New York State Veterans Home at Montrose
July 13, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews conducted during a recertification survey, the facility did not insure that: (1) the interdisciplinary team reviewed and revised the nutrition care plan in a timely manner to prevent further weight loss for 1 of 6 residents (Resident #153) reviewed for nutrition. Resident #153 had an unplanned weight loss of 15.5 pounds (lbs.) in a period of three months and monitoring of the resident's consumption of a nutritional supplement to prevent further weight loss was not performed, and (2) the reasons or causes of bladder incontinence for 1 of 1 resident (Resident #12) reviewed for bladder and bowel incontinence were not determined in order to develop an appropriate patient-centered care plan to assist the resident improve or prevent decline of the existing level of continency as possible. The findings are: 1. Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) and the 14-day MDS dated [DATE] and 4/24/18, respectively, indicated the resident's height was 67 inches and weighed 160 lbs at the time of the assessments; there was no or unknown significant weight loss or gain noted in the past 1-6 months; was receiving a mechanically-altered diet; had a severely impaired cognition; and the dental assessment indicated the resident has obvious broken natural teeth or likely cavities. The care plan for Nutritional Status indicated that the resident was over the IBW (ideal body weight) range of 120-147 lbs and current weight of 160 lbs; admitted on pureed diet with thin liquids; food consumption documented as 25-100% at breakfast and dinner, 0-75% at lunch and 0-100% for snacks. This care plan further documented that the family supplied [MEDICATION NAME] (a nutritional supplement) and was to be provided daily by nursing. Interventions included to provide medically prescribed diet - pureed with thin liquids; provide food preferences; monitor weight, provide counseling for diet compliance, monitor consumption, monitor labs, provide supplements, may deviate from restrictive diet on special occasions, and Speech Evaluation as ordered. The resident's weight record revealed the following: 4/11/18 - 160.0lbs (admission) 4/18/18 - 160.0lbs 4/25/18 - 157.7lbs 5/09/18 - 154.9lbs 6/01/18 - 154.4lbs 7/02/18 - 143.7lbs 7/11/18 - 144.5lbs (total weight loss of 15.5lbs in 3 months or 9.6%) There was no documented evidence in the nutrition care plan or the dietary notes that the on-going weight loss was addressed until the resident experienced a 15.5 lb. weight loss. Following surveyor inquiry about the appropriate nutrition interventions to address the resident's weight loss, the nutrition care plan was updated on 7/9/18 following the resident's significant weight loss and indicating the resident's dislike of the pureed diet. The care plan further indicated that speech evaluation was pending for diet upgrade to regular consistency. A Nursing Progress Note dated 7/10/18 indicated a 10 lb. weight loss in one month, medical and dietary made aware; speech therapy evaluation order put in place to upgrade diet due to resident request for diet change from pureed to regular diet. Interventions included weekly weights, Ensure ([MEDICATION NAME]) increased to three time per day, and Hi Cal (a high calorie oral supplement) for breakfast and lunch. The Registered Nurse (RN) unit manager who wrote the above note was interviewed on 7/13/18 at 11:00 AM and she stated she requested that [MEDICATION NAME] be given twice per day when the resident began losing weight. This RN manager was unable to state how long ago she had requested for [MEDICATION NAME] to be given twice daily. The RN manager further stated that the amount of [MEDICATION NAME] consumed by the resident was not being recorded as the family brings the [MEDICATION NAME] from home. A speech evaluation completed on 7/10/18 indicated no issues with the pureed diet and may be upgraded to ground. The note indicated the resident requested cream of wheat which will be communicated to dietary for high calorie cereal. The documentation for (MONTH) (YEAR) indicated the resident's intake was recorded as good for breakfast and fair to poor for lunch and dinner. There were several occasions where intake was poor for all meals and other times where the resident refused meals. The meal intake from 7/10/18-7/13/18 indicated the resident eats well at breakfast and described as good or excellent and fair to poor for lunch and dinner. On 7/13/18 the documentation indicated the resident refused breakfast and ate poorly for lunch. The Registered Dietitian/Food Service Director (RD/FSD) was interviewed on 07/13/18 at 9:54 AM regarding the resident's weight loss. In response, he reviewed the dietary documentation and could not find any explanation for the weight loss other than the resident's dislike of the pureed diet. The RD/FSD was unable to find any interventions added to the care plan to prevent the resident from further weight loss. When asked why the resident requested cream of wheat from the Speech Therapist if preferences were obtained from the resident as indicated on the care plan, he stated he did not know. He then checked the Geri Menus (a computerized program used to create individual menus) and could not find any of the resident's preferences. When asked why there were no interventions in place, he stated that the resident didn't hit the triggers for weight weight loss, for example 5% weight loss in 1 month, 7.5% in 3 months or 10% in 6 months until this time. Following the speech evaluation, interventions instituted included high calorie hot cereal that was implemented on 7/10/18 and soup and soft sandwich with lunch and dinner implemented on 7/13/18. In a follow up interview with the RD/FSD on 7/13/18 at 11:30 AM regarding documentation of [MEDICATION NAME] being added three times per day, he stated there was no documentation. He stated that beginning this week, [MEDICATION NAME] will be supplied by the facility so the nurses will have to document the amount the resident consumed. He stated further that the Hi-Cal cereal was started on Tuesday 7/10/18. The resident was observed on 07/13/18 at 12:00 PM. He was sitting in his wheelchair in his room, neatly dressed and well groomed. He did not respond when spoken to. A second observation during lunch on 7/13/18 at 12:37 PM revealed the resident did not eat any of his lunch. The resident ate the pudding and drank a small amount of milk. He was wheeling himself out of the dining room at the time of the observation.
2. Resident #12 is an [AGE] year old female and was admitted to the facility on [DATE] with the the [DIAGNOSES REDACTED]. The initial Nursing assessment dated [DATE] revealed that the resident was incontinent and the reason for the resident's incontinence was not known. The record used for this assessment included sections of the record to address frequency of voiding and the amount voided was not determined. These sections were checked as not applicable. The initial MDS dated [DATE] noted that the resident had no cognitive impairment and was frequently incontinent of urine (described in the MDS as having at least 7 episodes of incontinence weekly). The Annual MDS dated [DATE] also indicated that the resident was frequently incontinent of urine, non-ambulatory, and that a trial of a toileting program (for example prompted voiding, scheduled toileting or bladder training) was not done since admission to the facility. A bladder reassessment was done by nursing on 5/7/18 which revealed that the reason for the resident's incontinence was not known. The Care Area Assessment summary (an extension of the MDS that required further assessment and analysis) was completed on 5/8/18. This summary noted that the resident was frequently incontinent and still did not reflect underlying reasons for the resident's urinary incontinence. There was no documented evidence that any further assessments were done that focused on the resident's actual voiding pattern, when she is most likely to be continent and incontinent, and what the resident's preferred goal to address her incontinence should be, i.e. maintenance versus restorative. Documentation in the care activity by the Certified Nurse Aides (CNAs) for the period of 6/13/18 to 7/12/18 showed that the resident was noted to be continent 26 of 29 times according to data entries on the evening shift and 9 of 29 data entries on the day shift. The initial care plan that was initiated on 5/26/17 showed that the goal for the resident was not to develop complications related to incontinence. The evaluation section of this care plan noted on 1/24/18 that the resident was able to alert staff of her bathroom needs and on 2/15/18 the resident was able to make all of her toileting needs known. On 5/14/18 a new (or annual) care plan was developed which remained in effect at the present time. This care plan noted that the use of [MEDICATION NAME], an antidepressant (which was a part of the admission physician's orders [REDACTED]. The goal reflected in the new care plan was the same goal established for the resident a year ago as noted above. The interventions to achieve this goal were to monitor for signs and symptoms of a urinary tract infection, encourage adequate fluid intake, toilet resident every 2-3 hours and as needed, obtain bladder scan as ordered, provide bedpan upon request if needed, provide prompt incontinent cares every 2-3 hours as needed, to wear incontinent garments when in and out of bed, and to limit ingestion of bladder irritants. There was no documented evidence that the benefit of continuing the use of [MEDICATION NAME] versus the risk as it relates to urinary incontinence was addressed with the resident. The current plan of care does not address a toileting program based on the resident's actual voiding pattern. The MDS coordinator (RN #1) who completed the MDS and the Director of Nursing (DON) were interviewed on 7/12/18 between 12:00 noon and 12:15 PM. They were asked if the facility had determined the type of urinary incontinence the resident has (urge incontinence due to overactive bladder, stress incontinence due to poor closure of the bladder, overflow incontinence due to poor bladder contraction or blockage of the urethra, and functional incontinence due to medications or health problems making it difficult to reach the bathroom) in order to guide treatment and care planning decision. These interviews revealed no evidence that this was determined. The DON stated that the facility was aware of the problem with urinary incontinence and it is being addressed by the facility's Quality Assurance Performance Improvement program to include trial voiding program. The resident was interviewed on 7/12/18 at 4:10 PM and she stated the following. At times she calls for assistance and no one comes or was available. At times they will say that they (the CNAs) have to go to the lounge to monitor other residents and then she has to wait for another half hour before she is toileted. She stated she needs two people to put her on a lift and sometimes she gets wet when she is on the lift because she has to wait so long. The resident further stated that the bed pan was very small and uncomfortable and she never uses it. She stated she has no memory problems, is very aware of when she wants to go to the bathroom, and that she wears regular underwear with a pad when out of bed. The day shift CNA #1 assigned to the resident was interviewed on 7/12/18 at 11:50 AM. This aide stated that most of the time the resident is wet in the mornings and during the day time the resident can say when she wants to use the bathroom. The evening shift CNA #2 was interviewed on 7/12/18 at 4:40 PM. He stated that the resident is rarely incontinent on the evening shift. He waits for the resident to call before toileting her and that he is not aware of any toileting schedule for the resident. On 7/13/18 at about 10:15 AM the resident was observed during morning cares performed by CNA #1. CNA #1 stated that the resident's diaper was wet at the time care was rendered. An underwear was placed on the resident and she was then transferred from her bed with the aid of a lift operated by two CNAs and then placed on the toilet adjacent to her room. The RN (RN #2) who developed the resident's current plan of care was interviewed on 7/13/18 at 2:30 PM. The surveyor brought to the attention of this nurse that the goal for the resident did not address improvement in the level of her incontinence. The surveyor then asked RN #2 if the resident had any input into the development of the goal to address her incontinence. RN #2 stated that the resident did not. 415.3(g)(1)

Plan of Correction: ApprovedAugust 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F-Tag 657
Resident # 153
It is the policy of this facility to initiate a baseline care plan for each resident upon admission and readmission, renew and revised at intervals throughout the resident?s stay.
1. What corrective action will be done by the facility?
Resident # 153 was identified, and his care plan has been reviewed by the IDT and updated to reflect his weight loss as well as new interventions. Interventions include but is not limited to: [MEDICATION NAME] one can TID , weekly weight, food preferences reviewed to add high cal cereal started for breakfast and half soft sandwich every lunch and dinner . Additionally, he was reevaluated by the Medical Director and laboratory tests were ordered including CBC, BMP to rule out underlying causes.
2. How will the facility identify other residents having the potential to be affected by the same practice and what corrective action will be taken?
The IDT will review all residents who have weight loss in a month of 3% or above to ensure all care plans are updated as needed. Any resident who is identified as having a weight loss of 3% in a month will be brought to the morning meeting daily by the DFNS/designee. The morning meeting convenes at least 5 days a week, for further discussion and follow up as needed. The policy and procedures for weight changes has been revised to capture weight loss /changes of 3% or above in a month. An audit tool has been developed to monitor and track weight losses., and to ensure that care plans are revised and updated timely. The DFNS/designee will conduct the audits and analyze the findings.
3. What measures will be put into place to ensure that practice does not recur?
A lesson plan which includes a power point presentation was developed to in service all clinical staff. The lesson plan includes but is not limited to: Ensuring weight loss is captured timely to prevent further decline in weight. Reviewing and updating care plans. The Director of Food and Nutrition Services or designee will conduct an audit of all residents who experience a weight loss or gain weekly to ensure compliance with the plan of care. If any issues are identified, the Director of Food and Nutrition Services will follow up as indicated.
4. How will corrective action be monitored to ensure the deficient practice does not recur and what QA will be put in place to reflect resident preferences?
The Director of Food and Nutrition Services will bring the results of the audits to the monthly weight loss QA Sub Committee meeting for further review and recommendations and report to the QA committee quarterly for a year.
Date of Compliance: (MONTH) 11, (YEAR)





















































1. What corrective action will be done by the facility?
Resident # 12 was identified and assessed by the IDT including diagnosing her incontinence status and reviewing her care plan. She was offered a toileting program which she declined. She will be toileted based on her request and preference. Resident was placed on bladder scan to check post void residual (PVR) for 5 days. In addition, she was referred to a urologist for follow up. A flow sheet was developed to monitor her urinary incontinence pattern. The flow sheet will be reviewed after 2 weeks to determine her pattern of toileting and continence status. Based on the findings, her care plan will be modified.
2. How will the facility identify other residents having the potential to be affected by the same practice and what corrective action will be taken?
Other residents were reviewed for types of incontinence to ensure that their [DIAGNOSES REDACTED]. Policy for urinary incontinence management was reviewed and updated to reflect types of incontinence and appropriate interventions. An audit tool was developed to monitor and track resident continence status and to ensure that their care plans are updated timely. If any resident is identified as having a deficiency, immediate corrective action will be taken including IDT review.
3. What measures will be put into place to ensure that practice does not recur?
A lesson plan was developed with a Power Point presentation to in-service all clinical staff. The lesson plan includes but is not limited to: types of incontinence, interventions, and care planning. Based on the care plan schedule, the MDS Coordinator will review resident?s continence status to ensure a comprehensive assessment of the resident using the bladder assessment form, and to ensure that the reason for the resident incontinence is determined by the physician and documented. The MDS coordinators will ensure that the goals are resident centered, and interventions are geared towards restoring the highest possible bladder function. Residents who decline the toileting program will be re-approached periodically during care planning and as warranted.
4. How will corrective action be monitored to ensure the deficient practice does not recur and what QA will be put in place to reflect resident preferences?
An audit will be conducted by the MDS Coordinator or designee based on the care plan schedule using the audit tool to generate an appropriate plan of care. Competencies will be done to test staff knowledge. The findings of the audit will be analyzed for trends and patterns and will be reported by the MDS coordinator/ADON/designee to the QA committee quarterly for a year.
Date of Compliance: (MONTH) 11, (YEAR)



Standard Life Safety Code Citations

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 more than minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

2000 NFPA 101 -7.1.10 Means of Egress Reliability. 7.1.10.1 general. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Based on observation, it was determined that the facility did not ensure that all means of egress were continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 7.1. Reference is made to the vinyl and metal gates in the pathways from the emergency exits that were impeded from opening readily due to zip ties, a plastic bag, and/or a rusted latch on the gates. This situation affected access to the public ways from 3 of 5 resident units, and the Rehab and Recreation rooms. The findings include: During the recertification survey on 7/13/18 and 7/16/18 between the hours of 10:15 AM and 3:20 PM, the following issues were noted: - On 7/13/18 at approximately 10:25 AM, a tour was conducted of the emergency exit discharge from the open corridor that leads to a courtyard. A vinyl gate was installed at the end of the pathway. The gate could not be readily opened due to a plastic zip tie that was installed on the exterior side of the gate, preventing access to the public way. There are six emergency exits (2 from resident unit dining rooms and 4 corridor exits) that discharge into the courtyard and lead to this vinyl gate. This situation was also noted on the gate at the end of the pathway from three emergency exits from the resident unit and dining room on the Deer Park high side. - At approximately 12:25 PM the same day, a tour of the emergency exit from the Bear Mountain unit revealed that a plastic bag was wrapped around the vinyl gate at the end of the pathway, preventing unobstructed access to a public way. - On 7/16/18 at approximately 10:45 AM, the emergency exit from resident unit Fair Haven was examined and revealed that the 2 leaf metal gate leading to the public way would not open to due to a rusted latch that could not be readily released. A maintenance staff member removed the metal bar that secured 1 of the 2 leaves of the gate, allowing the latch to open to access the public way. In an interview at the time of the findings, the Plant Superintendent stated that security placed the plastic zip ties on the exterior side of the gates. In a subsequent interview with the maintenance staff member, he stated that the zip ties were placed on the gates to prevent residents from wandering beyond the gates. The Plant Superintendent also stated that the zip ties on the gates will be removed immediately and the facility will investigate another mechanism to ensure immediate access to the pubic way while preventing residents from wandering outside of the gates. 2012 NFPA 101 - 7.1.10.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedAugust 3, 2018

K271
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Zip ties, and Plastic bags were removed from identified vinyl and metal gates. Rusted latches were removed, and new gates shall be installed as warranted. This project shall be spearheaded by the Plant superintendent and Maintenance Supervisor

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.

The whole length of the vinyl and metal gates were inspected. Egresses or parts of the gates with broken or corroded latches were identified for removal and replacement by the Maintenance Supervisor.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.

A company specializing in the repair/installation of vinyl and metal gates has been retained to replace defective or rusted latches with ones that allow for easy release. All compromised parts of the vinyl gates will be replaced.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Ongoing checks of the vinyl gates including opening mechanism of the locks will be done by security every shift. Non-functioning locks shall be reported to the shift supervisor who shall report it to the Plant Superintendent. The Plant superintendent shall report on this monitoring to the safety committee as warranted and quarterly to the QA Committee for a year.
Completion Date: (MONTH) 11, (YEAR)


K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

2010 NFPA 110 Emergency and Standby Power Systems Chapter 7 Installation and Environmental Considerations 7.2 Location 7.2.1.1 The EPS shall be installed in a separate room for the Level 1 installations. EPSS equipment shall be permitted to be installed in this room. 7.2.1.1 The room shall have a minimum 2 - hour fire rating or be located in an adequate enclosure located outside of the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes. Based on observation, the facility did not ensure that the electrical switch gear room and the generator room were enclosed by construction having a minimum 2 - hour fire rating. Reference is made to the doors to the electrical switch gear room and the generator room that lack the 90 minute fire rated plates on 1 of 2 doors in the rooms, and unsealed conduits in the electrical switch gear room and in an electrical closet. The findings are: During the recertification survey conducted on 7/13/2018 between 10:00 AM and 3:00 PM, the following issues were noted: - On 7/13/18 at approximately 10:15 AM, the electrical switch gear room located within the IT room labeled G 133 was toured. Although the room was sprinklered and the door to enter the room had a 3/4 fire rated plate, the door to exit out of the room to the exterior side of the building lacked a fire resistive rating plate. It was also noted that a conduit pipe in the room had an opening that was not sealed. - At approximately 2:30 PM on 7/13/18, a tour of the electrical switch gear room labeled G 172 in the service area revealed that 1 of 2 doors in the room lacked a fire resistive rating plate. - At 2:40 PM the same day, the generator room located in the service area was toured and revealed that the room was sprinklered, but that 1 of 2 doors lacked a fire resistive rating plate. In an interview at the time of the observations, the Plant Superintendent stated that the door vendor will be contacted to evaluate the doors for the proper rating. 2010 NFPA 72: 7.2.1, 7.2.1.1 10 NYCRR 711.2 (a) (1)

Plan of Correction: ApprovedAugust 3, 2018

K918
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
Door Vendor was contacted by the Plant Superintendent to review and provide the appropriate fire resistive plate for 1 of 2 doors on the electrical gear Room (G172) as well as one of 2 doors on the generator room.
Opening identified around the conduit pipe was sealed by Maintenance Staff on 7/15/18
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Audit of Fire-rated doors was done by the Plant Superintendent. No other doors had missing fire plates. No other openings were identified around the conduit pipes.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
Ongoing audit of equipment ? specifically related to fire ? such as fire plates, holes around fixtures which compromise integrity of fire system will be done on a regular basis, by the Fire Safety Officer and Maintenance Supervisor. All issues identified will be fixed immediately.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
This monitoring will be presented to the QA committee quarterly by the Plant Superintendent for a year.
Completion Date: (MONTH) 11, (YEAR)

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

Based on emergency preparedness plan review, the facility could not provide documentation that a facility based or a community based drill had taken place in the last year, and the tabletop drill report provided did not include staff roles or sign in sheets. The findings are: On 7/17/18 at approximately 12:05 PM, the facility's disaster drill reports were reviewed and there was no documentation available that a facility based or community based drill had been conducted in the last year. Documentation of a table top exercise dated 12/27/17 was provided. However, it did not include staff roles or staff sign in sheets. In an interview with the Adminstrator at the time of the documentation review, she stated that facility based drills had been conducted, but that she was unable to locate documentation of the drills. She further stated that the facility was planning to do a facility based drill in the near future. 483.73(d)

Plan of Correction: ApprovedAugust 3, 2018

E039
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.

An annual plan for the required exercises/drills has been developed by the Plant Superintendent and Administrator to ensure that the required exercises are performed as required and timely.

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.

A full-scale community-based exercise comprising of the local Ambulance and local Fire Department has been scheduled by the Plant Superintendent by (MONTH) 31st. Documentation of the exercise including lessons learned, as well as attendance sheets shall be scanned into the computer within 30 days of the exercise.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
The plan will be added to the Preventative Management QAPI program and monitored for compliance by the Plant Superintendent.

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Reporting on compliance with required Emergency drills/exercises shall be reported quarterly by the Plant Superintendent to the QA committee for a year.
Completion Date: (MONTH) 11, (YEAR)

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

Based on observation, it was determined that the facility did not ensure that the pathway leading from the emergency discharge exit from the enclosed courtyards leading to the public way was maintained in accordance with 7.8. Reference is made to the lack of illumination along the pathway from the side of the building that leads to the public way. The findings include: On 7/16/18 at approximately 12:40 PM, a tour of the pathway leading from the emergency discharge exits was conducted and revealed that there was no illumination provided along the entire length of the pathway measuring over 100 ft. that terminates at a public way, i.e. the fire road. Three of five resident units would discharge In an interview at the time of the findings, the Plant Superintendent stated that he will install additional lighting along the pathway. 2012 NFPA 101: 7.8 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedAugust 3, 2018

K 281
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
The Plant Superintendent and Maintenance Supervisor conducted day and night time tours of the areas of egress. They were found to be illuminated. To determine illumination levels, a light meter will be used to ensure appropriate light levels.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.

Illumination shall be provided to the areas on the side of the building leading up to the public way in the front of the building.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.

Additional Lights with high beam bulbs shall be installed on the building in the areas identified, to provide illumination to the areas along the pathway from the side of the building leading to the public way. Placement of lights shall be installed such that they provide illumination without interfering with the resident?s ability to sleep
Security staff on their regular tours of the facility on the evening/night shift shall ensure that areas are lit when areas are dark or at night
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Ongoing monitoring of the pathway will ensure that the area is lit at all times when dark. Non-functioning bulbs will be replaced as necessary. This monitoring will be reported to the QA Committee by the Plant Superintendent quarterly for a year.
Completion Date: (MONTH) 11, (YEAR)


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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

NFPA 13, 2010 Edition 8.15.1.2.18 Sprinklers shall be permitted to be omitted from within combustible soffits, eaves, overhangs, and decorative frame elements that are constructed in accordance with 8.15.1.2.18.1 through 8.15.1.2.18.4. 8.15.1.2.18.1 Combustible soffits, eaves, overhangs, and decorative frame elements shall not exceed 4 ft 0 in. (1.2 m) in width. 8.15.1.2.18.2 Combustible soffits, eaves, overhangs, and decorative frame elements shall be draftstopped, with a material equivalent to that of the soffit, into volumes not exceeding 160 ft 3 (4.5 m 3). 8.15.1.2.18.3 Combustible soffits, eaves, overhangs, and decorative frame elements shall be separated from the interior of the building by walls or roofs of noncombustible or limited-combustible construction. Based on observation and interview, it was determined that the facility did not ensure that an approved automatic sprinkler system was installed in accordance with NFPA 13. Reference is made to the combustible overhang that measured approximately 6 ft. wide and lacked sprinkler coverage. During the recertification survey conducted on 7/13/18 between the hours of 10:00 AM and 3:00 PM, it was noted that an overhang was attached to the exterior side of the building above the emergency exit door from the Rehab room. The overhang measured approximately 6 ft. wide and, upon examination, was noted to be constructed of wood beams and boards covered with vinyl. Upon further examination The overhang lacked sprinkler coverage. In an interview at the time of the findings, the Plant Superintendent stated that he will remove the overhang. 2010 NFPA 13: 8.15.1.2.18 10 NYCRR 711.2 (a) (1)

Plan of Correction: ApprovedAugust 3, 2018

K 351
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
The facility Blue Print for the overhang in the rehab area showed that it had a 2-hour fire rating. Nevertheless, it was removed, and replaced with a metal beam. Aluminum siding was replaced by the Plant Superintendent and Maintenance Supervisor on (MONTH) 25, (YEAR).

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
There are no other overhangs in the building

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
Regular inspection will be done to the exterior of the facility to ensure patency of the structure. Repairs will be made as identified.


How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Reports of inspection ongoing monitoring will be submitted quarterly by the Plant Superintendent to the QA Committee for a year.


ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

1. 713-1.9 Mechanical Requirements. (i) All handwashing fixtures used by medical and nursing and food handlers shall be trimmed with valves that can be operated without the use of hands. Hand operated faucets may be fitted on lavatories in residents' rooms and residents' toilets. Based on observation, the facility did not ensure that the handwashing fixtures installed on sinks in the food prep area in the kitchen were of the hands free type in accordance with 713. This was noted for sinks in 5 of 5 food prep locations in the kitchen. The findings are: During the recertification survey conducted on 7/17/18 at approximately 10:40 AM, the kitchen was visited and revealed that the handwashing fixtures were equipped with 3 inch blades and not the hands free type fixtures required in food prep locations. In an interview at the time of the finding, the Plant Superintendent stated that hands free fixtures will be installed on the sinks in the food prep area. 10 NYCRR 7 13-1.9 10 NYCRR 711.2(a)(1) 2. 713 - 3.25 - Electrical Requirements (h)(3) Emergency electrical service shall be provided to the distribution systems as follows: (xi) Walk-in refrigerator and freezer. Based on observation, documentation review, and staff interview, it was determined that the facility did not ensure that required equipment was tied into the emergency generator in accordance with 713. Reference is made to the facility's refrigerator that was not connected to the emergency generator. The findings are: Documentation review conducted on 7/17/18 at approximately 11:05 AM during the recertification survey revealed that a list of the essential equipment on the emergency generator included the freezer. However, the list did not indicate that a refrigerator was connected to the generator, and the Plant Superintendent could not confirm that this essential equipment was tied into the generator. In an interview at the time of the findings, the Plant Superintendent, who has been in the facility for five months, stated he is in the process of confirming all the essential equipment in the facility that is tied into the emergency generator. 10 NYCRR 713-3.25(h)(3)(xi) 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedAugust 3, 2018

1560
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
Hands-free fixtures were installed on all sinks in the food preparation area in the kitchen.

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
An audit was done by the Maintenance Supervisor to identify all areas of food handling/ preparation, and hands-free fixtures were installed on the sinks.

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.

Ongoing monitoring of kitchen appliances by the Food Service Director will be done to ensure that the fixtures are working. Nonfunctioning equipment shall be reported to the Plant Superintendent for repair

How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Reports of repairs to hands-free devices will be monitored and forwarded to the QA Committee by the Plant Superintendent quarterly for one year.
Completion Date: (MONTH) 11, (YEAR)

1560
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.
A Consultant will be retained to perform an audit of the essential equipment including the kitchen refrigerator to determine whether it is tied into the facility?s Emergency generator. The Plant Superintendent shall initiate and monitor this project.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
The Audit will include all the facility?s Emergency equipment.

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
If not connected, the facility will ensure that the refrigerator is tied into the Emergency Generator.
Results of regular generator tests shall be forwarded to the QAPI Committee by the Plant Superintendent as part of its regular preventative management audit.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Audits shall be submitted to the QA Committee Quarterly for a year by the Plant Superintendent.
Completion Date: (MONTH) 11, (YEAR)

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 13, 2018
Corrected date: September 14, 2018

Citation Details

Based on emergency preparedness (EP) documentation review, the facility did not ensure that alternate sources of energy were provided to maintain sewer and waste disposal (i.e. ejector pumps or sump pumps, etc) in the event of an emergency. The findings are: Documentation review conducted on 7/17/18 at approximately 11:05 AM during the recertification survey revealed that, although the facility's EP policy and procedures addressed how sewage and waste disposal would be handled during a disaster or emergency, and a list was provided for the essential equipment tied into the generator, the list did indicate that any components of the sewer and waste disposal systems, such as ejector pumps or sump pumps, were connected to the generator. In an interview at the time of the findings, the new Plant Superintendent who has been at the facility for five months stated that he is in the process of confirming the essential equipment on the generator. 483.73(b)(1)

Plan of Correction: ApprovedAugust 3, 2018

Tag E 015
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice.

Consultant will be hired by the facility to determine and document equipment that is tied into the Emergency Generator, including Ejector and Sump pumps.

How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
Audit by consultant will identify all equipment tied into the Emergency Generator.

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur.
This information will be documented and placed in the Emergency Preparedness manual by the Safety Officer. All staff who have a need to know, will be in-serviced about the document and its placement.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
As part of their regular monitoring and testing, the Plant Superintendent will ensure that Emergency Equipment continues to be tied to the Emergency Generator. This will be monitored as part of the ongoing Preventative Management Program (QAPI) and submitted to the QA Committee quarterly for a year.

Completion Date: (MONTH) 11, (YEAR)