United Helpers Nursing Home
May 2, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(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: §483.80(a)(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; §483.80(a)(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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(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: May 3, 2018
Corrected date: July 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 1 of 3 residents (Resident #2) reviewed for blood glucose monitoring, the facility did not ensure the facility established and maintained an infection prevention control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the glucometer (used to monitor blood glucose) was not disinfected after use and was not placed on a barrier. Findings include: The 04/04/14 Cleaning and Disinfecting Shared Equipment policy documented it was the policy of the facility to ensure that staff clean and disinfect shared equipment including glucometers. The glucometer was to be cleaned and disinfected after each use. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. The 04/18/18 revised comprehensive care plan (CCP) documented the resident had diabetes requiring insulin therapy. Interventions included to monitor blood sugars as ordered. During an observation on 05/01/18 at 03:48 PM, LPN #8 gathered the supplies and placed them on top of the medication cart, washed her hands and put on gloves. She entered the resident's room and placed the glucometer and supplies on top of the resident's dresser. She performed the blood sugar test, exited the room, placed the glucometer on top of the medication cart without using a barrier, removed her gloves, unlocked her medication cart, and placed the glucometer in the top drawer of the medication cart without disinfecting the glucometer. She stated she had no more blood sugar tests that shift, and the resident did not need insulin coverage per the sliding scale. On 05/03/18 at 09:25 AM, registered nurse (RN) Unit Manager #9 stated she expected staff to wipe the glucometer with disinfectant prior to entering the room, place it on a barrier on top of the cart, gather supplies, set the glucometer on a barrier in the room, perform the blood sugar test, gather and discard used supplies, wipe the glucometer with disinfectant and return it to the cart. She stated the glucometer was to be disinfected prior to and after each use, and it was an infection control issue if not done. On 05/03/18 at 11:37 AM, Infection Control Nurse #10 stated she expected the glucometer to be disinfected by staff prior to and after each use to prevent the spread of disease and for infection control purposes. She expected staff to disinfect the glucometer prior to setting it down on top of a medication cart after using it, and she would expect them to disinfect the surface they set it on if they did not. She stated competencies were done yearly and as needed by the RN Unit Manager, Infection Control Nurse and the Staff Educator. On 05/03/18 at 12:20 PM, the Director of Nursing (DON) stated she expected the glucometers to be disinfected at a minimum after each use and before putting it back in the cart, and would like them disinfected before and after each use for infection control purposes. 10 NYCRR 415.19 (a)(1-3)(b)(1)

Plan of Correction: ApprovedMay 16, 2018

1.What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Resident #2?s nurse responsible for blood sugar monitoring on 5/1/2018 will receive directed education related to infection control and proper disinfection of glucometers, and will complete a Medication Administration competency to demonstrate proper technique.
2.How you identify other residents having the potential to be affected by the same deficient practice:
All residents who require blood glucose testing with a glucometer have the potential to be affected.
3.What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The policy for glucometer cleaning and disinfection was reviewed and no revisions were required. A competency was developed to use when evaluating compliance and proper infection control practice during glucometer blood glucose testing. Education will be completed for all licensed nursing staff on proper infection control technique. Each unit will have monthly audits x 3 for proper infection control technique when using glucometers to include proper disinfecting and use of a barrier.

4.How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
Monthly audits x 3 on each unit for each medication cart (5 units with 2 medication carts each), then monthly audits on 5 nurses x 3 months facility wide, then quarterly and as needed. Any licensed nurse that is not in compliance on audits will be retrained immediately and corrected to prevent the spread of infection.
5.Responsible Party: Director of Nursing.
6. Compliance date 07/01/2018

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 1, 2018

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not ensure a safe, homelike environment for residents in 5 isolated areas (Newell unit ice machine countertop, Bosworth unit ice machine countertop,(NAME)unit ice machine countertop, and Milligan unit ice machine countertop and Claxton kitchenette baseboard). Specifically, the above-mentioned area countertops and baseboard were in disrepair/damaged. Findings include: On 05/01/18 at 11:56 AM, a surveyor observed the(NAME)Unit ice machine countertop wood back splash was loose/damaged. On 05/01/18 at 12:13 PM, a surveyor observed the Bosworth Unit ice machine countertop wood back splash was loose/damaged. On 05/01/18 at 12:17 PM, a surveyor observed the(NAME)Unit ice machine countertop wood back splash was loose/damaged. On 05/01/18 at 05:03 PM, a surveyor observed the Milligan Unit ice machine countertop was damaged. On 05/02/18 at 12:05 PM, the Claxton kitchenette had the baseboard peeling near the sink next to the steam table. During an interview on 05/02/18 at 09:20 AM, the Administrator stated the facility did not have any work orders for the broken wood back splashes or the broken countertop. Work orders were created to repair these items on 05/01/18. 10 NYCRR 415.29(j)(1)

Plan of Correction: ApprovedMay 16, 2018

1.What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
The loose/damaged back splashes in the(NAME) Bosworth, and Knap kitchenettes were repaired by securing to the wall and caulking the edges.
The loose wood trim on the countertop of the Milligan neighborhood was secured to the counter and the edges were caulked.
The baseboard in the Claxton kitchenette will be replaced from the sink to the steam table.
2.How you identify other residents having the potential to be affected by the same deficient practice:
All kitchenettes are at risk for damaged counters and baseboards due to heavy use.
3.What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
All kitchenettes will be inspected for damaged counters and baseboards.
Work orders will be generated for all necessary repairs and will be systematically corrected. Food Service staff education will be performed regarding completion of work orders.
4.How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
The sanitation audit for the kitchenettes has been revised to include monitoring of damaged counters and baseboards. This will be conducted monthly for 3 months, then quarterly thereafter until the deficient practice has been corrected. Work orders will be generated for any identified repairs needs from the audit. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5.Responsible Party: Director of Food Service

6.Compliance date 07/01/2018

4FGA 400.12:SCREEN FORM.

REGULATION: NOTE: See Official Compilation for copy of Form DOH 695 (4/93). Title of form is "SCREEN". To view a copy of the "SCREEN" form, contact the NYS Department of Health, Division of Health Care Financing, Bureau of Financial Management and Information Support, Empire State Plaza, Room 984, Albany, New York 122 37 (518) 474-1673.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 3, 2018
Corrected date: July 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure that a screening assessment was conducted related to determination of services for possible intellectual disability as documented on the DOH-695 (February 2009) New York State (NYS) Screen Form, for 1 of 1 resident (Resident #126) reviewed for Pre-Admission Screening and Resident Review (PASRR). Specifically, Resident #126 did not have a qualified DOH 695 screen completed prior to admission. Findings include: The 03/07/12 revised PRI (Patient Review Instrument)/Screen Requirements facility policy documented a screen form may only be completed by health care professionals who have completed a New York State Department of Health (NYSDOH) Screen certification course and been issued a screener identification number, and the qualified screener was responsible for periodically checking the NYSDOH website and for updates to the screen and instructions. The policy documented the screen was needed when the resident was to be admitted for a stay longer than 30 days, and the transferring facility was responsible for ensuring the most recent screen accompanied the resident. The policy documented interfacility transfers require the most current PASRR screen accompany the resident to the new facility, and non-NYS facilities may substitute their state equivalent of the NYS screen. Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 03/27/18 Minimum Data Set (MDS) Assessment documented the resident had moderately impaired cognition and was admitted from another facility. The 02/16/11 Michigan Preadmission Screening (PAS) Form for mental illness/Intellectual Disability, DCH-3877 (REV. 8-17), included that the resident had no serious mental illness or intellectual disability. The form did not include a qualified New York State screener identification number. On 05/03/18 at 11:03 AM, social worker #11 stated she would know if a resident had a serious mental illness or developmental disabilities by asking family, hospital, or the psychiatric facility. She stated she would also know from the PASRR screen and [DIAGNOSES REDACTED]. She was not sure what was required if the resident came from out of state and thought a PASRR from another state was acceptable as that would document if services were needed, and what kind were needed. She stated Admissions checked for PASRR prior to admission and passed the information to social services and other staff. Social services was responsible to ensure the PASRR was accurate and appropriate, and would ensure recommendations were accurate, still needed, and in place for the resident. On 05/03/18 at 12:08 PM, the Director of Social Services stated a PASRR from a facility in another state would be acceptable as the process and information was the same, just on a different form done by a qualified screener. She stated she was a qualified screener, and was not sure what NYS regulations were regarding that, but the facility had accepted them since she had been employed there. She stated each PASRR needed a qualified screener number at the end of the screen. She stated the resident came to this facility from another local nursing home and from Michigan before that. She stated the resident did not have a mental illness or developmental disability. On 5/3/2018 at 12:20 PM, the Director of Nursing (DON) stated social services was responsible for review of PASRR screens. 10NYCRR 415.11(e)

Plan of Correction: ApprovedMay 16, 2018

1.What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
A new DOH 695 screen was completed by a qualified screener for Resident #126.
2.How you identify other residents having the potential to be affected by the same deficient practice:
All residents were reviewed to determine if screens were appropriately completed by a NYS qualified screener. No further residents were identified.
3.What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur:
The policy regarding PRI/Screen requirements has been revised to reflect that all residents admitted from outside of New York State will have a Screen completed upon admission by a NYS qualified screener. Social service and admissions staff will be educated on the revised policy.

4.How the corrective actions(s) will be monitored to ensure the deficient practice will not recur:
An audit will be developed to monitor PRI/Screen completion with all new admissions to ensure it was done by a NYS qualified screener. The audit will be completed monthly x 3, then quarterly thereafter until the deficient practice has been corrected. Results of the audit will be reported to and evaluated by the QAPI Committee on a quarterly basis.
5.Responsible Party: Director of Social Services
6. Compliance date 07/01/2018

Standard Life Safety Code Citations

K307 NFPA 101:ELEVATORS

REGULATION: Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 2, 2018
Corrected date: July 1, 2018

Citation Details

Based on observation and interview conducted during a Life Safety Code survey, the facility did not ensure the building elevators were inspected and tested , in accordance with ASME A17.1, Safety Code for Elevators and Escalators, for 3 of 3 elevators (two elevators near the entrance of the facility, and the service elevator). Specifically, the above mentioned building elevators were not in compliance with ASME A17.1. Findings include: On 04/30/18, between 02:00 PM and 05:45 PM a surveyor observed the facility had three elevators. Two were near the entrance of the facility, and one was the service elevator. During an interview on 05/02/18 at 09:31 AM, the Administrator stated the facility did not have ASME 17.1 elevator inspection/testing records for any of the facility elevators. A third party vendor had been due to complete this test in 10/2017. 2012 NFPA 101: 19.5.3, 9.4 2007 Ed. ASME A17.1 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 30, 2018

PLAN FOR AFFECTED RESIDENTS:
No residents were affected.
HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN:
All residents have the potential to be affected.
MEASURES/SYSTEMIC CHANGES TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR/MONITORING OF CORRECTIVE ACTIONS:
All three elevators received a ASME 17.1 elevator inspection on 5/9/18.
The required inspections will be scheduled annually as part of the Preventative Maintenance record for all three elevators. The Director of Buildings and Grounds and Maintenance Coordinator will be educated on the requirement of maintaining records of annual ASME 17.1 inspections. The Administrator or designee will review records for compliance semi-annually until deficient practice has been corrected.
RESPONSIBLE PARTY:
Director of Buildings and Grounds

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 2, 2018
Corrected date: July 1, 2018

Citation Details

Based on observation and interview conducted during a Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 6 of 6 emergency exit stairways (B/J stairway #1, C/F stairway, E/H stairway, D/G stairway, B/J stairway #2, and administration stairway), in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 and 8.15.3.2.1. Section 8.3.3.2 states: Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Section 8.15.3.2.1 states: In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. Specifically, the B/J emergency exit stairway #1, C/F emergency exit stairway, E/H emergency stairway, D/G emergency exit stairway, and B/J emergency exit stairway #2 contained both quick response sprinkler heads and standard response sprinkler heads; and the administration emergency exit stairway was not fully sprinklered. Findings include: 1) Mixed Sprinkler Heads On 04/31/18 at 02:00 PM, a surveyor in the B/J emergency exit stairway #1 observed basement through second floor contained 1 quick response head and 2 standard response sprinkler heads. On 04/31/18 at 03:42 PM, a surveyor in the C/F emergency exit stairway observed basement through second floor contained 3 quick response heads and 1 standard response sprinkler head. On 04/31/18 at 03:50 PM, a surveyor in the E/H emergency exit stairway observed basement through second floor contained 3 quick response heads and 1 standard response sprinkler head. On 05/01/18 at 10:15 AM, a surveyor in the D/G emergency exit stairway observed basement through second floor contained 3 quick response heads and 1 standard response sprinkler head. On 05/01/18 at 10:20 AM, a surveyor in the B/J emergency exit stairway #2 observed basement through second floor contained 2 quick response heads and 1 standard response sprinkler head. During an interview on 05/02/18 at 02:10 PM, the Director of Maintenance stated he was aware of the physical differences between quick response sprinkler heads and standard response sprinkler heads, and was aware the above mentioned stairways contained both quick response and standard sprinkler heads. He stated he thought it was acceptable as the sprinkler heads were rated for the same temperature. He planned on replacing the standard heads later this year, and there was no paperwork documentation to verify that. 2) Missing Sprinkler Head On 05/01/18 at 10:25 AM, a surveyor in the administration emergency exit stairway observed a quick response sprinkler head on the second floor landing. The landings for the first floor and basement lacked sprinkler coverage. During an interview on 05/02/18 at 09:31 AM, the Administrator stated he called a third party vendor to verify if the single head on the second floor landing of the administration emergency exit was allowed by code. He could not verify that this single sprinkler head met code requirements for sprinklering in a stairway. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 30, 2018

PLAN FOR AFFECTED RESIDENTS:
No residents were affected.
HOW YOU WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTION WILL BE TAKEN:
All residents have the potential to be affected.
MEASURES/SYSTEMIC CHANGES TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT RECUR/MONITORING OF CORRECTIVE ACTIONS:
Administration stairway: A sprinkler head will be installed under the first accessible landing above the bottom of the shaft.
Remaining stairwells (B/J #1, B/J #2, C/F, E/H, D/G): All standard response sprinkler heads will be replaced with quick response sprinkler heads.
The rest of the facility will be assessed by the Director of Buildings and Grounds for mixed or missing sprinkler heads and will be systematically corrected if identified. Third party vendor performing sprinkler testing will be informed of deficiency and instructed to assess for mixed/missing sprinkler heads during visual inspections at least annually.
RESPONSIBLE PARTY:
Director of Buildings and Grounds