: 6/26/2017
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. The Director of Food Service inventoried all food items stored within the Freezer, Cooler and storage areas at that time to ensure all items were properly prepared, dated, and/or stored.
b. Staff were instructed/inserviced on FDA Guidelines and the need to ensure that all food and equipment temperatures are within FDA compliance at all times.

Completion Date: 6/26/17
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Director of Food Service and Head Chef will reestablish/revise daily food temperature logs to ensure food items are prepared, stored, and dated according to FDA Guidelines. A new written policy reflecting this new practice standard will be established.
b. The Director of Food Service, Head Chef, and Administrator will review the policy and procedure on food temperatures and all food service employees will be inserviced on the new policy.
c. The Director of Food Service and Head Chef will monitor compliance with general food storage/temperatures by conducting daily audits. Corrective action will be taken if indicated.
d. The Director of Food Service and Head Chef will conduct daily audits for each meal on all food items and the various temperature logs within the kitchen to ensure there are checks and balances with the daily food prep practices and monitoring/logs. Corrective action will be taken if indicated.
Completion Date: 8/25/17


4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Food Service or her designee, will audit weekly temperature logs to ensure temperatures are properly recorded and maintained in a timely manner.
b. The Director of Food Service and Head Chef will submit weekly audits of the temperature logs to the Administrator for review.
c. The Director of Food Service?s audit findings will be evaluated and additional corrective actions will be implemented if indicated.
d. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits will be presented to the Dining Committee, Corporate Compliance committee and the Quality Assurance Performance Improvement committee where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 8/25/17
5. The Director of Food Service will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Completion Date: 8/25/17

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during a recertification survey, the facility did not ensure the resident's environment remained free from accident hazards for two (2) (Resident #'s 122 and #173) of thirty (30) residents reviewed. Specifically: For Resident #122, the facility did not ensure the resident received the mechanically altered diet ordered by the physician. For Resident #173, the facility did not ensure the resident received thickened liquids ordered by the physician. This is evidenced by: Resident #122: The resident was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident could understand and was understood with a Brief Interview for Mental Status (BIMS) of 10/15 or moderately impaired for decision making. It documented the resident received psychotropic medication from 6/23-6/27 for depression. During observation on 6/27/17 at 8:05 am, a facility staff member (SM) #1 delivered another resident's breakfast tray to Resident #122, in the Chestnut unit's main dining room. The tray the resident received had thinned liquids, (juice, coffee, and water), scrambled eggs, and french toast. SM #1 was directed to bring breakfast trays to other residents by a Registered Nurse. It was observed the SM #1 was not familiar with the residents identity and diet preferences. SM #1 was observed conversing with residents while passing 5 trays. SM #1 did not check the resident's name band with the resident's meal ticket to ensure the resident received the right tray, before removing the lids from drinks on the tray. SM #1 was heard calling the resident by name, asking the resident how she liked her coffee. The resident looked at, but did not respond to SM #1. SM #1 left the table briefly, returned to the resident, and began to cut up the food, again addressing the resident by name. During observation on 6/27/17 at 8:15 am, SM #2 heard SM #1 call the resident by name, and informed SM #1 that she was calling the resident by the wrong name and had given the resident a breakfast tray prepared for another resident. SM #2 then pointed to a resident at the end of the table, and identified that resident as the correct person to receive the tray. Review of a physicians order for Resident #122, dated 5/18/2017, documented: Regular diet with mechanical soft consistency and nectar thickened liquids. During an interview on 6/27/17 at 8:35 am, SM #1 stated she was new to the facility and was not familiar with all the residents. She stated that she was taking direction from other staff members when she was passing trays, but knew she was supposed to check the residents name band to ensure the right resident had the right tray. She stated it was completely her fault and had become nervous and gotten confused. She stated the RN had told her to bring the tray to the woman at the end of the table, with the white sweater and she brought it to the wrong place. She stated she realized it, only after SM #2 (who she identified as the Speech Language Therapist), stopped her after she called the resident by the name on the food ticket. She stated the resident whose tray she had mistakenly given to Resident # 122, was on a regular diet with thin liquids. She also stated she had received the mandatory inservice all new employees have to get before being allowed to pass trays to residents. During an interview on 6/27/17 at 8:45 am, SM #2, identified herself as the Speech Language Pathologist (SLP), and stated while helping another resident she heard SM #1 call the resident the wrong name. She stated she realized the wrong resident was being given the wrong tray and stopped her before any was consumed by the resident. She was familiar with the residents diet and knew she was on nectar thickened liquids and was at risk for choking. She stated thank goodness I stopped her before any harm was done. She said that the staff members are trained to check a residents name band when passing food trays if they are not familiar with a resident to prevent mistakes like this from happening. She hadn't seen this done but said the RN in charge is supposed to make sure the right tray reaches the right resident. She had spoken to the RN in charge and believed SM #1 would be reeducated. She said all staff help at meals to prevent delay of meals to the residents. During an interview on 6/27/17 at 10:00 am, the RN charge nurse stated she saw that SM #1 had given the wrong tray to the wrong resident after she had directed her to the correct resident, but did not see this immediately. The RN said by the time she realized what happened, she hadn't intervened because the SLP was at the table and figured she would handle it. She stated the staff is supposed to check the name bands of the residents before giving them their trays. She stated she had directed SM #1 using identification cues, but ultimately the staff should check the name bands and tickets as they are directed during their orientation. She further stated she had already spoken to the Director of Nursing (DON) and SM #1 had been corrected and reeducated. Resident #173 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was understood and could understand and had a Brief Interview for Mental Status (BIMS) score was 12/12. Review of a physicians order dated 6/14/2017, documented: Regular diet with nectar thickened liquids. During meal observation on 6/27/17 at 9:15 am, a food service worker (FSW) cleaning the kitchenette was observed talking to the Registered Dietician (RD) about a resident from the facility that was given a thin liquid in the main dining room the day before. The FSW identified the resident by name. During an interview on 6/27/17 at 9:20 am, the FSW stated that she had been told by a Nutrition Service Assistant (NSA) that Resident #173 had been given a soda at lunch in the main dining room. She stated the NSA was upset because the resident was on thickened liquids and was at risk for choking. She stated she was talking to the RD about this because she wasn't sure it had been reported to her. During an interview on 6/27/17 at 10:00 am, the Food Service Director (FSD) stated that staff had reported Resident #173 had been given a soda in the dining room on 6/26/17. She had notified the Assistant Director of Nursing (ADON) and it was being investigated. The FSD said the residents meal tickets identify what they are supposed to have according to their orders and are supposed to be checked by the staff before giving any food or drinks to the resident. She stated the resident was on thickened liquids and the drink she was given is considered a thin liquid. She stated staff would be reeducated. During an interview on 6/27/17 at 2:00 pm, the ADON stated the resident had recently been downgraded to thickened liquids due to noticed coughing and choking events in the dining room. She stated she had been evaluated by SLP who did a swallowing test and the resident had been downgraded to nectar thickened liquids. She stated after the investigation was completed and it was determined that a CNA not familiar with the resident had in fact given the resident a soda and the resident was being monitored. The ADON stated the CNA had not checked the meal ticket as taught during orientation and would need to be reeducated. 10 NYCRR 415.12(h)(1)

Plan of Correction: ApprovedJuly 17, 2017

F323 ? Free of Accident Hazards/Supervision/Devices
1. The following corrective action was taken for the residents identified in the sample:
a. The staff directly responsible for serving residents #122 and #173 were in-serviced by the Assistant Director of Nursing on the policies and procedures of safe meal serving.
Completion Date: 6/27/2017
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Nursing Administration will identify all facility staff responsible for participating in serving of meals to residents. Further education and training will be provided to staff as necessary to ensure meals are served safely and appropriately.
Completion Date: 7/30/2017
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator and Director of Nursing will review the policy and procedure on safe meal serving. The policy will be revised as necessary.
b. The Director of Nursing will monitor compliance of safe meal serving by conducting weekly meal audits. Corrective action will be taken if indicated.
Completion Date: 8/25/2017
4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Nursing, or her designee, will audit at least 10% of the meals served weekly to ensure each resident is served the correct diet.
b. The Director of Nursing will review the meal audit findings weekly. Audit findings will be evaluated and additional corrective actions will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits will be presented to the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 8/25/2017
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Completion Date: 8/25/2017

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: June 29, 2017
Corrected date: August 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection determined for 1 of 2 dressing changes observed. Specifically, for Resident #75, the facility did not ensure standard and transmission based precautions were maintained during a dressing change. Additionally, for Resident #75, the facility did not ensure the resident's urinary catheter bag was kept off the floor. This is evidenced by: Resident #75: The resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as being cognitively intact, could understand others and could be understood. Finding #1: The facility did not ensure that dressing changes were performed following standard and transmission based precautions. Policy and Procedure for Clean Dressing Change dated 3/17/15, documented gloves are to be removed and pulled over the soiled dressing and discarded into plastic bag. Wash and dry hands. Open clean dressing supplies. Wash and dry hands and put on clean gloves. physician's orders [REDACTED]. Pack wound loosely with DermaGinate Rope and cover with bordered foam protective dressing. The resident's Weekly Wound assessment dated [DATE], documented the resident had a stage IV pressure ulcer to his posterior right ischium. Wound measured 1 cm x 0.5 cm x 1.4 cm. Appearance of wound bed was blanchable (color difference of wound from surrounding area). Tunneling measured 3 cm. Progress Note dated 6/19/17 at 11:07 am, documented during dressing change the old dressing was noted to be saturated with brownish exudate (fluid seeped out of blood cells). Wound noted to have very foul odor. Wound clinic contacted and awaiting recommendation for other treatment options. Progress Note dated 6/21/17 at 11:30 am, documented the resident refused surgical intervention to assist in healing osteomylitis9Infection and inflammation of the bone), therefore the odds of healing his ulcer are low. A supra pubic catheter had been placed related to urethral trauma and would aid in keeping skin ulcer dry from urine. During an observation of a dressing change on 6/28/17 at 10:05 am, the Registered Nurse (RN) washed her hands, gathered supplies and cleaned the overbed table with an alcohol wipe. The RN took her gloves off and went to the medication room to get the canister of normal saline. She used the hand sanitizer, donned clean gloves and assisted the CNA (certified nursing assistant) to position the resident onto his right side. The RN opened the resident's diaper and removed the dressing to resident's right ischium. A moderate amount of sero-sanguinous drainage was observed on the old dressing. She removed her gloves, used hand sanitizer, opened the package containing the barrier drape and placed it next to the resident on the bed. The RN opened the package containing the tweezers and cotton tipped applicators, keeping them in their package. The RN pulled the packing out of the wound using the tweezers. Packing was observed to contain sero-sanguinous drainage. The RN then sprayed the wound with normal saline from the container without removing her gloves or washing her hands. She then placed the canister on the bedside table and put the cap back on the container without removing her gloves or washing her hands. She then packed the wound with the alginate rope using the cotton tipped applicator. The RN then opened the package containing the protective dressing and covered the wound without changing her gloves or washing her hands. She disposed of the used dressing supplies. The RN removed her gloves and used hand sanitizer. After the bed was lowered, the RN kicked the floor mat under the foley bag. The foley bag was observed to be touching the floor mat. She then brought the container of normal saline into the medication room and placed it on the counter. During an interview on 6/28/17 at 10:20 am, the RN (Registered Nurse) stated she thought she had removed her gloves after removing the old dressing then stated she had not changed gloves, but should have. The RN stated she threw the canister of normal saline away after putting it on counter in medication room because it was almost empty. During an interview on 6/29/17 at 9:50 am, the Director of Nursing (DON) stated it was nursing home policy for the nurse to remove her gloves and wash her hands after removing a soiled dressing from a wound. The DON stated the nurse should not have brought the normal saline into the medication room after she touched it with gloves used during removal of the soiled dressing. Finding #2: The facility did not ensure the resident's urinary catheter bag (foley bag) was kept off the floor. Policy and Procedure for Urinary Drainage bag dated 7/2015, documented the drainage bag and tubing is to be kept off the floor at all times to prevent contamination and damage. During observations on Unit 2 west, on 6/28/17 at 9:45 am, 10:05 pm, 10:20 am, and 4:00 pm, the resident was in bed with her uncovered foley bag lying on the floor. During an interview on 6/28/17 at 4:00 pm, Certified Nursing Assistant (CNA) #1 stated when the resident is in bed, the foley bag hangs off the side of the bed by the floor without touching the floor. During an interview on 6/29/17 at 9:00 am, LPN (Licensed Practical Nurse) #1 stated the foley bag is placed lower than the resident on the side of the bed without touching the floor. When the resident is transported to another location, the foley bag is covered. During an interview on 6/29/17 at 9:15 am, the RN (Registered Nurse) stated when a resident is in bed, the foley bag is to be looped off the side of the bed ensuring that it is not touching the floor. The RN then asked if a foley bag touching a floor mat was considered a barrier or if it was considered lying on the floor. During an interview on 6/29/17 at 9:45 am, the DON (Director of Nursing) stated the foley bag should be hooked to the side of the bed frame to keep it from falling. The DON stated it is not recommended for the foley bag to touch the floor. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedJuly 17, 2017

F441 ? Infection Control
1. The following corrective action was taken for the resident identified in the sample:
a. The nursing staff directly responsible for the care of resident #75 was inserviced by the Director of Nursing on the policies and procedures of general infection control practices, with specific focus on performing dressing changes in a sanitary manner and appropriate urinary catheter care.
Completion Date: 7/06/2017
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Nursing Administration will identity all residents requiring routine clean and/or sterile dressing changes to ensure sanitary measures are taken to prevent the spread of infection. Further education will be provided to the nursing staff as necessary.
b. Nursing Administration will identify all residents with an indwelling catheter to ensure appropriate catheter care measures are provided. Further education will be provided to the nursing staff as necessary.
Completion Date: 7/30/17
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Medical Director, Director of Nursing, and Infection Preventionist will review the policy and procedure on general infection control practices for clean and sterile dressing changes. The policies will be revised as needed.
b. The Administrator, Medical Director, Director of Nursing, and Infection Preventionist will review the policy and procedure on general infection control practices for indwelling catheter care. The policies will be revised as needed.
c. The Director of Nursing will monitor compliance with general infection control practices, specifically relating to sanitary dressing changes by conducting weekly dressing change audits. Corrective action will be taken if indicated.
d. The Director of Nursing will monitor compliance with general infection control practices, specifically relating to indwelling catheter care by conducting weekly catheter care audits. Corrective action will be taken if indicated.
Completion Date: 8/25/17

4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Nursing, or her designee, will audit 10% of all nurses performing dressing changes, weekly to ensure dressing changes are performed in a sanitary manner.
b. The Director of Nursing, or her designee, will audit catheter care for 20% of residents with indwelling catheters, weekly to ensure appropriate catheter care and drainage bag placement is provided in a sanitary manner.
c. The Director of Nursing will review the dressing change and catheter care audit findings weekly. Audit findings will be evaluated and additional corrective actions will be implemented if indicated.
d. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits will be presented to the Infection Control Committee monthly and the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 8/25/17
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Completion Date: 8/25/17

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: June 29, 2017
Corrected date: August 25, 2017

Citation Details

Based on staff interview during the recertification survey, it was determined that the facility did not protect all cooking facilities in accordance with adopted regulations. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Section 11.1.4 requires that instructions for manually operating the kitchen fire-extinguishing system shall be reviewed with employees by the management. Specifically, 2 of 3 kitchen staff interviewed did not know how to manually activate the kitchen fire-extinguishing system and the facility management had not reviewed the procedure with employees. This is evidenced as follows. When interviewed on 06/26/2017 at 1:10 pm, Dietary Aide #1 stated that she had not received instruction on how to manually operate and did not know how to manually operate, the kitchen fire-extinguishing system. When interviewed on 06/26/2017 at 1:15 pm, Dietary Aide #2 stated that she had not received instruction on how to manually operate and did not know how to manually operate, the kitchen fire-extinguishing system. The Food Service Director stated in an interview conducted on 06/28/2017 at 9:45 am, that she is responsible for training the kitchen staff on the manual activation of the kitchen fire suppression system and that the dietary aides interviewed did not yet received this training. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.2.3; 2011 NFPA 96 11.1.4; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.2.6; 1998 NFPA 96

Plan of Correction: ApprovedJuly 18, 2017

K 324

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified the two employees who did
not receive proper instructions on how to
manually activate the kitchen fire extinguishing
system and educated them on the proper
instructions.

Completion Date: 6/26/16
II. The following corrective actions will be implemented to identify any additional areas
of the facility that may be affected by the same deficient practice:

The Director of Food Service conducted an
inservice for all dietary employees on the
proper use of the kitchen fire extinguishing
system.

Completion Date: 6/29/17
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Food Service, as part of the
overall dietary orientation program, will
ensure that all employees are knowledgeable on
the utilization of the fire extinguishing
system within the kitchen.

Completion Date: 7/25/17
IV. The facility?s compliance of ensuring the kitchen staff are trained on the kitchen?s fire extinguishing system will be monitored utilizing the following continuous quality improvement system:
a. The Director of Food Service will submit to the H.R. Department copies of the kitchen orientation sheet for all kitchen employees. As part of the orientation process, a written/role playing test will be given to each employee verifying their knowledge.
Both the Director and employee will sign off on the test of their competency.
b. A copy of the test and orientation sheet will be placed in their personnel file.
c. The Director of Food Service and her designee will review weekly the procedures for utilizing the system. Weekly meeting will be recorded.
d. The Director of Food Service will be held responsible for ensuring that the deficiency cited is corrected and in compliance with NFPA. The Safety Committee will conduct monthly audits on kitchen staff knowledge and on filed written tests and report the findings to the Corporate Compliance committee and the quarterly C.Q.I. committee.

Completion Date: 8/25/17

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not store pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.6.5.3 requires that empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Specifically, empty cylinders were not marked in 3 of 5 resident-unit oxygen storage rooms. This is evidenced as follows. The resident-unit oxygen storage rooms were inspected on 06/28/2017 at 2:30 pm. Empty cylinders were not marked in the Unit 1, Unit 2-west, and Unit 3 oxygen storage rooms. The Director of Engineering stated in an interview conducted on 06/28/2017 at 3:25 pm, that the smaller oxygen cylinders are not marked when empty, only the larger cylinders are marked when empty. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.6.5; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-3.5.2.2(b)2

Plan of Correction: ApprovedJuly 26, 2017

K 923

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified the area of concern for
the deficient practice of storing non-marked
oxygen cylinder within the facility

Completion Date: 6/28/17
II. The following corrective actions will be implemented to identify any additional areas
of the facility that may be affected by the same practice:

The Director of Engineering marked all the
oxygen cylinders in the observed areas as being
either empty or full within the building to
ensure NFPA 99 2012 Edition standard is met for
marked oxygen cylinders.

Completion Date: 6/29/17
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Engineering will be responsible
to ensure all oxygen cylinders are
properly marked as indicated ensuring the
storage of oxygen cylinders in in compliance
with NFPA 99 Standard of Health Care Facilities
2012 Edition section 11.6.5.3.

Completion Date: 8/01/17
IV. The facility?s compliance will be monitored utilizing the following continuous quality
improvement system:
a. The Director of Engineering and
Administrator will conduct weekly audits on
the oxygen storage practice of the facility.
b. The Safety Committee will conduct monthly
audits of the facility?s oxygen storage
practice and report the findings to the
Quarterly Quality Assurance Program.
c. The Director of Engineering will be held
responsible for ensuring that the deficiency
cited is corrected and in compliance with NFPA.
Completion Date: 8/25/17

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. The Centers for Medicare and Medicaid Services published a Final Ruling in the Federal Register on (MONTH) 13, 2008 (73 FR ) requiring all long-term care facilities to have full automatic sprinkler protection in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition by (MONTH) 13, 2013. Specifically, unacceptable obstructions to the automatic sprinkler protection were found and not all areas were protected. This is evidenced as follows. An assessment of the sprinkler system was conducted on 06/27/2017 at 2:50 pm. Sprinkler protection was missing behind the main panel in the electrical room, and storage within 18-inches of sprinkler head deflectors was found in the kitchen dry storeroom and the activities room. The Director of Engineering stated in an interview on 06/27/2017 at 2:50 pm, that he was not aware that storage on shelving against a wall above 18-inches from sprinklers was unacceptable and that he will have a sprinkler head added behind the main panel in the electrical room. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-13.3.2

Plan of Correction: ApprovedJuly 26, 2017

K 351

The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified those newly interpreted
areas of the need for sprinkler protection within
an electrical room that were observed by the
surveyor that failed to meet the requirement of
unacceptable obstructions.
Completion Date: 6/27/17
II. The following corrective actions will be implemented to identify any additional areas
of the facility that may be affected by the same practice:

The Director of Engineering will conduct a full
and complete inspection of all
areas within the building to identify any
additional sprinkler heads, storage on shelving
against a wall above 18-inches from sprinkler not
observed by the surveyor that fail to meet the
requirement of having unacceptable obstruction or
are in need of installation.


Completion Date: 8/01/17
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Engineering
will ensure that all sprinkler heads
are installed and meet the requirement of NFPA
13 Standard for the Installation of Sprinkler
Systems 1999 edition of having no unacceptable
obstructions or lack of protection and all
stored items are 18-inches away from a sprinkler
head.

Completion Date: 8/1/17

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
Upon completion of the installation of
sprinkler heads, and 18-inch clearance of
storage from sprinkler head and ensuring that
they all meet NFPA 13 standards, the
Administrator and Director of Engineering will
be held responsible for continual compliance. A
quality assurance audit will be conducted
by the facility?s Safety Committee and findings
reported to the quarterly Continuous Quality
Improvement committee. Additional corrective
action will be implemented as necessary.
Completion Date: 8/1/17


K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

Based on observation and staff interview during the recertification survey it was determined that the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, sprinkler heads in the main kitchen were found with a coating of dust. This is evidenced as follows. An assessment of the sprinkler system was conducted on 06/26/2017 at 10:35 am and again on 06/27/2017 at 2:50 pm. Three sprinkler heads in the main kitchen were found with a coating of dust. The Director of Engineering stated in an interview conducted on 06/27/2017 at 2:50 pm, that the facility does not have a schedule for cleaning sprinkler heads, and the sprinklers in the kitchen will be cleaned. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedJuly 19, 2017

K353
The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified the three sprinkler heads
within the kitchen in need of cleaning that were
observed by the surveyor that failed to meet the
requirement of being free of foreign materials.
Completion Date: 6/26/17
II. The following corrective actions will be implemented to identify any additional areas
of the facility that may be affected by the same practice:

The Director of Engineering will conduct a full
and complete inspection of all
areas within the building to identify any
additional sprinkler heads not
observed by the surveyor that fail to meet the
requirement of being free of foreign material.


Completion Date: 8/01/17
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Engineering
will ensure that all sprinkler heads
are free of foreign material and meet the
requirement of NFPA 25 Standard for the testing
and maintenance of Sprinkler Systems 2011
edition.

a. The Director of Engineering will implement a policy and cleaning schedule for all sprinkler heads and record evidence of work performed.

Completion Date: 8/25/17

IV. The facility?s compliance will be monitored utilizing the following continuous quality
improvement system:
The Administrator and Director of Engineering
will be held responsible for
continual compliance of the proper maintenance
and cleaning of the facility?s sprinkler
heads. The new cleaning schedule will be
submitted to the Safety Committee for review. A
quality assurance audit will be conducted by
the facility?s Safety Committee and
findings reported to the quarterly Continuous
Quality Improvement committee. Additional
corrective action will be implemented as
necessary.
Completion Date: 8/25/17

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2017
Corrected date: August 25, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Specifically, the walls of the south stairwell were not continuous from floor to the underside of the roof. This is evidenced as follows. The south stairwell, fourth floor was inspected on 06/28/2017 at 10:30 am. In the corridor, a 2-inch by 2-inch hole for the elopement control system was found; inside the stairwell, a 3-inch hole for a sprinkler pipe, a 1-inch hole for wiring, and an 18-inch by 24-inch hole for a wall heater was found. The Director of Engineering stated in an interview conducted on 06/28/2017 at 10:30 am, that he will repair the penetrations found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedJuly 18, 2017

The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.
K 311
I. The following actions were accomplished for the areas identified in the SOD:
The Director of Engineering identified the
penetrations within the stairwell
that were observed by the surveyor within the
building that failed to meet the requirement of
proper fire resistance within vertical openings.
Completion Date: 6/28/17
II. The following corrective actions will be implemented to identify any additional areas
of the facility that may be affected by the same
practice:

The Director of Engineering will conduct a full
and complete inspection of all
areas within the building to identify any
additional vertical openings that fail to meet
the requirement of having unacceptable
obstruction.


Completion Date: 8/1/17
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Engineering
will ensure that all stairwells, chutes and
other vertical openings are enclosed all in
compliance to meet the requirement of NFPA 101
Life Safety Code 2012.

Completion Date: 8/25/17

IV. The facility?s compliance will be monitored utilizing the following continuous quality
improvement system:
Upon completion of the project to ensure that
stairwell penetrations are enclosed and
protected to ensure that they all meet NFPA 101
Life Safety Code 2012 edition section 8.6.2
and have a 1-hour fire resistance rating, the
Administrator and Director of Engineering will
be held responsible for continual compliance.
A quality assurance audit will be conducted
by the facility?s Safety Committee and findings
reported to the quarterly Continuous Quality
Improvement committee. Additional corrective
action will be implemented as necessary.
Completion Date: 8/25/17