Hilaire Rehab & Nursing
May 24, 2017 Certification Survey

Standard Health Citations

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: May 24, 2017
Corrected date: July 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the Recertification Survey the facility did not ensure that the resident environment remained as free from accident hazards as is possible on 1 of 2 nursing units. Specifically, 1) Resident # 82, with a [DIAGNOSES REDACTED].# 40's room. The finding is: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/2/2017 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview of Mental Status (BIMS) score as the resident is rarely or never understood. The MDS documented that the resident wanders on a daily basis and was independent with personal hygiene, transfers and ambulation. A Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) initiated 2/17/2017 documented that the resident had problems associated with Dementia, Hypertension, and wandering. The CCP documented that the resident was independent with personal hygiene. The Certified Nursing Assistant (CNA) Accountability Record (CNAAR) documented that the resident required an assist of one for ADL care and that the resident wanders. On 5/17/2017 at 11:30 AM Resident #82 was observed in his room. The resident ambulates and transfers independently. The resident had a wanderguard on his left wrist. The resident removed a disposable razor from his drawer, sat down on his bed, and began shaving himself. The resident's face was dry and did not have shaving cream on it. The resident then stopped shaving and put the disposable razor in his right pants pocket. On 5/17/2017 at 11:32 AM the resident's wife was seen in the hallway. She stated that the resident is not suppose to shave himself and that she had complained about him having disposable razors and trying to shave himself before. On 5/17/2017 at 11:34 AM the unit Registered Nurse (RN) Supervisor was notified of the resident having a razor in his pocket. The RN and the wife went into the resident's room and the resident's wife was able to remove the razor from the resident's pocket. The RN stated to the resident's wife that the resident has been wandering into other residents' rooms. She took the razor to dispose of it in a sharps container. The RN Supervisor confirmed that the disposable razor was a standard razor that is used by the facility. On 5/18/2017 at 12:39 PM the Unit RN Supervisor was interviewed about Resident #82. She said she assumed Resident #82 got the razor from another room. She said disposable razors are supposed to be locked up. On 5/19/2017 at 12:41 PM Resident #82's CNA was interviewed. She stated the resident wanders around the unit and sometimes goes into other residents' rooms. She stated razors are not left with residents. They are supposed to be put into a sharps container and they are locked in a storeroom. 2) On 5/17/2017 at 11:57 AM a disposable razor was observed on the sink in Resident #40's room. This razor was not the same as the standard razor used by the facility. On 5/17/2017 at 12:04 PM the razor in Resident #40's room was brought to the attention of the unit Licensed Practical Nurse (LPN). She took the razor to dispose of it in a sharps container and said it should not be there. On 5/24/2017 at 3:00 PM Resident #40's room was observed with the RN Unit Supervisor and a CNA. Resident #40's roommate uses an electric razor and it was observed with the staff members in his drawer. The RN and CNA stated that Resident #40 requires total assistance for personal hygiene and is unable to shave himself. They stated the razor may have been left on the sink by the resident's spouse. The facility's policy on Sharps Disposal, dated (MONTH) 2002, states all sharps including needles, syringes, scalpel blades, suture set scissors, and intravenous needles are disposed in the appropriate receptacle. 415.12(h)(1)

Plan of Correction: ApprovedJune 30, 2017

F TAG 323
1- The following actions were accomplished for the resident(s) # 82 and 40
A. Resident #82 was identified and razor was removed from his person.
B. Resident #40 was identified and his spouse was notified and instructed to remove any disposable razors from room after use and give to nurse for proper disposal in Sharps Container 5/17/2017.
2- The following corrective action will be implemented to identify other residents who may be affected by the same practice:
- An observation of all Residents room was completed by the RN Supervisor to identify any residents who may be affected by the deficient practice. Nothing was found 6/12/2017.
3- The following system changes will be implemented to identify other residents who may be affected by the same practice:
A. The policy and procedure ?Sharps Disposal? was reviewed by the DNS and revised to include Razors are in their proper disposal in a sharps container after use.
B. All nursing staff will be in serviced on the revised policy for ?Sharp Disposal? 7/18/2017.
4- Facility Compliance will be monitored utilizing the following QAA system:
- An audit tool was developed by the DNS to monitor compliance with proper storage disposal of razors.
- Audits will be done monthly by RN Supervisor for 6 months.
- Negative findings will be referred to the DNS for immediate action.
- Lesson plan and attendance sheets on file for validation and compliance.
- Competency audits will be presented to the QAA committee for validation and compliance on 7/18/2017.
5- The DNS will be responsible for the completion of F-323 by 7/20/2017.

FF10 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: (b) Physician Visits The physician must-- (1) Review the resident?s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; (2) Write, sign, and date progress notes at each visit; and (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review during the Recertification Survey the facility did not ensure that each resident's total program of care, including medications and treatments, were accurately documented by the Physician for 1 of 6 residents observed during the Medication Pass. Specifically, Resident #67 had an order for [REDACTED]. The finding is: Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/10/2017 Quarterly MDS Assessment documented a BIMS score of 3, indicating the resident had severe cognitive impairment. A Physician's order, dated 3/26/2016, ordered Aspirin 81 mg chewable tablet one tablet by mouth daily for [DIAGNOSES REDACTED]. On 5/17/17 at 9:30 AM during the medication pass observation for Resident #67 the LPN stated that the 81 mg chewable Aspirin was not available in the medication cart or in the stock room. The LPN stated that the Physician will be called to get an order change. A Physician's order, dated 5/17/2017, ordered Aspirin 325 mg tablet by oral route once daily for [DIAGNOSES REDACTED]. The order was signed off by the Physician on 5/22/2017. On 5/19/2017 at 9:36 AM a Pharmacy representative was interviewed from the Pharmacy that provides the medications for the facility. He said for stock items the facility has to let the pharmacy know when medications are needed. He said the pharmacy was not made aware of the need for the Aspirin 81 mg. On 5/23/2017 at 12:00 PM the Physician was interviewed. She stated that she did not want the Aspirin order for Resident #67 changed from 81 mg to 325 mg permanently. She stated that she intended the Aspirin 325 mg to be administered once. Review of the Medication Administration Record [REDACTED]. On 5/24/2017 at 2:15 PM the RN Unit Supervisor was interviewed. She stated that she got a telephone order from the Physician to change the aspirin dosage from 81 mg to 325 mg for Resident #67, but that she did not get parameters for how long the medication should be administered. 415.15(b)(2)(iii)

Plan of Correction: ApprovedJune 19, 2017

F TAG 386
1- The following actions were accomplished for the resident(s) # 67
- The physician was notified and discontinued ASA 325mg daily and ASA 81mg was instituted.
2- The following corrective action will be implemented to identify other residents who may be affected by the same practice:
- All residents who have physician orders for ASA 81mg have the potential to be affected by this practice were identified. No further deficient practice found 5/12/2017.
3- The following system changes will be implemented to identify other residents who may be affected by the same practice:
- All licensed nurses will be in serviced on:
A. Maintaining an adequate supply of stock medications at all times.
B. Proper communication and reading back of all physicians orders to ensure residents receive the correct medication dosage and duration of order 7/18/2017.
4- Facility Compliance will be monitored utilizing the following QAA system:
A. An audit tool was developed by the DNS to ensure compliance of adequate supply of stock medication. Audit will be done monthly for 6 months by RN Supervisor.
B. An observation of each licensed nurse by the ADNS will be done to ensure competency when transcribing physician order.
- Negative findings will be referred to the DNS for immediate action.
- Lesson plan and attendance sheets on file for validation and compliance.
- Competency audits will be presented to the QAA committee for validation and compliance on 7/19/2017.
5- The DNS will be responsible for the completion of F-386 by 7/20/2017.

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during the Recertification Survey the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident reviewed for Skin Conditions from of a total Stage 2 sample of 31 residents. Specifically, Resident #65 entered the facility in (MONTH) (YEAR) with a [DIAGNOSES REDACTED]. The resident was seen by a Dermatologist in (MONTH) (YEAR) and the follow up recommendation by the Dermatologist was not followed; a Court-directive to have a Physician discuss treatment options with the resident was not done; and open, draining [MEDICAL CONDITION] were observed without dressings or wound treatment orders in place. The finding is: Resident #65 entered the facility on 5/2/2016. [DIAGNOSES REDACTED]. The 4/10/2017 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. There were no skin conditions identified in the MDS. A Patient Review Instrument (PRI) prior to admitted d 3/28/2016 documented that the resident had [DIAGNOSES REDACTED] to the right lower extremity and was receiving wound care three times per week from a home care agency. An admission Body/Skin Checklist dated 5/2/2016 documented multiple scabs on upper chest and right leg, as per resident they [MEDICAL CONDITION]. On 5/17/2017 at 9:41 AM Resident #65 was observed in bed during medication administration with the Licensed Practical Nurse (LPN) medication/treatment nurse present. Dried blood was observed on the resident's pillow. When the resident sat up an open wound was observed on the back of the resident's head. There was no dressing in place. There was a dressing in place on the resident's right lower extremity. On 5/17/2017 at 10:40 AM the resident was observed again in bed. There was no dressing over his head wound. The resident stated he had [MEDICAL CONDITION] and that is what was bleeding. On 5/17/2017 at 12:07 PM the LPN medication/treatment nurse was interviewed. She stated she was not aware of any treatment for [REDACTED]. On 5/18/2017 at 8:44 AM the resident was observed in bed. He had no shirt on. Multiple [MEDICAL CONDITION] were observed on the resident's torso, there was an open wound on his back, and there was a dressing on his right shoulder. There was some dried blood on his pillow and sheets. There was no dressing on the head wound. Review of the medical record revealed that the only wound care order was for the right shin, dated 4/12/2017, to cleanse with normal saline, apply [MEDICATION NAME], and cover with a dry sterile dressing twice daily. On 5/18/2017 at 9:00 AM the RN unit supervisor was interviewed. She stated the resident has [MEDICAL CONDITION] and that usually the [MEDICAL CONDITION] are closed. She stated that if a lesion opens, the Physician is contacted to get treatment orders to prevent infection. She stated she was not aware of the open lesion on the resident's back. She stated she did not know who put the dressing on the right shoulder, but there was no documentation or current treatment order for the shoulder. Treatment orders dated 5/18/2017 at 9:07 AM ordered to clean the back of the head with normal saline, apply [MEDICATION NAME], and dry protective dressing; and 5/18/2017 at 9:09 AM an order to clean the opening on the back with normal saline, apply [MEDICATION NAME], and dry protective dressing. A Comprehensive Care Plan (CCP) initiated 4/21/2017 titled Diagnosis: [REDACTED]. [REDACTED]. An update to the CCP on 5/19/2017 documented that the RN Supervisor was informed by the night nurse of another opening on the right shoulder and treatment orders were received. On 05/19/2017 at 10:16 AM the resident's Certified Nursing Assistant (CNA) was interviewed. She stated the resident has [MEDICAL CONDITION] and she may need to change him a couple of times a day because of blood on the sheets or gown. The CNA said the resident likes to stay in bed and sometimes he picks and rubs at the [MEDICAL CONDITION]. She stated that if she notices blood on the sheets or clothing, she will tell the nurse. On 5/19/2017 at 12:00 PM the RN Unit Supervisor was re-interviewed. She stated that there was no order for skin checks. She stated that usually when the CNAs provide care they report if there are any skin openings and that she checks the resident during morning report, which takes place between 7:15 AM and 8:00 AM. She stated the last Dermatology consult was in (MONTH) (YEAR). She stated that a Dermatologist would be called on an as needed basis, such as if a wound is not responding to treatment, if there is a new lesion, or if [MEDICAL CONDITION] are opening up more frequently. She stated that she was going to arrange for a Dermatology consult. She further stated that there was no current order for the right shoulder wound. Treatment orders dated 5/19/2017 at 1:23 PM ordered to clean the lesion on the right shoulder with normal saline, apply [MEDICATION NAME], and a dry protective dressing. Review of the record revealed that the resident was being seen by the Wound Physician starting 5/9/2016, a week after the resident entered the facility. The wound consult on 5/9/2016 identified the right shin [DIAGNOSES REDACTED] site measuring 4.5 cm x 4.5 cm x 0.1 cm, and documented that the resident apparently had multiple [DIAGNOSES REDACTED] lesion sites, and that the only definitive treatment would be with excision. Until/if that is chosen as treatment, all else is palliative care. The plan was for the MD/family to decide on treatment--palliative or aggressive. In the meantime the Wound Physician ordered a wound treatment for [REDACTED]. A Wound Physician consult dated 8/22/2016 documented that the resident now had two open [MEDICAL CONDITION] sites; to the right shin and the right shoulder. The Wound Physician ordered a treatment and documented that the wounds will not heal, and if the family wants aggressive care, send to a Dermatologist. A Wound Physician consult dated 8/29/2016 documented both the right shoulder and right shin sites and documented that attempts to retard the [MEDICAL CONDITION] sites with the ordered treatment has been futile. The Wound Physician documented, There is nothing more I can do. Await Dermatology consult for treatment versus palliative. The physician documented that he would follow up when needed; however, the wound care treatment should continue. A Wound Physician consult dated 11/7/2016 documented the right lower extremity wound as 3.5 cm x 4.0 cm x 0 cm. The Wound Physician documented that if a more aggressive attempt is okay with all deciding parties a trial of Aldara cream was recommended. This was the last wound consult documented by the Wound Physician. The resident was seen by a Dermatologist for the first time on 11/16/2016. The Dermatologist documented the right shin ulcer as large (greater than 4 cm) and was probable [DIAGNOSES REDACTED]. Aldara cream was recommended 5 times per week for 8 weeks. The Dermatologist documented that if the wound does not respond, may need surgical debridement in office. Review of the record revealed that the Aldara cream was ordered by the Physician and applied to the right lower extremity for 8 weeks as recommended. The order was discontinued after the 8 weeks. However, there was no further follow up with the Dermatologist as recommended by the Dermatologist and no documentation regarding the status of the right shin wound. There was no documented evidence that the family was contacted regarding treatment options. A Social Work note dated 11/21/2016 documented that there was a Guardianship Hearing in the facility with the Social Worker and Resident #65 present on 11/21/2016. The SW note documented that previous to this date the resident's son was the Health Care Proxy (HCP). The Judge revoked the son as the HCP at the 11/21/2016 hearing and the resident would be appointed a Legal Guardian to make medical and financial decisions. The social work note dated 11/21/2016 documented that the social worker was advised by the Judge to have the Wound Care Physician (identified by name) see the resident upon next visit to the facility to discuss the [MEDICAL CONDITION] and treatment options and that the resident was able to verbalize and make medical decisions at this point in time. The social worker documented that she would request the Wound Care Physician see the resident and that the nursing team and administration were aware. There is no documented evidence that a Physician discussed treatment options with the resident following the 11/21/2016 guardianship hearing. On 5/19/2017 at 1:44 PM the Director of Nursing Services (DNS) was interviewed. She stated the Dermatologist named in the order is no longer associated with the facility. She stated that another Dermatologist is needed. On 5/22/2017 at 9:43 AM the wound care RN who is also the Assistant Director of Nursing (ADNS) was interviewed. He said the wound physician would be referred to a resident with significant skin issues. He said Resident #65 is no longer seen by the wound physician. He stated that he was unaware of the directive from the 11/21/2016 Guardianship hearing requesting that a Physician discuss treatment options for the [MEDICAL CONDITION] with the resident. On 5/22/2017 at 10:57 AM the Social Worker was interviewed. She stated that she was present at the 11/21/2016 Guardianship hearing. She stated that she brought up the concern regarding the [MEDICAL CONDITION] because we were in limbo. She stated the Judge discussed the [MEDICAL CONDITION] matter with the resident and the Judge made a determination that the next step would be for the resident to express his wishes directly to a Physician regarding [MEDICAL CONDITION] treatment options. She stated that she brought this up in morning report and that the DNS and Administrator from that time period are no longer with the facility. She stated she did not speak to the wound Care Physician, and that talking to the physician was a nursing responsibility. On 5/23/2017 at 8:22 AM the Wound Care Physician was interviewed. He stated he was not made aware of the directive from the Judge regarding a Physician having a conversation with the resident regarding treatment options and that he did not have this discussion with the resident because he did not feel the resident had capacity to make medical decisions. He said the next step would have been possibly using Aldara cream as a trial or more likely plastic surgery. Review of the record revealed that there was an order for [REDACTED]. Review of the record revealed that the Dermatology consult was renewed on (MONTH) (YEAR). On 5/23/2017 at 11:04 AM the nursing secretary was interviewed regarding consults. She stated that she schedules the transportation and the appointments for the consults. She stated that she has not received any consults for Dermatology for Resident #65. On 5/23/2017 at 11:27 AM Resident #65's Attending Physician was interviewed. He stated he became the Attending Physician in (MONTH) (YEAR). He stated that he was not aware of the 11/21/2016 directive from the Guardianship Hearing to have a Physician discuss the [MEDICAL CONDITION] treatment options with the resident. He stated that it was his understanding from nursing that the resident was refusing treatment. He stated, My approach was palliative because it was my understanding that he refused all treatment. He stated he did not discuss treatment options with the resident. He stated that he was aware that the Dermatologist named in the consult order no longer worked in the facility. He stated that he did not intend for the resident to see a Dermatologist and that the order dated 4/4/2017 was a mistake. On 5/24/2017 at 2:30 PM the Medical Director was interviewed. He stated that he started working in the facility in (MONTH) (YEAR) and was not aware of the resident's situation or of the Guardianship Hearing that took place on 11/21/2016. He stated that if a resident entered the facility with [DIAGNOSES REDACTED], than the facility should act on it as quickly as possible and solicit the resident's and family's wishes immediately. On 5/24/2017 at 2:49 PM the DNS was re-interviewed. She stated that if an LPN notices a wound, the first step is to protect the wound with a dry dressing, then notify the RN supervisor. The RN will do an assessment, make notes, and then notify the Physician for treatment orders. For Resident #65, a dry dressing should be used since they [MEDICAL CONDITIONS] and the wounds should be protected. The CNAs are supposed to do body checks in the morning and they are supposed to report concerns to the nurse. 415.12

Plan of Correction: ApprovedJune 30, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F TAG 309
1- The following actions were accomplished for the resident(s) # 65
A. A body check was completed to identify all open [MEDICAL CONDITION] on body of resident #65.
B. The physician was notified of all open lesion and treatment orders were obtained 5/18/2017.
1- The following corrective action will be implemented to identify other residents who may be affected by the same practice:
- All residents with skin conditions have the potential to be affected by the practice and a body assessment was done. No further deficient practice found 6/12/2017.
2- The following system changes will be implemented to identify other residents who may be affected by the same practice:
A. The P+P for ?Skin Ulcer/Wounds? was reviewed and revised by the DNS.
- Revision include: Licensed nurses will do daily skin checks on any resident who exhibits multiple open [MEDICAL CONDITION], for new open [MEDICAL CONDITION]/scars and report to the RN for assessment and follow up treatment with physicians.
B. All licensed nurses will be in serviced on revised P+P.
C. All C.N.A?S all shifts will be in-serviced on residents with skin changes and prompt immediate reporting of any new/ worsened or open areas observed during care to the licensed nurse.
D. Licensed nurses on both units will maintain a log of all residents who require follow up appointments for dermatologists.
E. Resident seen by wound care physician. Skin [MEDICAL CONDITION] and treatment was discussed with resident as per legal court adviser.
F. 6/15/2017 Brittni(NAME)Esq. will advise when she receives commission from the judge.
3- Facility Compliance will be monitored utilizing the following QAA system:
A. An audit tool and dermatology consultant tracking form was developed by the DNS to monitor that appropriate treatment plan for all residents with open [MEDICAL CONDITION] are in place and any follow up appointments are made and monitored.
B. Audits will be completed by ADNS weekly for 4 weeks then monthly for 6 months.
- Negative findings will be referred to the DNS for immediate action.
- Lesson plan and attendance sheets on file for validation and compliance.
- Competency audits will be presented to the QAA committee for validation and compliance on 7/19/2017.
C. The DNS will be responsible for the completion of F-309 by 7/20/2017.

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews during the recertification survey, the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. This was evident for 1 of 31 Stage 2 sampled residents reviewed for Activities of Daily Living. Specifically, Resident #62 was observed to be using an oxygen concentrator adjusted to an incorrect setting. The finding is: Resident # 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment, dated 5/23/17, documented the resident's Brief Interview for Mental Status Score as 15 out of 15 indicating intact cognition. The resident is documented as receiving oxygen therapy during the last 14 days of the assessment period. The current physician's orders [REDACTED]. On 5/18/17, during an interview with the resident at 11:00 AM, the resident's Oxygen concentrator was observed to be set and running at 5 liters per minute with a nasal cannula attached to the resident's nostrils. The resident denied making any adjustment to the concentrator or being in any distress at the time of the interview. At 11:35 AM, the unit Licensed Practical Nurse was escorted to the Resident's room at which time she confirmed that the oxygen concentrator was set incorrectly. Upon interview, she stated that she should have checked the device that morning but did not. She could not recall the last time she checked it. She stated that it was the responsibility of all staff to check medical equipment, including the oxygen concentrator, during their shift. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJune 30, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F TAG 282
1- The following actions were accomplished for resident (s) #62
- At the time of the finding the resident?s oxygen changed to the correct liter setting as per the physician order [REDACTED].
2- The following corrective action will be implemented to identify other residents who may be affected by the same practice:
- All residents who utilize oxygen were identified by the DNS on 6/12/17. No further deficient practice was found.
3- The following system changes will be implemented to identify other residents who may be affected by the same practice:
- The P+P for ?Oxygen Use? was reviewed and revised by the DNS. Revisions include:
A. Orders will be obtained by the physician to include checking the oxygen setting Q Shift and deliver the oxygen as per the physician order.
B. All Licensed Nurses will be in serviced on the revised policy by the ADNS or designee 7/18/2017.
4- Facility Compliance will be monitored utilizing the following QAA system:
- An audit tool was developed by the DNS to ensure compliance with oxygen delivery rate as per physician order.
- Audits will be done weekly 4 times a week by the RN then monthly for 6 months.
- Negative findings will be referred to the DNS for immediate action.
- Lesson plan and attendance sheets on file for validation and compliance.
- Competency audits will be presented to the QAA committee for validation and compliance on 7/18/2017.
5- The DNS will be responsible for the completion of F-282 by 7/20/2017.

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.2.3.4 Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms. Based on observation and staff interview, exit access corridors on 1 of 2 floors were noted less than the required 4 foot width. The findings are: On 5/18/17 between 9:30am- 2:30pm during the recertification survey, exit access corridors on the 1st floor were noted less than the required 4 foot width. Examples are: 1) An approximately 40 inch wide corridor in the vicinity of the Director of Nursing office and the main entrance. 2) An approximately 36 inch wide corridor in the vicinity of resident room [ROOM NUMBER]W1. In an interview on 5/18/17 at approximately 9:30am, the Director of Maintenance stated that the facility was in the process of addressing the corridor width issue. 2012 NFPA 101: 19.2.3.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 23, 2017

K-232 Formerly K-039. An equivalency has been completed in accord with an approval between BAER and the Architect. The Equivalency is an additional means of egress that has been added to the corridor to allow egress from the opposite side of the corridor in question 7/20/2017.

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver (s) to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. The West Building (Old Bldg.) is two stories, fully sprinklered, and is Type V (000) construction. The building should be at least Type V (111) construction. 483.70(a), 711.2(a)(1), NFPA [PHONE NUMBER]: 19.1.6.2

Plan of Correction: ApprovedAugust 23, 2017

K-161 Formerly K-012 Building type v(000). Hilaire Rehab and Nursing is requesting that the waiver for this deficiency be extended in accord with the recommendation from the DOH Plan of correction 7/20/17.

K307 NFPA 101:DISCHARGE FROM EXITS

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

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver (s) to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. The ramp on the 2nd floor between the East and West buildings has a slope ranging from 1:8 to 1:10. Existing ramps are only permitted to be 1:10. 483.70(a)(1), 711.2(a)(1), NFPA [PHONE NUMBER]: 7.2.5.2

Plan of Correction: ApprovedAugust 23, 2017

K-271 Formerly K-038 ramp. Hilaire Rehabilitation and Nursing is requesting a continuation/renewal of the existing waiver in accord with the recommendation sited in the plan of correction 7/20/2017.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

2012 NFPA99: 6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. (110:5.6.6) 6.4.1.1.17.4 Individual alarm indication to annunciate any of the conditions listed in Table 6.4.1.1.16.2 shall have the following characteristics: (1) It shall be battery powered. (2) It shall be visually indicated. (3) It shall have additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. (4) It shall have a lamp test switch(es) to test the operation of all alarm lamps. 2011 NFPA 70: 110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. Based on observation and staff interview, the facility failed to ensure that the generator annunciator panel contained safety indication lights in accordance with Table 6.4.1.1.16.2. and was maintained in a workman like manner. The findings are: On 5/18/2017 between the hours of 9am and 3pm during the recertification survey, the following was observed: At the 1st floor nursing station, a remote annunciator for the generator was observed. When performing a lamp test, it was observed that some of the lights were not illuminated, identification of each light was not specified and 2 light bulb cover plates were missing. In an interview on 5/18/2017 at approximately 11am with the Assistant Director of Environmental Services, he stated the annunciator and generator are functioning but he is not sure what conditions are reported by the annunciator. He further stated he would have the generator company come in to look at the annunciator panel. 2012 NFPA 99 2011 NFPA 70 711.2(a)(1)

Plan of Correction: ApprovedJune 20, 2017

K-916 The director of Maintenance has ordered that Diesel Systems inspect and make any necessary Repairs to the generator alarm enunciator system. Two light bulb covers were replaced, the system was tested and signed off as fully functional in accord with 2012 NFPA 90, 2011 NFPA 70, 711.2 (a) (1)
d. The maintenance department will inspect the enunciator panel every week when performing generator testing to ensure future compliance 5/12/17.
e. The director of Maintenance will inservice the maintenance staff concerning this deficiency to prevent future occurrences 7/18/17.
f. The Director of Maintenance is responsible for correction and compliance of this deficiency K-916 by 7/20/17.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

Time Limited Waiver- Expires on 6/30/2018 The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver (s) to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. The facility was not provided with a NFPA99- Health Care Facilities and NFPA70- National Electrical Code conforming Type 3 Essential Electrical System. NFPA 99-2012 Standard for Health Care Facilities: 6.6, 6.6.2.2.3, NFPA 70-2011 National Electrical Code: Article 700, NFPA [PHONE NUMBER] Standard for Emergency and Standby Power Systems

Plan of Correction: ApprovedAugust 23, 2017

K-915 Formerly K-146 Hilaire Rehabilitation and nursing is requesting that the temporary construction waiver that is to expire on 6/30/2017 be allowed to continue to allow the necessary time to correct this deficiency 6/30/2017.

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: May 24, 2017
Corrected date: July 20, 2017

Citation Details

2012 NFPA 99: 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. Based on observation and staff interview, the facility failed to ensure that oxygen storage tanks were properly stored or supported with a cylinder stand or cart. This occurred in the basement of the facility. The finding is: On 5/18/2017 between the hours of 9am and 3pm during the recertification survey, the following was observed: In the Dentist Office in the basement of the facility, 5 E sized oxygen tanks were observed being stored on the floor without a proper stand or cart. In an interview on 5/18/2017 at approximately 11:45am with the Director of Environmental Services, he stated the tanks should not be stored in the room, will have them removed and will need to in-service staff. 2012 NFPA 99 711.2(a)(1)

Plan of Correction: ApprovedJune 20, 2017

K923 1. The Director of Maintenance has ordered that all oxygen cylinders in the dentist office that were improperly stored be moved to the oxygen storage shed and placed in
a storage location approved for compressed gasses located outside the facility 5/12/17.
2. The Director of Maintenance has ordered that the rest of the facility be inspected for deficiencies of the same practice.
a. No deficiencies of the same action were found 5/12/17.
3. The Director of Maintenance along with The Director of Nursing will in-service the entire staff including agency personnel on the proper storage of compressed gasses
In accord with NFPA 99 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 to ensure future compliance
with this deficiency. The nursing department will report any negative findings immediately to the Director of Maintenance for remediation 7/18/17.
4. On a daily basis, the Director of Maintenance/ Designee will inspect all oxygen storage areas of the building to ensure compliance. Any negative findings will be recorded and brought to the QAA committee 7/18/17.

5. The Director of Maintenance is responsible for correction and compliance of this deficiency K-923 by 7/20/17.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

2012 NFPA 101 19.2.2.2 Doors. 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted 7.2.1.5 Locks, Latches, and Alarm Devices. 7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied. 7.2.1.5.10* A latch or other fastening device on a door leaf shall be provided with a releasing device that has an obvious method of operation and that is readily operated under all lighting conditions. Based on observation and staff interview, it was determined that the facility did not ensure that egress doors were equipped with a single motion, lock releasing device. This was noted on the 1st and 2nd floors of the facility. The finding is: On 05/18/2017 at approximately 10:20am during the life safety recertification survey, it was observed that the facility ' s Nursing Supply Storage Room on the 2nd floor was provided with an egress door that contained 2 door knobs. This door locking arrangement requires two operations to unlock and open the door. The same situation occurred on the nursing supply storage room on the 1st floor. In an interview on 05/18/2017 at approximately 10:20am with the Director of Environmental Services, he stated he could replace the double handles on the door with a single key coded door lock. 2012 NFPA 101- 19.2.2.2.1, 7.2.1.5 711.2(a)(1)

Plan of Correction: ApprovedJune 20, 2017

K-211 1. The Maintenance Director ordered that one of the two locksets immediately be removed from the door located at the nursing storage area. In addition a single ADA acceptable combination hand set has been ordered and will be installed to replace the single lock set currently there. All holes created by additional locks have been sealed to maintain the integrity of code requirements 5/12/17.
2. The Maintenance Director has performed and inspection of the entire facility to identify deficiencies affected by the same practice.
a. All deficiencies affected by the same practice have been identified and corrected 5/12/17.
3. The staff responsible for installing and maintaining doors and door locks will be in-serviced as to the deficiency to prevent further occurrence of this deficiency 7/18/17.
4. On an annual basis the Director of Maintenance/Designee will inspect the entire facility to ensure compliance. Any negative findings will be presented to the QA committee.
5. The Director of Maintenance is responsible for correction and compliance of this deficiency K-211 by 7/20/17.

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: May 24, 2017
Corrected date: July 20, 2017

Citation Details

2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5.3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary. 2011 NFPA 25: 5.4.1.4* A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. 2011 NFPA 25: 5.4.1.4.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. Based on observation and staff interview, the facility did not ensure that automatic sprinkler systems are inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems in that: 1) there was no documentation provided for the annual antifreeze testing; and 2) the facility did not provide spare sprinklers of each type and temperature rating installed throughout the building. The findings are: On 5/18/17 between 9:30am- 2:30pm during the recertification survey, the following was noted: 1) An antifreeze loop was noted serving the West stair. The documentation provided by the sprinkler company indicated that the section for testing the antifreeze system was checked off as not applicable. In an interview on 5/18/17 at approximately 12:30pm, the Director of Environmental Services stated that he would call the company. 2) The facility did not provide spare sprinklers of each type and temperature rating installed throughout. Dry sidewall sprinklers were observed in the walk-in refrigerator and freezer in the kitchen. The facility lacked spare dry sidewall sprinklers. In an interview on 5/18/17 at approximately 12:16pm, the Director of Environmental Services stated that they would get the spares. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.4, 5.4.1.4, 5.4.1.4.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJune 20, 2017

K-353 1. The Director of Maintenance has ordered Apollo Sprinkler Company to Immediately inspect the anti freeze loop and include this inspection with the contracted quarterly inspections going forward 5/12/17.
2. The Director of Maintenance has ordered Apollo Sprinkler Company to provide a dry spare sidewall sprinkler head in accord with 2012 NFPA 101:9.7.5, 2011 NFPA 25:5.3.4,
5.4.1.4, 5.4.1.4.1 10 NYCRR 7112 (a) (1)
a. The maintenance Director will inspect work tickets from the sprinkler vendor as well as the spare head location quarterly to ensure future compliance.
b. The director of Maintenance will in-service the maintenance staff concerning this deficiency to prevent future occurrences 7/18/17.
c. The Director of Maintenance is responsible for correction and compliance of this deficiency K-353 by 7/20/17.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 24, 2017
Corrected date: July 20, 2017

Citation Details

2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2010 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. Based on observation and staff interview, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on two of two floors of the facility. The findings are: On 5/18/2017 between 9am- 2pm during the recertification survey, fire-rated doors were not provided with legible fire-rated labels and/or lacked fire-rated labels. Examples include but are not limited to: 1) Smoke barrier doors on floors 1 and 2 lacked fire rating labels 2) Exit door #16 label was illegible In an interview on 5/18/17 at approximately 10:00am, the Director of Environmental Services stated the building is very old and they may have to have a company recertify the doors. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105 2010 NFPA 80 711.2(a)(1)

Plan of Correction: ApprovedOctober 18, 2017

K- 374 Hilaire Rehabilitation and nursing wishes at this time to request a temporary construction waiver to allow adequate time to research a repair or a replacement of the doors in question, to bid on the remediation work and final certification 7/18/17




























10/30/17