Edna Tina Wilson Living Center
August 30, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.25(h):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2016
Corrected date: October 28, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined that for one (Resident #50) of five residents reviewed for accidents, the facility did not ensure that the resident received adequate supervision to prevent accidents. The issue involved a lack of a timely response to a resident's bathroom call bell light resulting in the resident self-transferring and falling. This is evidenced by the following: Resident #50 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/2/16, revealed that the resident has moderately impaired cognitive skills for daily decision making, and requires extensive one person physical assistance for toileting and transfers. The current Comprehensive Care Plan for falls includes to take the resident to the toilet as requested, do not leave the resident alone on the toilet, and if the resident attempts to toilet herself, intervene right away. The fall assessment, dated 7/26/16, identified the resident as a high risk for falling. A nursing progress note, dated 8/13/16, documented that the resident was found on the floor in the bathroom in front of the toilet. The resident said she slipped. An Incident/Accident Report, dated 8/13/16, revealed the resident self-transferred to the toilet and was at risk for falling. CNA #1's Investigation Statement Form, dated 8/13/16, documented that she looked at her pager and noticed the bathroom emergency call bell light was on for this resident. At the time, she was in the dining room getting drinks ready for dinner. When she saw the light on, she went to the resident's room and the resident was on the floor. Licensed Practical Nurse (LPN) #1's Investigation Statement Form, dated 8/13/16, documented that she was called to the room by CNA #1, who went to the room to answer the call bell light. Comments on the Incident/Accident Report, dated 8/19/16 by the Registered Nurse Manager (RNM), include that staff encouraged the resident to call for assistance and wait for staff to respond. The resident was also reminded that she had falls in the past when she did not wait for help. The area on the form asking, Was anything learned from this event that could have prevented this fall? was blank. The Fall Debriefing Tool, dated 8/19/16, revealed the resident did not wait for staff to help her to the bathroom. Immediate actions taken to prevent recurrence/protect the resident included to encourage her to wait and call for help. An Individual Account Report sheet that tracks the call bell response time revealed the resident's bathroom emergency call bell light was on 8/13/16 from 4:23 p.m. to 4:39 p.m., a period of approximately 16 minutes. During an interview on 8/26/16 at 7:40 a.m., the resident said during the night she has turned on the call bell light many times and asked staff to change her because she was wet. She said staff say, We already changed you/you can't be wet. The resident said sometimes staff just turn the call bell light off, and sometimes they change her. The resident said at times during the day, she has turned the call bell light on and no one responds. The resident said when this happens, she just toilets herself even though staff do not want her to. She said she just does not bother to turn the call bell light on anymore. An observation made at that time with the primary Certified Nursing Assistant (CNA) revealed the resident had a wet brief. Interviews conducted on 8/30/16 included the following: a. At 11:11 a.m., the Assistant Director of Nursing said the expectation for answering a call bell was ten minutes or less, and the bathroom/emergency light would be five minutes. She said they teach this to the staff in orientation. b. At 11:20 a.m., LPN #2 said the expectation for answering a call bell in the room or the bathroom is one minute. She said whenever a resident puts the call bell on and the CNAs do not respond, it indicates this on the nurses' pagers. LPN #2 said she did not know the timeframe involved before the call bell alert is sent to the nurses' pagers. c. At 11:23 a.m., CNA #2 said the expectation for answering a call light is one to three minutes, which she learned when she was hired. She said the facility also has a no pass zone, which means no one is to walk by a call bell light and anybody can answer the light. She stated an emergency/bathroom call bell light should be answered right away. She said everyone including the nurse gets the page at the same time. CNA #2 said if a call bell is not answered within 15 minutes, it kicks off to the administrative office. d. At 12:31 p.m., the RNM said she tries to get all of the employee statements and reads them before she writes comments or recommendations on the Incident/Accident Reports. After reviewing the CNA statement, she said she was not aware the resident had bathroom call bell light on when she fell or that the call bell light was on for 15 minutes. e. At 3:15 p.m., CNA #1 said normally the pager vibrates and also rings, but the pager that she had only vibrated. She remembers answering the page soon after she felt it vibrate, however, she said she may not have felt it vibrate right away, as she was in motion in the dining room. When she got to the resident's room, the resident was on the floor. She turned off the ringing bathroom call bell light, and went to get the nurse. She said she was not aware the call bell had been ringing for 15 minutes or so. The facility's policy, Center for Aging and Continuing Care Services Standards of Practice, used for teaching new employees, includes to answer all call lights promptly, with a goal for call lights to be answered within ten minutes. (10 NYCRR 415.12(h)(2))

Plan of Correction: ApprovedSeptember 22, 2016

F323 (h) FREE OF ACCIDENTS HAZARDS/SUPERVISION/DEVICES
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Resident #50 was assessed and care card and care plan updated to reflect high fall risk during toileting needs.
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. Care cards will be updated to identify resident at high risk for falling
2. High risk for falls will be placed in the unit assignment book
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. The policy was reviewed and updated as needed.
2. Nursing staff will be in-serviced on Center for Aging and Continuing Care Services Standards of Practice which include call light response
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to DON/designee who will review results at the quarterly Quality Improvement Committee meeting. The Quality Improvement Committee will determine length of audits.
Overall Responsibility:
1. DON/Designee

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must 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. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2016
Corrected date: October 28, 2016

Citation Details

Based on observations and interviews, it was determined that for one of three residential units, the facility did not maintain infection control procedures to provide a sanitary environment to help prevent the development and transmission of disease and infection. The facility did not follow appropriate standard precautions that includes cleaning the resident's equipment or items in the environment likely to have been contaminated with infectious fluids or other potentially infectious matter. Specifically, a soiled shower chair and doorjamb. This is evidenced by the following: During an observation on 8/26/16 at 2:06 p.m., a shower chair on the Mission Unit was visibly soiled with brown spots on the footrest and in a track under the seat. Under the chair seat was orange colored debris and orange rings around the joints. In addition, the doorjamb to the tub room had a dry brown smeared substance approximately 2 inches wide at eye level. Interviews conducted on 8/29/16 included the following: a. At 2:12 p.m., a Certified Nursing Assistant (CNA) said he cleans the shower chairs with a bleach wipe. Sometimes housekeeping cleans the chair. He looked at the chair and said this one needs to be cleaned. b. At 2:26 p.m., the Nurse Manager (NM) and the Licensed Practical Nurse (LPN) were shown the soiled shower chair. The LPN tried to wipe the chair with water and was unable to remove the brown debris on the footrest. When the NM used a bleach wipe, she was able to remove some of the spots on the footrest and the orange buildup on one of the joints. When asked what the brown substance was, the LPN said she knew what it looked like on the footrest but did not want to say. The NM was shown the brown smeared substance on the doorjamb to the tub room. She said, Oh no. When asked what the brown substance was, she said, We both know what it is, but I'm not going to say. She then took a bleach wipe, and the substance was removed from the doorjamb. When interviewed on 8/30/16 at 8:41 a.m., the Director of Nursing (DON) said the bleach wipes are used for cleaning the shower chairs. She said they are currently working on revising the equipment cleaning policy. When interviewed on 8/30/16 at 10:57 a.m., Environmental Services Manager said that the Nursing Department is responsible for the cleaning of shower chairs. He said the chairs can be powerwashed if nursing lets them know. (10 NYCRR 415.19(b))

Plan of Correction: ApprovedSeptember 22, 2016

F441 483.65 INFECTION CONTROL, PREVENT SPREAD, LINENS
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Shower chair was power washed on 8/29/2016.
2. Door jam was disinfected with bleach on 8/29/2016
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. The neighborhood CNA assignment sheets will be updated to include cleaning of shower equipment
2. Environmental services will verify on a daily basis the shower rooms/equipment for cleanliness. Equipment will be power washed by environmental services if visibly soiled.
3. Environmental services will power wash all shower equipment on a routine schedule
4. Cleaning guidelines will be posted in the shower rooms.
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. The policy will be reviewed and revised as necessary
2. Staff will be inserviced on the Cleaning and Disinfection of Equipment Policy
3. Staff will be inserviced on the new CNA assignment sheets
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to DON/designee who will review results at the quarterly Quality Improvement Committee meeting. The Quality Improvement Committee will determine length of audits.
Overall Responsibility:
Responsible Person: DON/Designee

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2016
Corrected date: October 28, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #113) of one resident reviewed for abuse, the facility did not thoroughly investigate an incident to rule out abuse, neglect, or mistreatment. The issue involved lack of a thorough investigation of an unwitnessed fall. This is evidenced by the following: Resident #113 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/9/16, described the resident's cognitive status as moderately impaired and totally dependent with one assist for bathing. The current Comprehensive Care Plan included that the resident is at risk for falls and requires assistance of one to complete bathing. A Safety Portal Incident/Accident Report, dated 6/10/16, revealed that the resident was found on the floor while assisted by a Certified Nursing Assistant (CNA). The CNA's statement documented that she was with the resident, turned to get some towels, and when she turned back, the resident was on the floor with the shower chair over her. During an interview on 8/26/16 at 10:47 a.m., the Nurse Manager (NM) said the resident had a fall on 6/10/16 in the evening, where the resident was found on the floor in the shower room doorway. She said the resident attempted to self-transfer herself and was not given a shower. When she reviewed the Health Care Safety Portal Report with the surveyor, it was documented that the resident was receiving a shower and was not left unattended when she fell . The CNA turned to get towels and the resident was found on the floor. When the NM was asked if the resident was left unattended in the shower room, she responded, No. It is documented that the CNA turned her back but it does not say she left. The surveyor and NM entered the shower room, at which time the NM demonstrated how she thought the fall happened and estimated the distance between the CNA and resident to be 2 feet. The NM stated she did not question the CNA regarding the incident. Interviews conducted on 8/26/16 included the following: a. At 11:28 a.m., CNA #1 said the resident is an extensive assist for all cares. She said sometimes the resident tries to get out of the chair when she is upset. b. At 2:06 p.m., CNA #2 said she provided care for this resident on 6/10/16. She said when she completed the shower, she wheeled the resident to the shower room doorway and turned to get a towel. She said when she turned back, the resident was on the floor with the shower chair over her. CNA #2 demonstrated what happened in the shower room and stated she turned her back to get a towel and then went into the tub room to get the resident's lotion that was located in a closet in the corner. She said while retrieving the lotion, she heard the resident fall. She said the resident was not within her sight, and she was unsure how long it took her to get the lotion. CNA #2 said when she returned from the closet in the tub room, the resident was on the floor. The facility's policy, Event Accident and Incident Investigaton, currently in place, directs staff to make every effort to determine the cause of each accident or event and to put measures in place in an attempt to prevent reoccurence. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedSeptember 22, 2016

F225 M 483.13(c)(1)(ii)-(iii), (c)(2)-(4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS
What Corrective Action will be accomplished for any residents/areas affected by the deficient practice.
1. Resident #113 was assessed and care plan updated in regards to falls.
How the facility will identify other residents/areas that could potentially be affected by the deficient practice and what corrective action will be taken:
1. Fall incident reports will be placed on the 24 hour nursing report sheet
What measures that will be put into place or systemic changes made to ensure that the deficient practice will not recur:
1. Fall incident reports will be reviewed by nursing administration on a routine basis
2. Fall incident reports will be kept in the nursing administration office
3. The Incident reporting policy will be reviewed and revised to include re-enactment of the scene if appropriate
4. Nursing will be in serviced on the updated policy
How will the corrective action will be monitored to ensure the deficient practice will not recur and the title of person responsible:
1. The compliance will be monitored through audits on an ongoing basis. Copies of audit checks will be submitted to DON/designee who will review results at the quarterly Quality Improvement Committee meeting. The Quality Improvement Committee will determine length of audits
Overall Responsibility:
Responsible person: DON/Designee

FF09 483.12(b)(1)&(2):NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR

REGULATION: Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2016
Corrected date: October 28, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 370), it was determined that for one (Resident #89) of two residents reviewed for transfer and discharge notification, the facility did not provide the resident's representative with a written notice of the bed hold policy at the time of transfer. This is evidenced by the following: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated Admission Agreement revealed that the representative desired a bed hold (payment of the facility's daily rate to hold a bed) if the resident was to be away from the facility. Review of a progress note, dated 6/26/16, revealed that the resident was transferred to the hospital due to mental health concerns. Review of the medical record revealed no documented evidence that the resident's representative was provided a notice of the bed hold policy when the resident was sent to the hospital on [DATE]. When interviewed on 8/29/16 at 3:51 p.m., the Social Worker (SW) said that the facility SW provides the Discharge/Transfer Notice, which includes the bed hold policy, to the resident and representative if the resident is discharged from the facility. She said if the resident goes to the hospital, the Admission Department at the hospital provides the verbal and written notice to the representative. Interviews conducted on 8/30/16 included the following: a. At 10:21 a.m., the resident's representative said when she contacted the facility regarding the resident's return to the facility, she was told that they could no longer meet the resident's needs. She said she was not provided any written or verbal notice of the bed hold status. She said that she would have preferred the resident return to the same facility when he was discharged from the hospital. b. At 12:04 p.m., the Admission Coordinator said she does not provide a written bed hold notice to the resident or representative. She said if a resident is a private pay, then she will call the representative within 24 hours of hospitalization to determine if they want to continue to pay privately for a bed hold. She said there is no process in place to document that the phone call was made, and she does not give a written discharge notice which addresses bed holds. c. At 12:39 p.m., the Acting Director of Nursing said a Transfer/Discharge Notice could not be found for the resident. The facility's policy, Transfer and Discharge Requirements, dated (MONTH) 2012, included that the Nursing Supervisor/Charge Nurse would provide written notice of the discharge/transfer using the Discharge/Transfer Notice to the resident/designated representative upon transfer or discharge. If the individual's bed hold status requires clarification, status pending will be indicated. If the Discharge/Transfer Notice was unable to be issued at the time of the transfer or discharge, and/or if the bed hold status requires clarification, the Patient Accounting Office will contact the designated representative, clarify the individual's bed hold status, and complete the Discharge/Transfer Notice and send it to the designated representative. (10 NYCRR 415.3(h)(4)(i)(a))

Plan of Correction: ApprovedSeptember 23, 2016

F 205 Notice of bed-hold Policy before/upon transfer
Based on interviews and record reviews conducted during the recertification survey and complaint investigation (NY 370) it was determined that one of two residents reviewed for discharge and transfer did not receive a written notice of the bed hold policy at the time of the transfer.
A notice of bedhold was provided to the resident's representative (#89) via certified mail on 9/20/16.
For other residents affected by this, a notice of bedhold will be given verbally at the time of transfer to the responsible party, followed by a written notice of bedhold that will be sent via certified mail.
Date of completion:9/19/16
Edna Tina(NAME)will also be reviewing and revising our written policy and procedure regarding notice of bedhold to ensure our process is compliant.
Date of completion: 10/24/16
An audit tool will be developed to review that all discharged residents received notification of bedhold. The results of this audit will be reported at the quarterly quality assurance committee meeting. Notice of bedhold notification will also be reviewed twice monthly during the hospital readmission review by the Medical Director, Director of Social Work, and Director of Nursing.
The Director of Social Work is responsible for monitoring this plan of correction.
Date of completion: 10/28/16
Person responsible for this plan of correction is the Director of Social Work

FF09 483.12(a)(4)-(6):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2016
Corrected date: October 28, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 370), it was determined that for one (Resident #89) of two residents reviewed for transfer and discharge notification, the facility did not provide the resident's representative with a notice of transfer/discharge and the reason for the move in writing and in a language and manner they understand. Specifically, the resident's representative was not provided a written notice of transfer/discharge when the resident was sent to the hospital. This is evidenced by the following: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a progress note, dated 6/26/16, revealed that the resident was transferred to the hospital due to mental health concerns. Review of the medical record revealed no documented evidence that the resident's representative was provided a discharge or transfer notification when the resident was sent to the hospital on [DATE]. When interviewed on 8/29/16 at 3:51 p.m., the Social Worker (SW) said that the facility SW provides a Discharge/Transfer Notice to the resident and representative if the resident is discharged from the facility. She said a copy of the notice is then scanned into the computerized medical record. The SW said when the resident goes to the hospital, the Admission Department at the hospital provides the verbal and written discharge or transfer notice to the representative. Interviews conducted on 8/30/16 included the following: a. At 10:21 a.m., the resident's representative said when she contacted the facility regarding the resident's return to the facility, she was told that they could no longer meet the resident's needs. She said she was not provided any written or verbal notice of her appeal rights upon transfer/discharge. She said that she would have preferred the resident be returned to the same facility when he was discharged from the hospital. b. At 12:04 p.m., the Admission Coordinator said she does not provide a written transfer/discharge notice to the resident or representative. c. At 12:39 p.m., the Acting Director of Nursing said a transfer/discharge notice could not be found for the resident. Review of the facility's policy, Transfer and Discharge Requirements, dated (MONTH) 2012, included that the Nursing Supervisor/Charge Nurse would provide written notice of the discharge/transfer using the Discharge/Transfer Notice to the resident/designated representative upon transfer or discharge. If the Discharge/Transfer Notice was unable to be issued at the time of the transfer or discharge, the Patient Accounting Office will contact the designated representative and complete the Discharge/Transfer Notice and send it to the designated representative. (10 NYCRR 415.3(h)(1)(iii)(a-c)(v)(ab))

Plan of Correction: ApprovedSeptember 22, 2016

F 203
Notice Requirements before transfer/discharge
As part of interviews for our recertification survey and complaint investigation (#NY 370), it was determined that for one (resident #89)of two residents reviewed for transfer and discharge notification, the facility did not provide the resident's representative with a notice transfer/discharge and the reason for the move in writing.
A notice of discharge/transfer/bedhold was provided to the resident's representative (#89) via certified mail on 9/20/16.
For other residents affected by this, a notice of discharge/transfer is being given verbally at the time of transfer to the responsible party, followed by a written notice of discharge/transfer/bedhold that is being sent via certified mail to the resident and/or resident representative.
Date of completion: 9/19/16
Edna Tina(NAME)will also be reviewing and revising our written policy and procedure regarding transfer/discharge and notice of bedhold to ensure the process is compliant.
Date of completion: 10/24/16
An audit tool will be developed to review that all discharge residents received compliant notification of transfer/discharge and bedhold. The results of this audit will be reported at the quarterly quality assurance committee meeting. Notice of discharge/transfer and bedhold notification will also be reviewed twice monthly during the hospital readmission review by the Medical Director, Director of Nursing, and Director of Social Work.
Date of Completion: 10/28/16
The Director of Social Work is responsible for this plan of correction.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2016
Corrected date: October 24, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for three (Victorian, Mission, and Country Unit) of three resident units and one of one service wing, the facility did not properly maintain the sprinkler system. Specifically, sprinkler heads had foreign material on them, items were secured to sprinkler piping, there was storage within 18 inches of a sprinkler, and there was not at least a 1-inch clearance between the sprinkler deflector and the ceiling. The findings are: 1. Observations in the presence of the Director of Facilities on 8/24/16 from 9:35 a.m. to 11:25 a.m. revealed the following: a. The sprinkler head in the enclosure for the trash/linen/clothing bin outside Resident room [ROOM NUMBER] (Victorian Unit) had an accumulation of dust and debris on it. b. There was a piece of pink plastic partially covering and hanging from the deflector of a sprinkler head in room [ROOM NUMBER] (Depot) on the Country Unit. c. There was storage of packages of briefs to within approximately 6 inches of a recessed sprinkler head in the closet in room [ROOM NUMBER] (Bathing Suite) on the Country Unit. d. The sprinkler head located in the entry way of Resident room [ROOM NUMBER] (Mission Unit) extended down approximately 1/4 to 1/2 inch below the level of the ceiling. e. There was clear plastic tubing secured to sprinkler piping with zip-ties and located just outside the generator room (Service Wing). In an interview at that time, the Director of Facilities stated that it was a condensate line and was put in approximately three weeks ago. 2. Observations above the suspended ceiling on 8/25/16 at approximately 8:55 a.m. revealed a large wire bundle was supported by sprinkler piping using zip-ties and located in the corridor outside Resident room [ROOM NUMBER] (Mission Unit). 3. Observations above the suspended ceiling on 8/25/16 at approximately 9:20 a.m. revealed four large green wires were secured to sprinkler piping using zip-ties and located outside room [ROOM NUMBER] (Service Wing). The 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, states that under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 inch. The clearance between the deflector and the top of storage shall be 18 inches or greater. The 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, states sprinklers shall be free of corrosion, foreign material, paint, and physical damage. Sprinkler piping shall not be subject to external loads by materials either resting on the pipe or hung from the pipe. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.7.6, 4.6.12.1; 1999 NFPA 13: 5-6.4.1.1, 5-6.6; 1998 NFPA 25: 2-2.1.1, 2-2.2)

Plan of Correction: ApprovedSeptember 21, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 602 Life Safety Code
a. The sprinkler head in the enclosure for the trash/linen/clothing bin outside resident room [ROOM NUMBER] with an accumulation of dust was cleaned immediately on 8/24/16.
b. The piece of pink plastic partially covering and hanging from the deflector of a sprinkler head in room [ROOM NUMBER] was removed immediately on 8/24/16.
In addition, based on the sprinkler head inventory (in reference to d below), will be completed and concealed sprinkler heads will be installed in depot rooms. This will be completed by: 10/24/16.
c. The packages stored within six inches of the recessed sprinkler head in closet #215, a bathing suite on the Country Neighborhood, were immediately removed on 8/24/16. In addition, The top shelving will be removed so that items cannot be stored closer than 18 from the sprinkler head. Red tape will also be added to mark 18 from the ceiling in all nursing bathing suites and storage closets. Removal of shelving and installation of red tape will be completed by: 9/20/16.
d. An inventory of all sprinkler heads at ETW will be completed and sprinkler heads that are not in compliance will be replaced. Completion date: 10/1/16
e. All zip ties and wiring attached to sprinkler lines have been removed. Date of completion: 9/23/16
Environmental service staff will add dusting of the sprinkler heads to their quarterly housekeeping rounds. Date of completion: 10/1/16
Facilities Director will be completing a monthly audit tool to review the following areas:
a. Dusty Sprinkler heads
b. All nursing suites and storage closets have items stored below 18
c. No items are secured to sprinkler infrastructure
d. No debris is present on sprinkler heads
The results of this audit will be reported at the Quality Assurance committee.
The Facilities Director is responsible for this plan of correction.