New Roc Nursing and Rehabilitation Center
June 6, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined for 5 of 35 residents reviewed for Minimum Data Set (MDS) Assessment accuracy, the facility did not ensure that MDS Assessments accurately reflected the residents' status. Issues involved inaccurate coding for preferences for customary routines and activities on the Comprehensive MDS Assessment (Resident #17), dental status (Residents #35 and #88), vision status (Resident # 69), and medications (Resident #29). This is evidenced by, but not limited to, the following: 1. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Annual Comprehensive MDS Assessment, dated 3/3/18, revealed the resident had severely impaired cognition and Preferences for Customary Routines and Activities interviews were all blank indicating they were not done by the resident, a family member or a staff member. When interviewed on 6/5/18 at 11:39 a.m., the Registered Nurse (RN) MDS Coordinator said there was no Activities Director at the time of the assessment. She said she cannot do the activities section because she does not have the questions to ask. She said she called her corporate consultant and was told to mark the section as not assessed. 2. Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/8/18, revealed that the resident had moderately impaired cognition, was independent with personal hygiene, and had no identified dental concerns. A Physician Admission Assessment, dated 5/1/18, revealed the resident had missing teeth and caries (tooth decay). A Nursing Admission Summary entered in a progress note, dated 5/1/18, revealed that the resident had a few teeth of her own. Review of the Comprehensive Care Plan, dated 5/9/18, revealed the resident had oral/dental health problems related to poor oral hygiene. In an observation on 5/29/18 at 10:26 a.m., the resident's upper teeth were broken and decayed. When interviewed on 6/5/18 at 10:44 a.m., the MDS Coordinator said she had completed the Admission Assessment, including an oral exam, so she knew that the resident's teeth were in poor condition with caries, fragments, and missing teeth. She said the dental section of the MDS Assessment was coded inaccurately. She said the MDS Assessment should have been coded as obvious or likely cavity and/or broken natural teeth. 3. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/19/18, revealed the resident had severely impaired cognition, had the ability to see adequately (able to see fine details such as regular print in newspaper/books) and had no corrective lenses. When interviewed on 5/29/18 at 9:51 a.m., the resident said he was blind in one eye and needed glasses to see. He said he did not know where his glasses were, but would love to have a pair so that he could do artwork which includes drawing with fine pencils. During an interview on 6/5/18 at 9:30 a.m., the MDS Coordinator said she marked vision as adequate because the resident could see her hand when she held it up in front of him. She said she does not do an eye exam (per MDS Manual). She said she would not know if the resident had a vision problem unless staff told her. 4. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/29/18, revealed the resident used an anti-anxiety medication daily. Review of the current physician orders [REDACTED]. When interviewed on 6/5/18 at 12:03 p.m., the MDS Coordinator reviewed the medical record and said the resident was admitted on [MEDICATION NAME] (an anti-anxiety medication), but it had been discontinued on 12/20/17. The MDS Coordinator said that she missed the discontinuation of the anti-anxiety medication. She said the MDS Assessment was coded incorrectly. (10 NYCRR 415.11(b))

Plan of Correction: ApprovedJuly 14, 2018

Corrective Action Taken For Those Residents Affected:

Resident #17 MDS was corrected.
Resident #88 MDS was corrected.
Resident #69 MDS was corrected and an appointment was made with the optometrist.
Resident #29 MDS was corrected.
The facility hired an activities director
Corrective Action Taken For Those Residents Potentially Affected:
The facility recognizes that all residents have the potential to be affected however during a full record review of all MDS that no residents were affected during this deficient practice. The MDS Coordinator was educated on their responsibility to ensure that the MDS are completed and accurately reflecting each resident. The MDS Coordinator was also educated that all residents need to be assessed in person and thoroughly. The IDT should be consulted for areas that the MDS Coordinator is not familiar with.
Systematic Monitoring:
The Unit Managers or DON will inform the MDS Coordinator of any discontinued medications, upcoming appointments, and changes of the resident at the clinical meetings.
Quality Assurance Monitoring:
The facility will create an audit tool to monitor and track all MDS? to ensure completeness and accuracy of all parts to reflect the individual resident. The audits will be done weekly for 8 weeks and then monthly for 6 months. All audits will be brought to the QAPI committee for review and from there it will be determined it continued monitoring will be necessary.
The MDS Coordinator and Director of Nursing is responsible for compliance of this deficiency.

FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY 648 and #NY 571), it was determined that for 2 of 13 residents reviewed for Activities of Daily Living, the facility did not provide the necessary care and services to maintain good grooming and personal hygiene. Issues involved the lack of nail care (Residents #35 and #79) and the lack of shaving (Resident # 79). This is evidenced by the following: 1. Resident #35 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/10/18, revealed the resident had moderately impaired cognition and was totally dependent on staff for personal hygiene. The current Comprehensive Care Plan (CCP), and Care Card (CC) included the nurse was to perform diabetic nail care on shower days Wednesday and Saturday and as needed, and the resident was dependent on staff for bathing During observations on 5/29/18 at 11:11 a.m., on 5/30/18 at 2:20 p.m., and on 6/1/18 at 8:38 a.m., the resident had long nails on all five fingers of the left hand. and the nails of the right hand were long and filled with brown debris. During an interview on 6/1/18 at 3:04 p.m., Licensed Practical Nurse (LPN) #1 stated that the nurses perform diabetic nail care for the resident on shower days. She stated the resident received a bed bath on Wednesday evening (5/30/18) and nail care should have been provided. At that time, LPN #1 observed the resident's nails and stated yes, his nails need to be cleaned and trimmed. LPN #1 said she would provide the care. 2. Resident #79 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/30/18, revealed that the resident was cognitively intact and totally dependent on staff for personal hygiene. The Current CCP and CC revealed that the resident was to be shaved on his scheduled bath day (Tuesday evening and Friday evening), and directed that a nurse perform diabetic nail care on bath days and as needed. During an observation on 5/29/18 at 9:18 a.m., the resident had a 3/4-inch hair growth on his face and black debris under his long fingernails. When interviewed at that time, the resident said he gets a bed bath and no, he does not prefer a beard, but they do not have enough aides to get his scheduled shave. During observations on 6/1/18 at 9:27 a.m. and again at 1:56 p.m., the resident had a scruffy beard and his nails were long and filled with black debris. When interviewed at that time, the resident said the staff washed him up the previous night but did not give him a shave. During a joint observation and interview on 6/1/18 at 3:00 p.m., LPN #2 looked at the resident's nails and said yes, they are bad and they need to be cut. LPN #2 said the nurses are supposed to cut the resident's nails on his shower day. (10 NYCRR 415.12 (a)(3))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (Resident #17) of three residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care and services to maintain good grooming and personal hygiene. The issue involved the lack of nail care. This is evidenced by the following: Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/3/18, revealed the resident had severely impaired cognition and required total assistance of one staff for bathing and personal hygiene. The Comprehensive Care Plan for skin and ADLs, dated 3/7/18, revealed that the resident had a self care deficit and was at risk for skin breakdown. Interventions included to check skin and nails twice weekly, and the resident requires assistance with bathing the upper body. The Certified Nursing Assistant (CNA) Care Card documented that the resident required total assistance of one staff for bathing. The Treatment Administration Record for (MONTH) (YEAR) included to check the resident's nails on bath and shower days. During an observation on 8/13/18 at 12:03 p.m., four fingers on the resident's right hand had dark debris under the nails. On 8/14/18 at 10:35 a.m., all of the resident's fingernails on the right hand had brown debris under the nails. When interviewed at that time, the Nurse Manager said that the resident's fingernails needed to be cleaned. Additionally, the facility was unable to provide documentation that an initial audit was conducted, education was completed, and an audit tool was developed per the Plan of Correction. When interviewed on 8/13/18 at 8:45 a.m. and 12:40 p.m., the Administrator stated that the initial audits were not started per the Plan of Correction. The Administrator said that she found an education sheet for Activities of Daily Living that had six signatures. She said the Director of Nursing (DON) was responsible for providing the education, and she was no longer employed by the facility. She said that the consultant recorded the directed inservice, however, the tape and the recorder were missing. (10 NYCRR 415.12(a)(3))

Plan of Correction: ApprovedSeptember 10, 2018

415.11(c)(ii)
483.24(a)(2) ADL Care Provided for Dependent Residents
The facility will ensure all residents who are unable to provide self care for activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene.
Resident #35's fingernail were cleaned and cut on 6/1/18 by LPN #1 once deficient practice was identified. The medical provider was notified on 6/29/2018. Order was obtained to have nurse to inspect and cut residents fingernail once weekly on the 7-3 shift. The nurse transcribed above orders to the MAR to ensure fingernail care is provided weekly by the licensed nurse not specific to bath/shower day. Resident's CCP and closet care plan were reviewed and revised on same day to include the above physician ordered interventions. Chart review also occurred. Resident #35 remains at the facility in stable condition.
Resident #79's fingernail's were cleaned cut and trimmed by LPN #2 on 6/1/18 and the resident was groomed/shaved by CNA assigned on the 3-11 shift same day once deficient practice was identified. The medical provider was notified on 6/29/2018, order was obtained to have nurse inspect, cut and trim fingernails weekly on the 7-3 shift. The nurse transcribed above orders to MAR to ensure fingernail care is provided weekly by the licensed nurse not specific to bath/shower day. Resident #79 CCP and closet care plan were reviewed and revised on same day to include fingernail care as ordered and for CNA to shave resident everyday during AM care. Resident #79 remains at the facility in stable condition.
All residents who are unable to provide self care for their activities of daily living have the potential to be affected by this same deficient practice.
The RN unit managers will conduct ADL audits for all identified residents who are unable to provide self care. The residents observed will be evaluated for resident grooming, nail care, hair care including personal care and oral hygiene. Each resident's shower/bath sheet will also be audited against ADL care plan. and CNA closet care plan. The nurse will observe the resident's hair, nails, and body appearance including condition of clothing. They will review shower/bath sheets and bathing schedules to ensure the CNA's have notified the shift charge nurse of shower/bath refusals. Any resident who refused will be re-approached. All findings will be recorded on the audit tool and forwarded to the DON for review. Immediate corrective action will occur whenever deficient practice is identified. The DON will analyze and trend data collection and report findings to the QAPI committee at the next scheduled meeting.
The RN consultant has developed resident activities of daily living policies and procedures to ensure residents who are depend on staff to provide ADL care receive necessary services to maintain good grooming and personal hygiene. While maintiaining dignity and promoting resident participation in the plan of care and ensuring communication occurs between shifts.
. Nail Care
. Brushing and Combing Hair
. Shaving the Resident
. Giving a Bed Bath
. Bathing/Showering
. Shampooing Hair
. Shower/Tub Bath
. Changing the Resident Gown, Pajamas
. Dressing and Undressing the Resident
. Perineal Care
. Incontinence Care
. Quality of life - self determination and participation
. Quality of life - dignity
. 24 hour shift report
The RN Consultant will in-service the DON/ADON, all Licensed Nurses and CNA's including facility and agency staff and create a audio recording of the training for those CNA's and Licensed Nursing staff employees who were unable to attend. the DON will schedule the audio presentation for all remaining nursing staff that were unable to attend. The Live Presentation Training. All nursing staff will be in-serviced by 7/10/2018.
The LPN who was assigned to cutting resident #35's fingernails Wednesday 5/30/18, and Saturday 6/1/18 and did not provide fingernail and ensure resident nails were cleaned and trimmed as indicated on the MAR, will be counseled and in-serviced by the DON on ensuring Diabetic residents fingernails are cut weekly as indicated on MAR.
The LPN who was assigned to cutting resident #79's fingernails on his shower days Tuesday 5/29/18 and Thursday 5/31/18 and did not provide fingernail care as indicated on the MAR and ensure resident nails were cleaned and trimmed will be counseled and in-serviced by the DON.
The CNA's who were assigned to resident #79 on the 7-3 shift on and 5/29/18 and 6/1/18 did not shave the resident on his non-shower day providing Am care will be counseled and in-serviced by the DON on following the residents closet care plan for ADL care _ shaving. On ensuring diabetic nails are cut weekly as indicated on MAR.
The DON who did not provide proper oversight for ADL fingernail care for Resident#35 and #79, and ensure Resident #79 will provided shaving will be counseled by the Adminstrator 6/29/2018.
The RN unit manager who did not provide proper oversight of the residents ADL care and did not identify that resident #35 and resident #79 was not provided grooming, and provided personal hygiene, specific to nail care on their scheduled bath/shower days during the week of 5/30/18 - 6/1/18, and did not ensure resident #79 was shaved on 6/1/18 will be counseled and in-serviced by the DON and fingernail care is provided weekly by the nursing staff, for diabetic resident and documentation is completed and CCP's and closet care plan are followed by the nursing staff for ADL care and male residents are shaved daily and fingernails are cut weekly on shower day.
The RN unit manager will conduct weekly ADL visual observation audits and verbal interviews and document finding on a ADL audit tool when applicable with all residents who are unable to provide self care for activities of daily living for personal care, nail care, grooming, brushing hair, oral care and showering/bathing. The Diabetic resident MARS, bathing schedule, CCP closet care plan will also be reviewed/audited when observation is conducted. The resident will be interviewed at that time. The RN unit manager will immediately address deficient practice identified with CNA/Nurse providing resident ADL care i.e. shaving, bathing, fingernail care etc. assigned to and ensure the resident is groomed and care is provided at that time. The DON will be notified when deficient practice is identified to ensure progressive disciplinary action and in-servicing occurs. The RN unit manager will revise the plan of care at same time audit is conducted. The DON will analyze and trend data collection from ADL audit tools. All findings will be reported to the QAPI committee monthly, this will be ongoing
The DON will be responsible for compliance

FF11 483.70:ADMINISTRATION

REGULATION: §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practical, physical, mental and psycho-social well-being of each resident. Specifically, the Administrator did not ensure the facility complied with the acceptable Plan of Correction for staff education and audits related to the deficient practices for both the Health and Life Safety Code Surveys. This is evidenced by the following: The facility's Plan of Correction documented that the following education and/or audits would be completed by the following dates: a. All nursing staff would be re-educated on their responsibility with assisting resident's during meal times and maintaining dignity while dining. The facility educator would be responsible for education of all staff by 7/30/18. Audits would be conducted weekly for eight weeks, and then monthly for three months, and would be the responsibility of the Director of Nursing (DON) (F550). b. The Registered Nurse Manager (RNM) would be re-educated regarding the policy and procedure for filling out Incident/Accident (I/A)'s Reports to rule out abuse, neglect or mistreatment. A full review of all I/A's for the past six months would be reviewed for completeness and accuracy of all investigations and an audit would be done to track that it was completed and would be the responsibility of the DON and the Administrator with a completion date of 7/20/18 (F610). In an interview on 8/15/18 at 9:50 a.m., the new DON (effective 8/13/18) stated that she had not come across any in-service education that had been conducted on I/A Reports. The DON said that she has requested several policies that were reviewed. She said after thoroughly looking she was unable to produce any documentation to support education on Incident and Accident Reports at that time. c. The facility would develop and implement a Baseline Care Plan for each resident and provide a copy to the resident and/or resident representative within 48 hours of admission. All Interdisciplinary Team members would be educated on the process and the Social Worker (SW) would be responsible for reviewing and providing it to the resident and/or representative. An audit would be conducted by the DON/designee, Registered Nurse Supervisor and Unit Managers. The DON would be responsible for compliance with a completion date of 7/20/18 (F655). d. A full house audit would be completed to ensure nail and hand hygiene was completed for all residents, alarms and/or assistive devices reviewed to ensure necessity and appropriate application, and all care plans for residents with pressure ulcers would be reviewed to ensure the application of air mattresses. All nursing staff would be educated on Comprehensive Care Plan accuracy and documentation on treatment records. All staff education would be provided by the staff educator or designee with a completion date of 7/27/18 (F656). e. All nursing staff will be educated by the staff educator on the use of mechanical lifts regarding weight limitations and proper operating guidelines and maintenance. Audits would be conducted weekly on all residents who require a mechanical lift and care plans reviewed. The audits would be the responsibility of the DON, Assistant DON (ADON) and the Unit Managers with a completion date of 7/20/18 (F689). f. All nursing staff would be educated to ensure appropriate skills related to Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machines (a noninvasive ventilation machine that involves the administration of air by an external device at a predetermined level of pressure). Weekly audits of Treatment Administration Records (TARS) would be done by the DON and ADON to ensure compliance with care of the [MEDICAL CONDITION] machines. Physician order [REDACTED]. Review of the education for [MEDICAL CONDITION], dated 7/19/18, had six nurses signatures. There was no educational outline and/or summary. An additional five LPNs were interviewed (8/13/18 at 11:24 a.m., 12:08 p.m., 2:45 p.m., 8/14/18 at 10:50 a.m. and 8/16/18 at 10:22 a.m.), and four LPNs said they had not received any education regarding [MEDICAL CONDITION]. When interviewed on 8/14/18 at 10:54 a.m., the Registered Nurse said she was no longer the staff educator as of the middle of July. She said that she did not have any input regarding the Plan of Correction the facility submitted, nor did she receive a copy of the Plan of Correction. She said that she did not know who was responsible to educate the staff per the Plan of Correction. g. All Social Workers and Unit Managers would be educated regarding the Hospice policy as it relates to the referral process. The facility would develop an audit tool to monitor and ensure compliance with the Hospice policy and the Director of Social Work (DSW) would be responsible for completing the audits weekly for 12 weeks and then monthly for nine months with a completion date of 7/21/18 (F745). In an interview on 8/14/18 at 1:12 p.m., the DSW stated that she was not included in the Plan of Correction and she was unaware of any audit tools related to Hospice. h. All nurses would be educated on the Gradual Dose Reduction (GDR) policy as it relates to antipsychotic medications. The DON would conduct weekly audits on all residents medical records that include scheduled and as needed antipsychotic medications and ensure the GDR meetings are held monthly with the provider and the Interdisciplinary team to ensure timely GDRs take place and recommendations are followed. The completion date was 7/20/18 (F758). i. A full house audit was conducted to ensure that all new and current residents have seen a dentist. An audit would be completed to determine a schedule for six months rotation for all residents. All new admissions will be provided with the dental consult within three days of admission or referral for next scheduled dental service day. All audits would be completed by the DON or designee with a completion date of 7/20/18 (F791). j. All staff would be educated to ensure that all residents receive assistance related to their personal level of need at meal time. An audit would be done by the Registered Dietician or designee to ensure all diets are reflective of each resident's individual need. The DON/designee will ensure compliance with audits with a completion date of 7/20/18 (F805). k. All nursing staff will be educated on proper handling of resident food, proper perineal care, personal hygiene products, and the process if a wound dressing is missing. Audits were to be conducted weekly for each area of concern. A Legionella Risk Assessment was to be completed. The DON and Administrator were responsible for completion on 7/20/18 (F880). When interviewed on 8/17/18 at 10:17 a.m., the DON said that education related to perineal care was not completed. She said that some of the staff had education on handwashing. When interviewed on 8/17/18 at 10:18 a.m., the Administrator said that the Legionella Risk Assessment was not completed. She said that the Maintenance Director was supposed to complete the assessment. The Administrator said she was unsure if the Maintenance Director knew it was his responsibility and that ultimately, she was responsible for the completion. l. The Plan of Correction included that the Director of Maintenance was responsible for auditing all sprinkler heads to ensure they are free of corrosion, foreign materials, paint, physical damage, and installed in the appropriate orientation. The audits will be completed monthly by the Maintenance Director or designee. The completion date was 8/11/18 (K353). When interviewed on 8/17/18 at 9:17 a.m., the Director of Maintenance said that the audits have not been done because he just has not had the chance to get to them. m. The Plan of Correction revealed that the Director of Maintenance would create a map of all fire extinguishers throughout the facility so no fire extinguisher will go without inspection. The Director of Maintenance was responsible for all fire extinguisher audits which will be conducted weekly for three months and then monthly for six months. The completion date was 8/11/18 (K355). There was no documentation provided by the Administrator or Director of Maintenance to show that a map of all fire extinguishers had been created or that weekly audits were occurring When interviewed on 8/15/18 at 1:12 p.m., the Director of Maintenance said that up until now the weekly audits for the fire extinguishers have not been occurring. n. The Plan of Correction revealed all staff will be re-educated on fire procedures by 8/11/18. An audit tool will be created to capture staff knowledge and understanding of all fire procedures. The audit will be done weekly on random shifts for eight weeks and then quarterly to capture new employees. The Director of Maintenance and the Administrator were responsible for all audits. The completion date was 8/11/18 (K712). Record review on 8/16/18 at 10:07 a.m. revealed that the staff in-service sign-in sheet from 8/8/18 at 11:30 a.m. included the day staff only. There was no additional documentation to show that staff on the evening and night shifts were educated on fire procedures. There was no documentation provided by the Director of Maintenance or the Administrator to show that an audit tool was created to capture staff knowledge and understanding of fire procedures and no weekly audits were completed. o. The Plan of Correction revealed education would be provided by the staff educator and the Maintenance Director on the procedure for safe resident transfers with any mechanical lift and what to do when it has been identified there is an issue with the lifts or any equipment. A whole house audit of the patient care related electrical equipment will be completed by the Maintenance Director. The biomedical contractor had been contacted to come and repair and /or inspect any equipment in the facility. The Maintenance Director was responsible for compliance with a completion date of 8/10/18 (K921). An interview with the Director of Maintenance on 8/15/18 at 1:12 p.m. revealed there was no staff education for Patient Care Related Electrical Equipment (PCREE) and a full building audit of PCREE was not done. Observations throughout the facility on 8/17/18 between 10:20 a.m. and 2:30 p.m. revealed the following PCREE on all three resident use floors including, but not limited to: electric beds, oxygen concentrators, tube feed pumps, battery powered lifts, suction machines, and air mattresses/pumps. There was no documentation provided by the Administrator or Director of Maintenance to show that all staff were educated with regard to PCREE, no documentation that a biomedical contractor had been at the facility to inspect and/or repair equipment, and no documentation of a full house audit of PCREE. When interviewed on 8/13/18 at 8:45 a.m., on 8/14/18 at 9:20 a.m. and 11:49 a.m., the Administrator stated that they had not completed any audits related to the Plan of Correction yet. She said she did not have a DON as of that day (8/13/18). When asked if Nurse Managers were completing audits she stated she did not know. The Administrator said that she and the previous DON completed the Plan of Correction. She said that the Nurse Educator had reduced her hours and was no longer doing education but she was not aware that she had stopped providing education in July. She said she sent the Plan of Correction out to staff members including the Nurse Managers, Director of SW, Director of Maintenance and Human Resources but missed the Nurse Educator. In an interview on 8/14/18 at 10:54 a.m., the prior Registered Nurse Staff Educator stated that she used to be the staff educator but does not do in-services anymore and has not for approximately a month. She said she did not have the proper tools such as office space, lap top, videos or manuals to do the job effectively. She said she did not receive the Plan of Correction and had no knowledge of who was responsible or if she was. She said she did not provide education on [MEDICAL CONDITION], mechanical lifts, Incident and Accident Reports, Gradual Dose reductions, or dining assistance. She said she did not know about any logs or audits. In an interview on 8/15/18 at 2:04 p.m., the Unit 3 Nurse Manager said that she had not received any audit tools or instructions for conducting audits or staff education. In an interview on 8/16/18 at 10:41 a.m., the Unit 2 Nurse Manager stated that they were not asked to complete audits since the last survey and were not asked to provide any education for staff related to the Plan of Correction. She said the ADON asked about audit tools, but they were never given any to utilize. In an interview on 8/16/18 at 1:56 p.m., the ADON stated that she received the Plan of Correction but had not had a chance to read it yet. She said no one told her she would be responsible for any part. When interviewed on 8/17/18 at 10:18 a.m., the Administrator said they did not complete education for the nurses regarding Respiratory Care and no audits were conducted. In an interview on 8/17/18 at 12:24 p.m., the Medical Director stated that he had not seen the Statement of Deficiencies or the Plan of Correction. (10NYCRR 415.26)

Plan of Correction: ApprovedSeptember 10, 2018

Corrective Action Taken for Those Residents Affected and for Those Residents Having Potential to be Affected-
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 550. All corrective actions, policy revisions, education, audits and monitoring for F 550 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 610. All corrective actions, policy revisions, education, audits and monitoring for F 610 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 655. All corrective actions, policy revisions, education, audits and monitoring for F 655 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 656. All corrective actions, policy revisions, education, audits and monitoring for F 656 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 689. All corrective actions, policy revisions, education, audits and monitoring for F 689 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 726. All corrective actions, policy revisions, education, audits and monitoring for F 726 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 745. All corrective actions, policy revisions, education, audits and monitoring for F 745 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 758. All corrective actions, policy revisions, education, audits and monitoring for F 758 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 791. All corrective actions, policy revisions, education, audits and monitoring for F 791 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 805. All corrective actions, policy revisions, education, audits and monitoring for F 805 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for F 880. All corrective actions, policy revisions, education, audits and monitoring for F 880 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for K 353. All corrective actions, policy revisions, education, audits and monitoring for K 353 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for K 355. All corrective actions, policy revisions, education, audits and monitoring for K 355 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for K 712. All corrective actions, policy revisions, education, audits and monitoring for K 712 will be completed under the supervision and guidance of the consultant in a timely manner.
The Administrator was educated regarding her responsibility to ensure the facility complied with the Plan of Correction for K 921. All corrective actions, policy revisions, education, audits and monitoring for F 921 will be completed under the supervision and guidance of the consultant in a timely manner.

The administrator was educated regarding her responsibility to ensure the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically her responsibility to ensure the facility complied with the P(NAME) submitted to the DOH for both the Health and Life Safety Code Surveys.
The facility hired a Consultant to develop an acceptable plan of correction, educate the staff regarding the plan of correction, and develop audit tools.
The Consultant assisted the Administrator in organizing the cited tags, the corrective actions for the residents affected, the corrective actions for those residents having potential to be affected, education required and auditing.
The facility will hold QA meeting the last Friday of every month minus one winter month.
The Administrator will hold a Plan Of Correction / Quality Assurance mini meeting every Monday after morning report to document progress and compliance with the current Statement of Deficiencies. The Consultant will attend and or review the documentation from these meetings on a weekly basis until the facility is back in compliance.
The Staff Educator was informed of the Statement of Deficiencies, and educated regarding her responsibility in implementing it.
The 3rd floor unit manger was informed of the Statement of Deficiencies, and educated regarding her responsibility in implementing it.
The 2nd floor unit manager was informed of the Statement of Deficiencies, and educated regarding her responsibility in implementing it.
The 1st floor unit manager was informed of the Statement of Deficiencies, and educated regarding his responsibility in implementing it.
The Medical Director and the Midlevel Provider were informed of the Statement of Deficiencies, and educated regarding their responsibilities in attaining and maintaining compliance.
The Statement of Deficiencies, for survey exit date 8/17/18 was reviewed at morning report. The plan for Consultant Services to write the P(NAME), review, revise and update policies, educate, and audit was reviewed.

Systemic Monitoring-
The administrator was educated by the Consultant regarding her responsibility to ensure the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically her responsibility to ensure the facility complied with the P(NAME) submitted to the DOH for both the Health and Life Safety Code Surveys.
The policy for Quality Assurance Committee was reviewed. The policy was updated to include scheduling QA the 4th Friday of every month, with allowance for one winter month off. The Consultant will be responsible to in-service all QA staff members staff regarding the policy / QA meeting schedule.

Quality Assurance Monitoring-
The Consultant in conjunction with the facility will develop an audit tool to monitor and ensure compliance with the Administration regulation. The audit will include ensuring the facility is in compliance with the Plan of Correction under the guidance of the Administrator and that the Administrator verbalizes understanding regarding the regulation. The Director of Nursing or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months, at which time it will be reviewed for continued frequency guidance at QA. The Administrator will report findings at the QACM monthly for follow up and review.
The Consultant in conjunction with the facility will develop an audit tool to monitor and ensure compliance with the policy for Quality Assurance Committee. The audit will include ensuring QA meetings occur monthly as scheduled and that staff verbalize understanding regarding the policy. The Administrator or designee will be responsible to complete these audits weekly for 4 weeks and then monthly for 3 months, at which time it will be reviewed for continued frequency guidance at QA. The Administrator will report findings at the QACM monthly for follow up and review.
The Consultant in conjunction with the facility will develop an audit tool to monitor and ensure compliance with the policy weekly mini meeting following the Monday morning report meeting. The audit will include ensuring the meeting occurred, monitoring the results of the meeting and ensuring proper follow and follow through occurs to attain and maintain compliance with the Plan of Correction. The Unit Manager or designee will be responsible to complete these audits weekly for 12 weeks at which time it will be reviewed for continued frequency guidance at QA. The Administrator will report findings at the QACM monthly for follow up and review.

Person Responsible for the Correction of this Deficiency- Administrator
Date of Completion- 10/12/18
Layla Kuek, RN is an Independent Consultant. Mrs. (NAME REDACTED) Kuek, has been retained by the facility for required compliance with the Statement of Deficiencies Directed Plan of Correction and Directed In-Services.
A. The causative factors that may have contributed to the issue identified is lack of education.
B. The steps/interventions undertaken or proposed to eliminate and correct the causative factors identified during the assessment phase is staff in-servicing or education.
C. The routine triggers or parameters the facility will implement for the above deficiency, that will signal or alert all staff of an evolving problem or deficient practice situation. This system will be carried out by the facility by conducting of the quality assurance committee meeting, mini meetings and the administrators overall ability to administer the facility.
D. The facility will measure whether efforts are successful or unsuccessful in maintaining compliance through QAPI.
A. Mandatory In-Servicing For F 835 will be conducted on 9/17/18 at 10:00am and 2:00pm, 9/18/18 at 10:30am, 9/19/18 at 10:00am and 2:00pm, 9/20/18 at 10:30am, 9/21/18 at 10:30am and 3:30pm, 9/25/18 at 10:00am, and 9/27/18 at 10:00am. Each in-service will be approximately 60 minutes in length, depending on the length of the question and answer session at the end. The in-service will be given by Layla Kuek RN. Targeted staff will include all members of the QA Committee. Monitoring and Evaluation of the effectiveness of the program will be conducted facility audits that are completed by facility staff designated in the P(NAME). The Quality Assurance Audit findings will be reviewed monthly at the Quality Assurance Committee Meetings for follow up and guidance.
B. In-Service Outline- The administrator was educated by the Consultant regarding her responsibility to ensure the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically her responsibility to ensure the facility complied with the P(NAME) submitted to the DOH for both the Health and Life Safety Code Surveys.
The policy for Quality Assurance Committee was reviewed. The policy was updated to include scheduling QA the 4th Friday of every month, with allowance for one winter month off. The Consultant will be responsible to in-service all QA staff members staff regarding the policy / QA meeting schedule.
Questions and Answers
Post Test

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

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 648), it was determined that for 3 of 14 residents reviewed for Baseline Care Plans, the facility did not develop or implement a Baseline Care Plan within 48 hours of admission that included instructions needed to provide effective and person-centered care (Residents #59 and #455) and/or provide the resident or representative with a written summary of a Baseline Care Plan (Resident #88). This is evidenced by the following: 1. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/25/18, revealed the resident was cognitively intact. Review of the resident's electronic medical record and paper chart did not include an interim Baseline Care Plan. When interviewed on 6/5/18 at 1:12 p.m., the Registered Nurse Manger (RNM) stated that he transferred to that unit about one month ago and did not audit the resident charts for completion of the Baseline Care Plan. At that time, the RNM reviewed the resident's chart and was unable to find the Baseline Care Plan. The RNM said that the prior manager usually did a good job of completing the Baseline Care Plan. He said he assumed that since the resident was an established resident, it would have been completed. 2. Resident #455 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/30/18, revealed the resident had severely impaired cognition. A review of the electronic medical record and the paper chart did not include an Interim or Baseline Care Plan. When interviewed on 6/5/18 at 9:07 a.m., the RNM said it was his responsibility to initiate the Baseline Care Plan at the time of admission. He said he was not on the unit at the time of the resident's admission and did not know why the Baseline Care Plan was not done. 3. Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/8/18, revealed the resident had moderately impaired cognition. The Admission Baseline Care Plan, documented that the resident was admitted on [DATE], but does not document the individual(s) completing the document or the date(s) the information was completed. There was no documented evidence in the resident's medical record that a summary of the Baseline Care Plan was provided to the resident or resident representative. Interviews conducted on 6/5/18 include the following: a. At 8:48 a.m., the RNM stated that the Baseline Care Plan is usually completed within the first 24 hours of admission. The RNM said that a copy is not usually given to the resident or resident representative, it is just placed in the front of the chart. b. At 10:34 a.m., the Director of Social Work (DSW) said she has not received any in-house training on the development of the Baseline Care Plans. The DSW said there was a form to use but she thinks there is another one that needs to be initiated. c. At 10:44 a.m., the MDS Coordinator stated that she knew that the regulation for the Baseline Care Plans changed in (MONTH) (YEAR), that the Care Plans needed to be completed within 48 hours of admission and a copy was to be given to the resident and/or resident representative. The MDS Coordinator said that she notified the staff educator and the Director of Nursing (DON) that staff needed to be educated on Baseline Care Plans. She said that when she realized the education had not been done, she went to staff individually to tell them that it needed to be done. She said that she had done an audit herself and realized that the Baseline Care Plans were not being done. The MDS Coordinator said that she expected that the Unit Nurse Managers to complete the Baseline Care Plans, obtain the resident's or resident representative's signature and provide them with a copy of the care plan, and then file the Baseline Care Plan in the chart. d. At 1:43 p.m., the DON stated that whomever is admitting the resident is responsible for completing the Baseline Care Plan. She said that the Baseline Care Plan is initiated by the MDS Coordinator, then passed to each department to complete their portion. She stated that there was a signature page that accompanied the Interim Baseline Care Plan that each discipline would sign once their section was complete. She said that she expected staff to complete the Baseline Care Plan within 48 hours of admission. She stated that once the Interim Baseline Care Plan was completed, the Social Work department was supposed to send it to the family and document that information in the resident's record. (10 NYCRR 415.11)

Plan of Correction: ApprovedJuly 14, 2018

Resident #455 is no longer in the facility
Resident #59 CCP will be reviewed and revised as needed.
The facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet the standards of quality of care, within 48 hours of admission, then provide the resident or representative a copy. SW will be responsible for reviewing and providing the resident or representative a copy of the baseline care plan within 48 hours of admission. All IDT members will be educated on the process and new policy and procedure regarding baseline care plans by the DON.
All residents who have been admitted have the potential to be affected by the same deficient practice. The IDT will conduct a review of all residents identified. A 100% will be conducted to ensure the baseline care plan was developed in 48 hours of admission. An audit will be conducted by the DON/designee, RN supervisor, and Unit manager. The audits will then be forwarded to the DON. The DON will be notified of deficient practice, analyzed and trended findings will be presented to the QAPI Committee at next meeting. This will be ongoing.
The DON will be responsible for compliance.

FF11 483.35(a)(3)(4)(c):COMPETENT NURSING STAFF

REGULATION: §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertifcation Survey, it was determined that for one (Resident #16) of one resident reviewed for respiratory care, the facility did not have sufficient staff with appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychological wellbeing of each resident. Specifically, staff were not provided education and competency review for the use of and maintenance of Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machines (a noninvasive ventilation machine that involves the administration of air by an external device at a predetermined level of pressure). This is evidenced by the following: See F695 for additional information regarding Resident #16. The Respiratory Care Tag (F695) was cited because the resident's [MEDICAL CONDITION] was not applied, respiratory equipment supplies were not maintained, and the respiratory care plan did not reflect the resident's current respiratory status. The facility policy, [MEDICAL CONDITION]/[MEDICAL CONDITION] (Bilevel Positive Airway Pressure) Support, dated 2/4/18, included to review and follow the manufacturer's instruction for [MEDICAL CONDITION] machine set up. The facility was unable to provide the manufacturer's instructions. The Facility Assessment, last reviewed on 5/21/18, revealed that the facility may accept residents with common diseases, such as [MEDICAL CONDITION] and [MEDICAL CONDITION], and was able to provide respiratory treatments including [MEDICAL CONDITION]. Resident #16 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/6/18, revealed the resident had moderately impaired cognition and received [MEDICAL CONDITION]. The physician orders, dated 3/16/18 and 5/3/18, included [MEDICAL CONDITION] on at bedtime and off in the morning. The order included to rinse and dry the mask prior to application, fill the container with sterile water, and the check filter at bedtime. The start date of the order was 7/30/17. Interviews conducted on 6/1/18 included the following: a. At 2:34 p.m., the Licensed Practical Nurse (LPN) Nurse Manager (NM) stated she did not know how often [MEDICAL CONDITION] supplies needed to be changed but thought they should be cleaned weekly. The LPN NM stated she had not received any training from the facility on the use of and or care and maintenance of the [MEDICAL CONDITION] machine. She said she had some knowledge from personal experience. b. At 2:42 p.m., LPN #1 stated she knew how to use a [MEDICAL CONDITION] machine from the personal use of one. She stated she had not received any training on the use and or care and maintenance of [MEDICAL CONDITION] machines from the facility. When interviewed on 6/4/18 at 10:27 a.m., the Director of Nursing stated there was no documentation of education or competencies for the use of and care and maintenance of [MEDICAL CONDITION] machines. (10 NYCRR 415.26(c)(1)(iv))

Plan of Correction: ApprovedJuly 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LPN unit manager was educated on proper care and cleaning of [MEDICAL CONDITION] on 6/6/2018. Comprehensive care plan was reviewed and updated on 6/10/18 to reflect [MEDICAL CONDITION] usage and settings. All nursing staff was educated on proper care and maintenance of [MEDICAL CONDITION] and mask by staff educator. DON and ADON will complete weekly audits of TARs to ensure compliance annual education and new hire education will be completed by staff educator. Staff educator will provide a list of new hires weekly to include in audit. The facility will educate all nursing staff to ensure sufficient and appropriate education for the safety of all residents to understand adequate competencies and to ensure appropriate skill sets of all staff. The staff educator will be in serviced and counseled with a skills checklist and annual education for all staff current and new hires. The DON or designee will conduct biweekly audits of all employees and new hires to ensure compliance. All residents involved their medical records were reviewed and updated to reflect orders as needed on 6/10/18. Physician orders [REDACTED]. The DON is responsible for compliance.

FF11 483.90(i)(3):CORRIDORS HAVE FIRMLY SECURED HANDRAILS

REGULATION: §483.90(i)(3) Equip corridors with firmly secured handrails on each side.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations and an interview conducted during the Recertification Survey, it was determined that for two (first and second floors) of three resident use floors, the facility did not properly equip corridors with handrails on each side. Specifically, there was a loose section of handrail and a section of corridor wall that lacked a handrail. This is evidenced by the following: 1. Observations on 5/30/18 at 8:40 a.m. revealed an approximately 10-foot long section of handrail that was loose from the half wall across from the second floor nurses' station. An interview with the Director of Maintenance revealed they had recently bought some new anchors for the handrail but have not had the chance to put them up. 2. Observations on 5/30/18 at 9:50 a.m. revealed an approximately 10-foot section of the half wall across from the first floor nurse's station lacked a handrail. An interview with the Director of Maintenance revealed the handrail came loose so they ordered new brackets and have to put it back up. Further observations on 6/5/18 at 2:35 p.m. revealed no handrail outside the first floor nurses' station, and a section of handrail was on the floor in the basement near the doors to the loading dock. (10 NYCRR: 415.29, 713-1.8(a))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two (first and second floors) of three resident use floors, the facility did not properly equip corridors with handrails on each side. Specifically, the facility did not complete their written Plan of Correction by correcting all of the handrails cited during the 6/6/18 Recertification Survey. This is evidenced by the following: 1. An observation on 8/13/18 at 11:26 a.m. revealed an approximately 10-foot long section of handrail that was loose from the half wall across from the second floor nurses' station. 2. An observation on 8/13/18 at 11:34 a.m. revealed an approximately 10-foot section of the half wall across from the first floor nurse's station lacked a handrail. 3. Observations conducted on 8/17/18 at 10:14 a.m. revealed a section of wall between Resident room [ROOM NUMBER] and the housekeeping closet that was approximately 18 inches wide and was not equipped with a handrail. The same issue was found between the supply closet and Resident room [ROOM NUMBER]. When interviewed on 8/17/18 at 9:17 a.m., the Director of Maintenance stated that there were no audits for the handrails. He said that he knows that fixing the handrails are a priority, but there were greater priorities. (10 NYCRR 415.29, 713-1.8(a))

Plan of Correction: ApprovedSeptember 10, 2018

No residents were harmed due to the deficient practice, however, the facility recognizes that all 1st and 2nd floor residents could have been affected.
1. The director of maintenance or designee has taken the 10-foot section of the 2nd floor handrail and applied the anchors to stabilize it for safety.
2. The director of maintenance or designee has taken the 10-foot section of the 1st floor handrail that was in the basement and placed it back on the wall near the nurses station with the new brackets to have it stabilized for safety.
The director of maintenance or designee has conducted a whole house audit to inspect all handrails to ensure stability and conduct any repairs as necessary.
The audit will be completed on a weekly basis for 8 weeks and then monthly for 4 months. All audits will be presented to the QAPI committee for review and from there the need for continued monitoring will be decided.
The Director of Maintenance is responsible for compliance.

E3BP 402.6(d):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (d) A provider may temporarily approve a prospective employee while the results of the criminal history record check are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

Based on interviews and record reviews conducted during the Recertification Curvey, it was determined that for one of eight employee files reviewed for the Criminal History Record Check (CHRC), the facility did not provide supervision for an individual awaiting results of a CHRC. This is evidenced by the following: On 5/30/18 from 1:00 p.m. to 1:41 p.m. the surveyor was presented with eight employee CHRC files for review. The records showed that a Certified Nursing Assistant (CNA) was hired on 6/20/17 and received a pending denial letter from the CHRC on 7/5/17. The CNA was terminated from employment on 8/2/17. A review of the electronic time records revealed that the CNA worked shifts at the facility on 6/20 through 6/22/17, 6/26 through 6/29/17, and 7/5/17. An interview with the Human Resources/Staffing Representative revealed there was no documentation of supervision in the CNA's file. Further review of the facility CHRC policy revealed Sections #11 and #12 read as follows: While CHRC results are pending, all provisional employees must be supervised by another employee supervision must be documented in writing on a weekly basis utilizing the daily supervisory tracking for temporary employees. (10 NYCRR Section 402.6(d), 402.4(b)(2)(i))

Plan of Correction: ApprovedJuly 12, 2018

A whole house audit was done to see which employees still has a pending CHRC results and if there is a weekly tracking log for the daily supervision. All new employees were reviewed and supervisory logged was implemented for those who needed a supervisory log. An audit was completed for accuracy of all employees. The Business Office Manager will conduct these audits and present them to the QAPI committee. The Administrator will educate the Business Office Manager on the policy and procedure of the CHRC. The audits will be ongoing. The Business Office Manager is responsible.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 52 residents reviewed for Comprehensive Care Plans (CCP), the facility did not develop a care plan based on the resident assessment and the facility did not implement interventions in accordance with the resident's care plan. Specifically, physician orders [REDACTED].#17), the care plan did not include specific interventions for inappropriate behaviors (Resident #90), and physician orders [REDACTED].#35). This is evidenced by the following: 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/3/18, revealed that the resident had severely impaired cognition and was totally dependent on staff for all Activities of Daily Living (ADLs). The current physician orders [REDACTED]. The CCP, dated 3/7/18, included [MEDICATION NAME] (tubular elastic bandage designed to provide tissue support and compression) size D to bilateral lower extremities to be worn at all times and may be removed for personal care and then reapplied and chair and bed alarms. Review of the 4/27/18 Certified Nursing Assistant (CNA) Closet Care Plan revealed a chair alarm and bilateral lower extremity [MEDICATION NAME]. When observed daily from 5/29/18 through 6/1/18, the resident was not wearing [MEDICATION NAME]. During observations of the resident in bed on 5/29/18 at 10:28 a.m. and 11:14 a.m., on 5/30/18 at 3:04 p.m., and on 6/1/18 at 7:34 a.m., the resident's bed alarm was not functioning. When observed in a chair on 5/31/18 at 1:08 p.m., and on 6/1/18 at 9:48 a.m., the resident did not have an alarm in the chair: Interviews conducted on 5/31/18 included the following: a. At 12:59 p.m., the CNA said the resident was not wearing [MEDICATION NAME] because the facility does not have any and has not had any for a couple of weeks. She said the nurse gives them to the CNA to put on the resident. She said that bed and chair alarms should be hooked up and working. b. At 1:13 p.m., the Licensed Practical Nurse (LPN) said that it is not the nurse's responsibility to sign off the [MEDICATION NAME], it is up to the CNAs. She said the [MEDICATION NAME] should be in the resident's room or can be obtained from Central Supply. At that time, she went into the medication room and found two [MEDICATION NAME] and put them on the resident. When interviewed on 6/1/18 at 2:02 p.m., the Interim Assistant Director of Nursing said the resident was care planned for [MEDICATION NAME] because she has swelling, and the CNAs should put them on. She stated that the resident is not at risk for falls but is on [MEDICAL CONDITION] precautions. She said the CCP included alarms so they should be in use. 2. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/8/18, revealed that the resident had severely impaired cognition and required extensive assistance for all ADLs, and no physical behaviors including scratching. The current CCP and the current CNA Visual/Bedside Kardex Report related to behaviors, included that the resident licks his hand, wipes it on his pants, and scratches at his face and scalp related to his [DIAGNOSES REDACTED]. The CCP does not include interventions for scratching at his face and scalp. When observed on 5/29/18 at 12:03 p.m. in the unit dining room, the resident had five open areas on his scalp. The areas were bright red and appeared to be weeping serosanguinous (blood tinged) drainage. The resident was scratching at his face and beard. The resident's fingernails had dried blood underneath. At 12:32 p.m., the resident was moved to a table in the dining room where he was set up with his lunch tray and proceeded to eat his meal with his hands. When interviewed on 6/4/18 at 2:35 p.m., the Social Worker (SW) stated that the care plan regarding repetitive behaviors should include more than educating the resident due to the resident's impaired cognition. The SW said the care plan should include a more hands on approach such as keeping fingernails trimmed, making sure hands are clean for meals, and monitoring for open wounds. During an interview with the Director of Nursing (DON) on 6/5/18 at 10:11 a.m. regarding the resident picking and scratching at his skin and licking his hands and wiping them on his pants, the DON stated that encouraging and educating the resident is not an appropriate intervention due to his cognition. The DON said that the education should be for the staff for proper hygiene during mealtime and to monitor for open wounds. The DON said that nursing would be responsible for writing a CCP for behavior and skin issues. 3. Resident #35 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/10/18, revealed that the resident had moderately impaired cognition, was totally dependent on staff for bed mobility, had a Stage II pressure ulcer with an onset date of 3/29/18, and treatments included a pressure reducing device for the bed. Physician orders, dated and signed 5/3/18, included an air mattress for pressure relief and directed to check functioning every shift. The (MONTH) (YEAR) Treatment Administration Records (TAR) included an entry for an air mattress for pressure relief and to check the functioning every shift. The entry was initialed to indicate the service was provided for days, evening and nights 89 out of 93 opportunities. The current Care Card included a pressure reduction low air loss mattress. Intermittent observations conducted from 5/29/18 through 6/4/18 revealed there was no air mattress on the resident's bed. Interviews conducted on 6/4/18 included the following: a. At 10:11 a.m., the LPN stated she thought the resident had an air mattress on his bed but was not 100 percent sure. Upon observing the resident's mattress, the LPN stated that the resident had a standard mattress the facility provided. The LPN said she was familiar with air mattresses. She stated the air mattress was signed off as completed, meaning the air mattress was in place and functioning. The LPN reviewed the TAR, which she had initialed, and then stated, Well the bed is working. b. At 10:25 a.m., the LPN Nurse Manager stated the mattress on the resident's bed was not an air mattress and she had ordered one that day. She stated she would not expect the nurses to sign for the air mattress if the resident did not have one on the bed. c. At 10:27 a.m., the DON stated the mattress on the resident's bed was not an air mattress. She stated nurses should not be signing the TAR if an air mattress is not in place. (10 NYCRR 415.11(c)(1))

Plan of Correction: ApprovedJuly 14, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action Taken For Those Residents Affected:

Resident # 17 will be reevaluated by physician for use of chair and bed alarm and for the use of [MEDICATION NAME] and see if there is a better device to be used. The comprehensive and the closet care plan will be reviewed and revised as needed. The current orders will be reviewed and updated as needed.
Resident # 90 was seen by the physician on 6/15/18 and the medical record was reviewed and revised as needed. The comprehensive care plan was reviewed and updated on 6/30/2018 as needed.
Resident # 35 medical records were reviewed and revised as needed. The air mattress was applied to resident?s bed on 6/4/18 and complete skin check was completed, and no further skin issues noted.
Corrective Action Taken For Those Residents Potentially Affected:
The facility recognizes that all residents have the potential to be affected through this deficient practice.
All residents currently have orders for the use of alarms and/or assistive devices to ensure necessity and appropriate application as ordered.
A full house audit was completed to ensure nail/hand hygiene was completed.
All residents with pressure ulcers orders and care plans were reviewed and updated accordingly to ensure the application of an air mattress.
Systematic Monitoring:
All nursing staff will be educated on comprehensive care plan and the closet care card as pertaining to each resident and to ensure to follow each order as prescribed by the physician.
The care plan was reflected to state that the nails to be kept short, trimmed and clean. His hands are to be cleaned at all times including but not limited to meal times. All nursing staff will be educated on proper hand hygiene for all residents including but limited to prior to meal times.
Nursing staff was educated on proper documentation on treatment and medication records.
All education will be provided by the staff educator or designee.
Quality Assurance Monitoring:
The ADON or designee will do the following weekly audits: ensuring that the comprehensive care plan and closet care plan are being followed by all nursing staff. A full house audit will be completed on TARs checking for incomplete and inconsistent documentation and match the current orders. All audits will be done weekly for 8 weeks and then monthly for 6 months. All audits will be brought to the QAPI committee for review and from there it will be determined it continued monitoring is necessary.
The Director of Nursing is responsible for compliance.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for four (Residents #20, #29, #32, and #102) of five residents reviewed for unneccessary medications, the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist. Specifically, drug regimens were not completed for the months of (MONTH) (YEAR) through (MONTH) (YEAR) and (MONTH) (YEAR). This is evidenced by the following: Review of the Medication Regimen Review books provided by the facility revealed no documentation of Consultant Pharmacy reviews or recommendations for (MONTH) (YEAR) through (MONTH) (YEAR) and (MONTH) (YEAR). Interviews conducted on 6/5/18 included the following: a. At 10:36 a.m., the Director of Nursing (DON) said that she was aware that the Pharmacy Consultant was supposed to review medical records monthly. She said when she started working in the facility in (MONTH) (YEAR), she became aware that the consultant had not completed reviews from (MONTH) (YEAR) through (MONTH) (YEAR). She said that she receives the reviews and recommendations and distributes them to the Nurse Managers to review with medical staff. The DON stated the Nurse Practitioner left in (MONTH) (YEAR), and she thinks she took some of the reviews and recommendations with her. b. At 11:10 a.m., the Administrator said she had no further documentation about pharmacy reviews and recommendations and had given everything to the DON. c. By telephone at 1:12 p.m., the Consultant Pharmacist stated that she had not been completing the reviews on a monthly basis due to a dispute over billing. The Consultant Pharmacist said that she was not paid last fall so she did not do any reviews until (MONTH) (YEAR) when she was paid. She said that happened again in (MONTH) (YEAR) when the facility did not pay her, and she cannot be sure it will not happen again. The Consultant Pharmacist said she will give a 30-day notice if she does not get paid and will not work until she is paid. d. At 2:03 p.m., the Administrator said she was aware that it was a requirement that a Consultant Pharmacist reviews the charts and medications monthly. The Administrator said when she started working with the facility in (MONTH) (YEAR), she knew that the Consultant Pharmacist had not been paid. The Administrator said she worked with the corporate office on billing and thought it was resolved in about 30 days. The Administrator said she was aware that it occurred again in (MONTH) (YEAR). (10 NYCRR 415.18(c)(1)(2))

Plan of Correction: ApprovedJuly 23, 2018

Residents #20, #29, #32, #102, medical records were reviewed and updated as needed.

The DON/Designee will conduct an audit of all residents monthly to ensure that all medical records are reviewed by the Pharmacy Consultant. The DON will ensure that all drug irregularities are reported to the provider upon receiving documentation from the Pharmacy Consultant. All irregularities will be identified and addressed per facility policy and procedure. The DON and Pharmacy Consultant will meet monthly to review and discuss drug regimen for residents. The DON will distribute recommendations to Unit Managers for provider to review. The Unit Managers will address new orders or changes from provider.
The Administrator will follow up with Pharmacy Consultant monthly to ensure that timely payments are made to ensure continued compliance with monthly pharmacy recommendations are maintained.
The Pharmacy Consultant will inform Administrator when there is a lapse in payment.
The DON is responsible for compliance.

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three of three residential units and one of one main kitchen, the facility did not maintain equipment in safe operating condition. The issues involved mechanical lifts not maintained per manufacturer's recommendations, a suction machine that failed a safety inspection, clothes dryers out of service, a refrigerator, a freezer and meat cooler that were not working properly, and several resident wheelchairs with torn armrests and chair cushions. This is evidenced by the following: 1. Observations conducted on 5/29/18 at 2:22 p.m. revealed a Contemporary Products, Inc. Model 6260 Aspirator on a crash cart in the second floor dining room. The unit was marked with a third party biomedical contractor sticker that read 'FAIL,' and the pressure gauge read 95 psi (pounds per square inch). When interviewed at that time, the Director of Maintenance said they do not use that contractor anymore. Further review of the inspection checklist on the crash cart revealed a Licensed Practical Nurse (LPN) had signed as completed on 5/28/18. When interviewed on 5/29/18 at 2:27 p.m., the Director of Nursing (DON) stated that she does not see how the suction machine in the second floor dining room would be in working order since the plug did not have a ground and there was no glass on the gauge. The DON stated that they would send someone to get a suction machine from another floor. A review of facility records provided by the Director of Maintenance on 5/30/18 at 10:00 a.m. revealed that on 4/30/18, the Contemporary Products Inc. Model 6260 suction machine in the second floor dining room had failed its inspection by the biomedical contractor because it needed a new gauge and plug. 2. Observations and record reviews on 5/30/18 between 10:30 a.m. and 10:43 a.m. revealed the following: a. An Invacare 450 lift, control number 1011, found on the third floor by Resident room [ROOM NUMBER] was also on the list of items which failed the 4/30/18 biomedical inspection because it needed a new control box and leg spreader assembly. b. An Invacare Reliant RPS350 Sit to Stand Lift, control number 1010, was found in Resident room [ROOM NUMBER] and had failed the biomedical inspection on 4/30/18 because it needed an emergency pull on the [MEDICATION NAME]. In an interview at that time, Certified Nursing Assistant (CNA) #1 stated that the emergency pull tab was broken, but there is a second way to use the emergency switch. CNA #1 stated that they use the sit to stand lift for Resident # 86 and that sometimes you have to hit the box to get it to work. CNA #1 stated that at one point Resident #86 had gotten stuck in the up position and they had to use a paperclip to get the stand to release. c. An Invacare Reliant RPS350 Sit to Stand Lift, control number 1018, was in the first floor shower room and had failed the biomedical inspection on 4/30/18 because it needed new casters and the leg spreader assembly was broken. When interviewed on 5/30/18 at 2:52 p.m., the Director of Maintenance stated that none of the lifts should be on the floor, they should be downstairs for repair. When interviewed on 5/30/18 at 4:52 p.m., the Administrator stated that approval was not given to repair the mechanical lifts. She said she was talking to corporate to get approval. In an interview on 5/31/18 at 9:19 a.m., the Administrator stated that she contacted the corporate office by email on 4/30/18. She said on that same day, corporate asked how many lifts they had and how many they needed. The Administrator said she reported to corporate that all lifts did not pass the inspection. She said that because a piece of equipment fails that does not mean it is not safe. She said the contractor fails a piece of equipment if it does not meet manufacture's specifications. The Administrator said maintenance makes the determination if the equipment is safe. She said all equipment that was tagged was taken out of service after the inspection. The Administrator said it appears that staff were still using the lifts after they failed and were tagged. She said corporate contacted the Administrator verbally and they were told to rent equipment. The Administrator contacted a vendor but was unable to rent any equipment due to the facility's past reputation. The Administrator then stated that they would need six mechanical lifts and three mechanical stands. They received one lift and one stand. She said the reason that they did not get six lifts and three stands was because corporate only approved two. The Administrator stated that they had decided they needed six lifts and three stands because they wanted to replace all stands and lifts because they failed the inspection, not because they were determined to be unsafe. During a telephone interview on 5/30/18 at 11:17 a.m., the President of Omnicor, the vendor who inspected the patient care equipment, stated that when an item fails, they use the user manual and determine if the items meet manufacturer's specifications. The President stated that if a piece of equipment fails, it does not mean that it is not safe. If the manual states that an item cannot be used if damaged, then they would take that into account. In an interview on 5/31/18 at 1:00 p.m., when asked if the lifts were taken out of service when they were identified as having problems, the Director of Maintenance stated that all the lifts were brought down to the basement and that he was not sure how the lifts got back up on the floors. The Director of Maintenance then stated that some lifts were taken out of service, and he was not sure which lifts were left in service. He said someone could have come down here and brought them back upstairs. He said the ones that were taken out service had a sign on them stating not to use or out of service. During a telephone interview on 5/31/18 at 2:22 p.m., an Invacare Technical Support Representative stated that if a lift fails an inspection then it should not be used. The emergency pull [MEDICATION NAME] needs to be in place, and in his opinion he would pull the lift out of service. The leg spreaders must be able to open and lock or close and lock. A review of the product manual for the Invacare Reliant RPS350 directed, in case of damage, DO NOT use the equipment. The manual also documented that, the shifter handle MUST lock into its mounting slot to lock the legs in the full open or closed position. A review of the facility's Building Audit Checklists revealed that on (MONTH) 14-18, (YEAR), there was a building wide audit and the Hoyer/Ready Stand on the first floor was listed as needing repair, the suction machine on the second floor was listed as failed/ground, the Hoyer/Ready Stand on the second floor was listed as needing repair, and the Hoyer/Ready Stand on the third floor was listed as needs repair. 3. Observations on 5/29/18 at 9:20 a.m., revealed a sign on the basement gas meter room that stated: In case of gas odor call Rochester Gas &Electric (RG&E). Observations on 5/29/18 at 10:40 a.m., revealed a smell of natural gas in the corridor by the first floor front elevator. When interviewed at that time, the Administrator said a vendor came in and said it was the basement dryer and they shut it down. The Administrator stated that she has noticed the natural gas odor, and she thinks the Director of Maintenance was going to call RG&E. Observations on 5/29/18 at 11:30 a.m. revealed a local city firefighter used an instrument and stated that there were minor gas leaks behind the basement dryers. Observations in the basement laundry room on 6/6/18 at 8:50 a.m. revealed a red tag on the dryer that included: RG&E 6/2/18 leaking appliance, repair or replace gas valve (dryer leaking at gas valve). Observations on 6/6/18 at 8:55 a.m. revealed the only two dryers in the basement laundry room were out of service. One was marked with a sign that read Do Not Use, and the other dryer was shut off due to a gas leak. 4. During an observation on 5/29/18 at 9:10 a.m., there was broken up chunks of ice on the freezer floor and ice that had been removed from the freezer was placed in a drain outside the freezer, and there was evidence of ice build -up on a carton of biscuits. In addition, one light was out in the back of the freezer. When interviewed at that time, the Food Service Director (FSD) said she had called the repair company to come and find out what the issue was with the ice build-up because the staff have to clean out the ice from the freezer every morning. The repair company repaired and presented their work order on 6/5/18, which revealed the freezer was running warm with a lot of ice buildup on the evaporation coil. The repair company installed a new defrost clock and readjusted the compressor setting. In an observation on 5/29/18 at 1:44 p.m., the refrigerator in the third floor dining room had an internal thermometer that read 55 degrees Fahrenheit (F). A chart posted on the outside of the refrigerator revealed that the temperature was recorded as 44F. The surveyor's thermocouple read 56.3F in the refrigerator, and the temperature of a small container of chocolate milk was 56.2F. The refrigerator contained potentially hazardous foods including milk products. In an observation on 6/5/18 at 1:45 p.m. in the main kitchen, the meat and milk cooler was registering at 50F. When interviewed at that time, the FSD said she was unaware of the problem and called the refrigeration company. 5. Observations made of the resident wheelchairs revealed the following: a. During an observation and interview on 5/29/18 at 9:57 a.m., Resident #93 stated that his wheelchair is new to him. He showed the surveyor that both arms were ripped with exposed foam and ragged edges. The resident stated that the only thing new about the wheelchair is the name band. b. On 5/29/18 at 10:46 a.m., Resident #61 was seated in a wheelchair that had tears in both armrests with exposed cushioning. c. On 5/30/18 at 2:38 p.m. and on 6/1/18 at 2:01 p.m., Resident #90 was seated in a wheelchair and the left armrest had a tear along the tip of cushion exposing the inner foam. d. Resident #11 was observed on 5/30/18 at 2:38 p.m. seated in a wheelchair with a tear along the front of the armrest cover exposing the cushion. e. On 6/1/18 at 12:34 p.m., Resident #154 was seated in the third floor dining room in a wheelchair eating his lunch meal. The right armrest on the wheelchair had a tear along the tip of cushion with foam cushion exposed. f. On 6/1/18 at 1:54 p.m., the right front corner of Resident #94's wheelchair had a 6-inch x 12-inch area of blue tape covering a tear. When interviewed on 6/1/18 at 2:11 p.m., the Interim Assistant Director of Nursing (ADON) stated that either maintenance or Physical Therapy fix wheelchairs. The ADON called the Director of Physical Therapy (DPT) with the surveyor present. The physical therapist said that he does not have a list of equipment requiring repair but he is starting one due to so many wheelchairs requiring repair. When interviewed on 6/4/18 at 2:45 p.m., the DPT stated that a full house audit of wheelchairs and cushions was completed on 5/22/18 and that replacement wheelchair cushions had been ordered. He said since the audit, no repairs have been done. The DPT said that there are not enough wheelchairs in house. He said there are no extras. During an interview and observation with the DPT on 6/5/18 at 8:59 a.m., the DPT looked at the resident's wheelchair and stated that he was not aware that Resident #93's wheelchair looked like that and he would get the resident a replacement immediately. (10 NYCRR 415.29(b))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (third floor)of three residential units, the facility did not maintain equipment in a safe operating condition. The issues included residents' wheelchairs with torn and/or missing armrests. This is evidenced by the following: Resident #154 was observed on 8/17/18 at 9:15 a.m., seated in his wheelchair. The right armrest was torn along the front edge exposing the foam cushion, and the left armrest was torn along the back edge exposing the foam cushion. Resident B was observed on 8/17/18 at 9:10 a.m., seated in his wheelchair. The left armrest had a large ripped area exposing the foam cushion, the right armrest had ripped fabric along the front and sides, and the foam cushion was completely missing. Resident #38 was observed on 8/17/18 at 9:15 a.m., seated in her wheelchair. The right padded armrest was missing completely, and the resident was resting her forearm on the bare metal. When interviewed on 8/17/18 at 9:55a.m. regarding resident wheelchairs, the Director of Physical Therapy (DPT) stated that he was aware of what repairs were needed. The DPT said he was not able to make the repairs due to not having the parts or equipment to fix and/or replace the wheelchairs. Additionally, the DPT stated that a full house audit of resident wheelchairs was not completed after the Recertification Survey (6/6/18) and that he has not been able to promptly repair and/or replace the wheelchairs. The DPT said that following the Recertification Survey ten wheelchairs were ordered and switched out. The DPT stated that every few weeks he places an additional order for more wheelchairs. The DPT said that when he placed a large order for wheelchairs and parts, it was denied by corporate. The DPT said when he places an order for [REDACTED]. (10 NYCRR 415.29(b))

Plan of Correction: ApprovedSeptember 10, 2018

1. The suction machine was taken off of the 2nd floor and replaced with a working suction machine. All nurses will be re-educated from the Director of Maintenance on the procedure for inspecting the suction machine is in working order. A new inspection checklist will be made to reflect how it is to be checked each night shift. An audit will be done facility wide to ensure all suction machines are working or removed from service. An audit will be conducted weekly for 8 weeks and monthly for 3 months to reflect staff knowledge on how to tell the suction machine is in working order. All audits will be brought to the QAPI meeting and from there it will be examined if further education will be needed.
2. A. Invacare 450 lift, control number 1011, was removed from the floor and was tagged out of commission. A new 450 lb lift was purchased, delivered, and inspected and placed in circulation.
b. The Invacare Reliant sit to stand was removed from the floor and tagged for non-use.
c. The Invacare Reliant sit to stand, control number 1018 was removed from the floor and tagged for non-use.
All lifts that have been removed from the floor has been tagged out, remotes and batteries removed from them to ensure staff will not take the lift back up to the floor for resident use. Monthly audits will be conducted by maintenance staff to ensure all lifts are safe for resident use. If any are deemed to need repair the machine will be removed from the floor, tagged until repairs are made.
3. Laundry vendor came and repaired the gas valve and replaced the dryer that was shut off due to a gas leak. RG&E came back in and removed the red tag to allow us to operate the dyers again.
4. The built up ice was removed. The carton of biscuits were thrown out. The freezer was repaired. The carton of biscuits were discarded. The light was repaired in the back of the freezer.
The third floor dining room refrigerator was inspected by the maintenance director after surveyor took their thermocouple read and the temperature was showing 41 degrees Fahrenheit. It has remained within range since 5/29/18. Staff have been educated on if the temperature is not within range to alert the maintenance staff and remove the food items from the fridge until repaired. The chocolate milk was thrown out.
The meat/milk cooler was inspected by refrigeration company and has made repairs to allow it to work properly. Audits will be conducted by diet technician of all cooler/freezer/refrigerator to ensure temperatures are within an appropriate range and there is no ice build up, light bulbs blown, etc. If there are any issues then the Dietary director and Maintenance director will be notified to ensure timely follow up and repairs.
5.
a. Resident #93's wheelchair has both arms replaced with new arm rests.
b. Resident #61's wheelchair has both arms replaced with new arm rests.
c. Resident #90's wheelchair left arm was replaced with a new arm rest.
d. Resident #11's wheelchair arm rest was replaced with a new arm rest.
e. Resident #154's wheelchair right arm rest was replaced with a new arm rest.
f. Resident #94's wheelchair was repaired to address the tear.
The Director of Physical Therapy (DPT) places an order monthly for more wheelchairs and/or parts and has received them already.
The DPT has conducted a whole house audit of residents who have/need wheelchairs and if they are in need of repair/replacement it is done promptly.
All nursing staff will be educated on how to handle and properly operate all lifts within the facility. They will also be educated on what to do when there is an issue with the lift.
A policy and procedure will be developed to address gas leaks and what staff is supposed to do. All staff will be educated on gas leaks.

Monthly audits on going by the director of maintenance and will present the audits to the QAPI committee for continued monitoring and to address any concerns.
The DPT, Maintenance Director and Administrator is responsible for compliance.

FF11 483.60(d)(3):FOOD IN FORM TO MEET INDIVIDUAL NEEDS

REGULATION: §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(3) Food prepared in a form designed to meet individual needs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #90) of seven residents reviewed for nutrition, the facility did not ensure food was prepared in a form designed to meet each resident's individual needs. Specifically, a resident with severely impaired cognition, who eats with his hands and refuses staff assistance, was not provided with a diet to meet his needs. This is evidenced by the following: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/8/18, revealed the resident had severely impaired cognition and required supervision and set up for eating. The Comprehensive Care Plan and Certified Nursing Assistant (CNA) Kardex revealed a diet order of no added salt, regular consistency with thin liquids, and Ensure Clear (dietary supplement). Review of a Plan of Care note, dated 5/17/18, and signed by the Social Worker, revealed that the resident was on a no added salt diet, regular consistency and thin liquids and receives Ensure Clear 240 cubic centimeters (cc) three times daily for his recent weight loss of 21.6 pounds in 180 days. The resident receives extra items and snacks between meals. During observations in the unit dining room on 5/29/18 from 12:32 p.m. through 1:13 p.m., and on 6/1/28 from 12:30 p.m. through 12:46 p.m., the resident was observed eating food items including rice with pork and gravy and cooked spinach with his hands, and apple crisp by picking up the bowl and eating directly from it with his mouth and hands. The resident was not seen using utensils at any time. The resident was observed on 5/30/18 at 1:28p.m., in his room lying in bed with his lunch tray on the overbed table with the remains of his lunch on the tray including mashed potatoes with gravy and corn. When interviewed on 6/1/18 at 1:10 p.m., the Diet Technician (DT) stated that the resident gets supplements, sandwiches, and snacks three times daily and eats them well because they are finger foods. She said the resident is also provided regular meals. The DT stated that Occupational Therapy attempted a consult and the resident got upset. The DT added that when staff attempt to help the resident, he gets upset and combative. When asked what could be done for a resident who cannot see and will not use utensils, the DT answered that the facility has a finger food selection for diet and it would be more dignified for him to have finger foods. At 1:24 p.m., the DT informed the surveyor that the Registered Dietician (RD) had been contacted via telephone, and the RD had shared that the resident does well with snacks (cheese and crackers), finger foods and supplements. The RD said that she would change his diet order to finger foods. When interviewed on 6/4/18 at 2:53 p.m., the resident's assigned CNA said that when the resident eats, he feels around on the tray with his hand and eats with his hands. The CNA said that she had noticed that day, that the resident received a grilled cheese and a fortified cookie and that he had eaten everything on his tray. (10 NYCRR 415.14(d)(3))

Plan of Correction: ApprovedJuly 16, 2018

Resident #90 diet order was changed to finger foods as tolerated by resident to accommodate his individual needs.
The staff will be educated to ensure that all residents receive prior assistance at the level of their personal need, related to meal time, hand hygiene, and noting any changes or patterns in the residents eating habits.
All residents have the potential to be affected by the deficient practice.
An audit will be done by the Registered Dietician or designee for all resident diets to reflect their personal preferences and to meet individual needs.
The audit will be done for all residents and new admits to ensure that resident individual needs are met upon admission and periodically to evaluate any changes.
The DON/Designee will ensure compliance of these audits.
The audits will be presented and reviewed by the QA committee at all meetings.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: October 18, 2018
Corrected date: October 22, 2018

Citation Details

Based on observations and interviews conducted during the Recertification Survey, it was determined that for one of one kitchen and one (third floor) of three nourishment rooms, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The issues involved an open ceiling tile above the tray line with exposed ready to eat food, improper hotholding of Time Temperature Control foods, thermometers that were not calibrated, mouse droppings on food items in the dry storage area, in the ceilings, and on the hood of the kitchen stove, and broken floor tiles in the dish room. This is evidenced by the following: 1. During the initial tour of the kitchen on 5/29/18 at 9:00 a.m. and follow-up visits that same day, the following issues were identified: a. At 9:00 a.m., the handwashing sink was not dispensing hot water because the foot pedal was broken. When interviewed at that time, the Director of Food Service (DFS) said she would call maintenance to fix the sink. b. At 9:15 a.m., the meat slicer had white residue stuck in the blade. When interviewed at that time, the DFS said that it was pieces of cloth from cleaning it, and then directed the dietary aide to get a cloth and wipe the meat slicer. c. At 3:35 p.m., there were multiple openings in the suspended ceiling tiles throughout the basement main kitchen. There was an approximately 4-inch x 8-inch opening with bowed ceiling tiles from water damage. When interviewed at that time, the Director of Maintenance said there was a leak from an overflowing sink in the first floor clean utility room. Further observations revealed hundreds of small brown mouse droppings on top of the stainless steel hood directly above the tilt skillet, plate warmer, and a cart of hamburger buns. d. At 3:42 p.m., there were multiple small brown mouse droppings on the floor in the basement dietary dry food storage room. Droppings were also observed on unopened boxes of food and on the tiles above the suspended ceiling. The ceiling grid was damaged and sagging from a prior water leak and was not tightfitting. The sagging tiles were located directly above boxes of food items on shelves including, but not limited to cereals. In addition, there was a brown liquid and dead bugs in the light fixtures in the dry storage room. 2. During observations on 5/30/18 at 11:45 a.m., there was an open tile in the main kitchen above the tray line where staff were assembling food for the lunch meal. At that time, the surveyor stopped the tray line, asked that the tile be replaced, and the exposed food be discarded. The DFS said the ceiling had been opened since the previous week because the electrician was working on fixing the steam table. 3. During an observation on 6/4/18 at 2:00 p.m., the ice water bath to check the accuracy of thermometers revealed that the digital thermometer was not calibrated. When interviewed at that time, the DFS said she checks the thermometer every morning and has had to calibrate it only three times. The temperature registered at 37 degrees (*) Fahrenheit (F). The DFS said she was unable to find the directions to recalibrate her Ecolab thermometer. She said she did not know what was wrong with the thermometer, and she was going to get a new thermometer out of supplies. Review of the Temperature Log documentation revealed that the thermometer had been recorded each day at 32 *F for the past five months. 4. In an observation on 6/5/18 at 10:35 a.m., there were pools of grayish colored water on the floor in the kitchen dishroom, and there were many cracked, broken, missing, and pitted floor tiles. 5. During an observation on 6/5/18 at 1:55 p.m., there were five approximately 8-inch deep stainless-steel pots that were covered and unlabeled sitting on a table in the kitchen. The vessels were reported by the Food Service Director and cook to contain pureed pizza, gravy, and minestrone soup. The temperature of the soup was 116.6 *F. When interviewed at that time, the cook said the items were taken off the steam table about 10 to 15 minutes ago, and they were going to get cooled down in the walk-in cooler. The facility, Sanitation Policy, dated (MONTH) (YEAR), included to keep all kitchens, kitchen area and dining areas clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. (10 NYCRR: 415.14(h), Subpart 14-1.30, 14-1.31(a), 14-1.40(a), 14-1.95, 14-110(d), 14-1.160)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one of one main kitchen and 90 of 93 residents residing in the facility, facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain kitchen plumbing systems in a manner to prevent contamination of food preparation areas by sewage or liquid waste, potentially exposing residents to the spread of a foodborne illness outbreak. This resulted in IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY that is widespread. This is evidenced by the following: Chapter 10 of the New York Code of Rules and Regulations (10NYCRR) part 415.14 (h) Dietary Services directs that: The facility shall store, prepare, distribute and serve food under sanitary conditions and in accordance with the sanitary requirements of Part 14 (Service Food Establishments) of Chapter I (State Sanitary Code) of this Title. Chapter 1 State Sanitary Code Subpart 14-1, Food Service Establishments, states if sewage or liquid waste is not disposed of in an approved and sanitary manner, this constitutes an imminent health hazard if such sewage or liquid waste contaminates any food, food storage area, food preparation area, or area frequented by consumers or employees. During a tour of the main kitchen on 8/14/18, the following interviews and observations were made: At 10:52 a.m., gray colored liquid waste was observed flowing from a floor drain below the cook's prep sink (Sink #1). The liquid waste was spreading out in a circular puddle about 3 feet wide, 1/8 to 1/4 inches deep, and moving towards the standing floor mixer (mixer bolted to the floor) crossing the width of the floor in the prep area. The water faucet was not on at that time. During that time, Cook #1 was prepping food in that area, walking back and forth through the liquid waste. When interviewed at that time, Cook #1 said he saw the water spilling from below Sink #1 onto the floor. He said that he had not turned the faucet on recently, it just started to flood. Cook #1 said he drains pasta in a colander in Sink #1, and he cleans, washes, and drains fruits and vegetables in Sink #2, a two bay sink directly across from Sink #1. Sink #2 was observed to have an indirect drain without the required air gap between the upper sink drain pipe and the lower sewer pipe creating the potential for contamination of sink water with liquid waste. There was a collection bucket below the sewer plumbing which contained gray colored liquid waste. There was also liquid observed dripping from the sewer plumbing where it entered the wall. At 11:04 a.m., the Director of Food Service (DFS) entered the kitchen and looked at the liquid waste on the prep area floor below Sink #1. The DFS said no one had told her about that and she would have to notify the Director of Maintenance. She said that Sink #2 was also leaking from one of the pipes. The DFS said Sink #2 was in use, for cleaning items like fruits and vegetables. She said there was an indirect drain but said she did not know specific requirements. The DFS observed the indirect drain and said the pipe coming from Sink #2 was sitting directly in the plumbing below it and there was no air gap. The DFS turned on the faucet for Sink #2 and waste water quickly filled the drain pipe, spilling liquid waste from the pipe into the bucket set below it and onto the floor. There was also liquid waste dripping down the wall, onto the floor, from where the pipe enters the wall. At that time, the DFS asked a dietary aide to mop the floor near Sink #1. Cook #1 had continued to work in the prep area, walking back and forth through the liquid waste while preparing lunch. At 11:25 a.m., Cook #1 was cutting cooked baked potatoes for the lunch meal in the prep area. The floor below Sink #1 had been mopped and was visibly damp, with several small puddles of liquid waste and bits of an orange colored substance were on the floor. Between 12:48 p.m. to 12:55 p.m., both Cook #1 and Cook #2 said anytime something is poured into Sink #1, like when they drain noodles, the water goes down the sink drain and then comes back up from around the pipe that goes into the floor, flowing onto the floor. Cook #2 pointed to a 2 to 2 1/2 inches long and 1/2 inch wide break in the seal around the pipe that was located at floor level. He said the water backs up through the break. Cook #2 said he also uses Sink #1 to clean knives and the food processor, fruit and vegetable prep, and leaves the colander in the sink when draining pasta. Cook #1 and Cook #2 said when water flows from the hole in the floor below Sink #1 and travels to the wall behind the floor mounted mixer, it hits the wall, and then flows along the baseboard to the pot sink area. The distance from the floor drain to the wall was 9 feet. Both Cook #1 and Cook #2 said they do not clean up the water themselves and walk back and forth in it until a dietary aide can mop it up. The floor below Sink #1 had a visible gray film on it. The bucket below Sink #2 was full of gray colored liquid waste and was overflowing onto the floor, heading in the direction of Sink #1, across a main kitchen walkway. Five dietary staff members continued to walk on the wet floor. Cook #1 and Cook #2 both said Sinks #1 and #2 have been backing up and leaking for a good five to six months, and they reported that to the DFS, and they thought the DFS had notified Maintenance. Cook #2 said the floors are often wet and that is why he wears shoes with non-slip soles. At 12:56 p.m., the DFS said Sink #2 was overflowing, not backing up. She said that the situation had been reported to both the previous and current Director of Maintenance. The DFS said the current Director of Maintenance said he needed a part to fix it. She said she just entered Sink #1 in the Maintenance Requests Log. At that time, a review of the Maintenance Requests Log, revealed there was one entry for kitchen repairs that included leaking under the sink and sink overflowing no specific sink was identified. The entry did not include a date, name of person requesting the repair, workman initials, remarks, or date of completion on the form. The DFS said that the form had been in the log book since at least the end of the last survey (June (YEAR)), but both sinks were leaking before that time. At 1:02 p.m., the Director of Maintenance said he was unaware of the issues with either Sink #1 or Sink #2. He said he had a plumber that was coming in later that day on an unrelated problem, but he would redirect the plumber to the kitchen. He said that was dirty water that was coming out of Sink #1 and Sink #2. At 1:09 p.m., the Administrator said the DFS had just told her about something in the kitchen, but it did not involve water backing up from the drains and onto the floor. At 1:12 p.m., a Maintenance Technician said he had known about a kitchen sink leaking for about a week. At 5:53 p.m., the Director of Maintenance said he did not have any paperwork regarding any plumbing issues or repairs made to kitchen drains because the previous director took everything when he left in (MONTH) (YEAR). At 6:38 p.m., the Director of Maintenance said that the maintenance workers complete building rounds and are suppose to sign the log when repairs are made. He said if they need assistance, they are to see him. He said the Maintenance Requests log book in the kitchen is always available. He said he expects his workers to routinely check the log book, signing off for repairs made, or reporting issues to him. He pointed out that the current form in the log book was not signed or dated by anyone in the kitchen. Also, at that time, the Administrator said a Registered Dietitian (RD)/Consultant was supposed to be doing kitchen sanitation rounds per the Plan of Correction, but those had not started yet. At 8:08 p.m., the Director of Maintenance stated that they had found that the plumbing for the two-bay sink (Sink #2) was broken in the wall. He said they will have to break out the wall to fix it. The Director of Maintenance also reiterated that he had not been notified about the drains backing up. At 8:09 p.m., Plumbing Contractor #1 stated that there was no water in the wall (Sink #2), so he did not think that the broken pipe was causing the backup. He stated that he believed that snaking the plumbing from the single-bay sink (Sink #1) would clear up the backup. Plumbing Technician #1 was then observed turning on the faucet at the double sink (Sink #2) and liquid waste started to overflow from the indirect drain into a bucket and was dripping from the bottom of the plumbing where the plumbing entered the wall. At 8:18 p.m., Plumbing Contractor #2 stated that when he ran the snake through the plumbing from the single-bay sink (Sink #1), he found a plastic knife and grease. He said that he punched through the grease and hoped that would clear it up. The surveyor observed a white plastic knife which was covered in brownish colored material. At 8:44 p.m., the Director of Maintenance stated that both sinks were no longer backing up. He said the only outstanding issue was that the pipe from the two-bay sink (Sink #2) into the wall was still broken. Interviews conducted on 8/15/18 included the following: At 7:12 a.m., the Director of Maintenance said no matter what term was used, sewage, waste water, or dirty water, it was all the same and it should not have been there. At 12:01p.m., the Medical Director said he was not made aware of the issue with the liquid waste coming from the two sinks in the kitchen. He stated he would have expected to be notified of the issue because that was a health issue concern and he is working for the resident's health. He said the Administrator or Director of Nursing should have contacted him and they should have immediately fixed the problem. Interviews conducted on 8/17/18 included the following: At 9:29 a.m. with both the DFS and Director of Maintenance, the Director of Maintenance said no preventive maintenance program was currently in place for the kitchen drains. He said that there was no documentation to support that any maintenance had ever been done. The DFS said that kitchen staff do not perform any maintenance to floor drains. At 10:35 a.m., Cook #3 said she has reported the water issues for a long time and that her pants and everything were dragging in it. At 11:35 a.m., the DFS said she was not fully aware of the potential for resident harm related to waste water in the kitchen. She said she did not think it was as bad as it was because there was not anything coming into the sink itself. She said, to her, back up means sewage, like bowel movement. The Immediate Jeopardy was removed on 8/14/18, prior to completion of the survey. The facility's allegation of compliance to remove the Immediate Jeopardy, dated 8/14/18, included the following: a. The facility hired a professional plumbing vendor that was onsite 8/14/18. b. The vendor snaked Sink #1's drain in the kitchen dislodging debris and clogs. c. The vendor capped Sink #2 with water turned off until it could be permanently repaired. d. The facility sanitized the affected sinks, pots and pans, and floors. e. Kitchen staff were to be educated on the purpose of the indirect drain, how to complete the maintenance log, how to properly clean sewage waste including washing, rinsing and sanitizing. The Immediate Jeopardy was removed on 8/14/18 based upon surveyor observation and verification on 8/15/18 which included the following: a. Vendor Invoice # 1 provided to surveyor for review. b. Sink #1 was observed to be unplugged and functioning properly, without return of water at floor level. c. Sink #2 was observed to be capped off until permanently repaired. d. Kitchen floor was observed to be dry and free of water. e. Kitchen staff interviews revealed that the proper sanitization process was followed for kitchen tables, sinks, dishes, pot and pans, floor and fixed equipment prior to the breakfast meal on 8/15/18. f. Kitchen staff interviews revealed 80 percent of the kitchen staff (18) were educated on the proper use and differences between Sink #1 and Sink #2 and the professional standards for food safety. (10 NYCRR 415.14(h), 14-1.10(c)(3) Imminent health hazard, 14-1.141 Indirect drain, 14-1.140 Plumbing)Based on observations and interviews conducted during the 2nd Post Survey Revisit completed on 10/18/18, it was determined that for one of one Main Kitchen reviewed the facility did not prepare food in a safe and sanitary manner. Specifically, Time/Temperature Controlled for Safety foods were not properly thawed and a sink without a proper indirect drain was used for food preparation. This is evidenced by the following: Observations conducted on 10/17/18 at 1:30 p.m. revealed the following: a. A tube of Wunderbar bologna was found thawing in a hotel pan of water in the stainless steel sink located in the cook prep station without running water going into the pan. b. The stainless steel sink in the cook's prep station that had a tube of bologna thawing inside, did not have an indirect drain. The drain plumbing for the sink was inserted into the plumbing for the sewer system. The annular space around the sink drain plumbing where it entered the sewer plumbing had been mostly sealed with only an approximate 1 inch x 1 inch opening where the sealant was in disrepair. In an interview on 10/17/18 at 1:31 p.m., the Interim Food Service Director (IFSD) was asked about the bologna in the sink. The IFSD stated that she had been doing a lot of education with staff and reached over and turned on the water to the sink so that it was running into the pan of water with the bologna. The surveyor then asked if the water was supposed to be running, and the IFSD stated, yes. The IFSD was then asked about the use of the stainless steel sink for food preparation to which she replied that they were not supposed to use the sink for food preparation. The IFSD then removed the bologna from the sink. (10 NYCRR: 14-1.86, 14-1.110(d) 14-1.140, 14-1.141 14-1.160)

Plan of Correction: ApprovedOctober 19, 2018

483.60(i)(1)(2) Food Procurement, Store/Prepare/Served-Sanitary
The facility will ensure that food is stored prepared, distributed and served in accordance with professional standards for food service safety.
1. The broken foot pedal and the hand washing sink was repaired on 5/29/18 once deficient practice identified. Hand-washing sink is now dispensing hot water.
2. The meat slicer was properly cleaned/sanitized on 5/29/18 by the DFS once deficient practice was identified.
3. The main kitchen suspended ceiling tiles throughout the basement main kitchen where repaired/replaced by maintenance on 6/30/2018.
4. The brown mouse dropping were immediately removed from the stainless steel hood directly above the tilt skillet and plate warmer, and hamburger buns were discarded on 5/29/18 once deficient practice identified. The entire stainless steel hood, plate warmer tilt skillet, cart and surrounding area was cleaned and sanitized at that time.
5. On 5/29/18 the brown mouse droppings on the floor in the basement dietary dry food storage room, on the tiles above the suspended ceiling and on the dry food storage bins were removed. The entire dry food storage room was cleaned and sanitized including the tiles, floors and storage bins/shelving. The dry foods located inside the bins were immediately discarded on 5/29/18.
6. On 5/29/18 the ceiling grid that was damaged and sagging inside the basement dietary dry food storage room was repaired/replaced by maintenance on 6/29/2018 ceiling grid is now tight fitting. The cereal boxes and food items located on the shelves were discarded, the entire area was cleaned and sanitized.
7. The Maintenance Department removed the light fixtures located in the dry storage room on 5/29/18. The light fixtures were cleaned and sanitized at that time.
8. On 5/30/18 the open tile in the main kitchen tray line where staff assemble food was immediately repaired and tiles were replaced and exposed food was discarded.
9. The DFS found the directions to re-calibrate the Ecolab thermometer and related policy and procedure on 6/4/18, same day deficient practice was identified.
10. The main kitchen dish room floor tiles were replaced by maintenance on 6/29/2018. There are no cracked, broken, pitted or missing tiles in the kitchen dishwasher room at this time.
All residents are identified at risk for this deficient practice. A audit tool will be developed by the Consultant RN. The dietitian and infection control RN will conduct a full house kitchen/nourishment rooms audit to ensure compliance with facility sanitation, food storage, food preparation, food distribution and service related activities are in accordance with professional standards for food service safety and facility policies and procedures and to identify items needing to be repaired i.e. (missing ceiling and floor tiles, dirty light fixtures, kitchen equipment needing repair, and identify if mouse droppings. The audit will also include the review of exterminator log book in the kitchen, dishwasher room on dry food storage room, review of the temperature log book to ensure cook and DFS are obtaining food temp calibration accurately, proper handling, preparing and distribution of food is occurring by the dietary staff. Deficient practice will be immediately reported to the Administrator and DFS for follow up action. All findings will be analyzed and trended by the Dietitian who will report findings to the QAA Committee at the next scheduled meeting.
The cook who worked on the day shift on 6/5/18 and removed the unlabeled stainless steel covered pots containing pureed pizza, gravy and minestrone soup from the steam table and placed them on the table for approximately 10-15 minutes was counseled and in-serviced by the DFS on policy and procedure for hot holding of time temperature control foods and labeling and dating food on 6/5/18 once deficient practice identified.
The DFS who did not ensure Ecolab thermometers were properly calibrated on 6/4/18 was be counseled by the Administrator and in-serviced by the Dietitian on Ecolab thermometer instructions and calibration policy and procedure on 7/9/2018.
The Director of Maintenance who did not repair items in disrepair in the kitchen dry food storage room, main kitchen area, dishwasher storage area specific to ceiling and floor tiles inspecting stainless stove hood, replace broken foot pedal on the hand washing sink, repair to the ceiling grid, clean light fixtures in the dry food storage area is no longer employed at the facility.
The Dietary aide who did not properly clean and sanitize the meat slicer on the day shift on 5/29/18 was counseled and in-serviced by the Food Service Director on properly cleaning and sanitation procedures for the meat slicer equipment.
All Dietary Staff was be in-serviced by the DFS on (MONTH) 6, (YEAR) the importance of storing and preparing food in sanitary environment and related policy and procedure entitled Sanitation Policy dated (MONTH) (YEAR).
An exterminator was contacted on 6/12/18 to evaluate the pest mouse dropping issues in the kitchen, and dry food storage room, dishwasher storage area. The vendor conducted an onsite pest assessment and treated the entire main kitchen and dry food storage area mentioned above on (MONTH) 22, (YEAR).
The RN Consultant will train on all existing policies and in-service DFS and all dietary staff and create a audio recording of the training for those dietary staff employees who were unable to attend. the food service director will schedule the audio presentation for all remaining dietary staff that were unable to attend. The Live Presentation Training. All dietary staff will be in-serviced by 7/9/2018 and 7/10/2018:
. Food receiving and storage
. Food preparation and service
. Dietary services sanitization
. Food service/distribution
. Refrigerators/Freezers
. Food - related garbage and rubbish disposal
All Dietary staff will be in-serviced on all dietary policies and procedures by the Consultant RN.
The Exterminator has been contracted to provide routine ongoing assessment and extermination of mouse/rodent concerns. The vendor will be on site weekly to ensure compliance with pest control.
The infection control RN and Consultant Dietitian will conduct weekly onsite kitchen audit inspections, and nourishment room audit inspections to ensure compliance with food service safety. The areas that will be audited will be pest control, and review of exterminator log book, dietary services sanitation food service distribution visual observations, refrigerator and freezer review, temp log book review, visual observation of thermometer calibration by cook and DFS, food related garbage and rubbish disposal, equipment observation, environmental review of floor tiles, ceiling tiles, light fixtures, etc. That could cause a food safety violation.
All deficient practice will be reported to the DFS and Administrator for follow-up action. all findings will be analyzed and trended by the Dietitian. The infection control RN will report findings to the QAPI Committee monthly. This will be ongoing.
The Director of Food Service will be responsible for compliance.

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of six residents reviewed for antipsychotic medications, the facility did not ensure that each resident's drug regimen was free of unnecessary medications. The issue involved the lack of a Gradual Dose Reduction (GDR) of an antipsychotic medication. This is evidenced by the following: Resident #20 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/11/18, revealed that the resident had severely impaired cognition, was understood and understands, did not have any signs and symptoms of [MEDICAL CONDITION], wandering, or rejecting care, and received an antipsychotic medication seven days a week. Physician orders, dated 3/14/17 ( and continues until (MONTH) (YEAR) unchanged), included [MEDICATION NAME] (medication for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 0.5 milligrams (mg) in the morning and 1 mg at bedtime. Review of the psychiatrist consult request, dated 12/9/17, revealed the facility Consultant Social Worker (SW) documented that the resident has been a little bit better and more easily redirectable. The resident still takes items, will hoard things, and has some episodes of aggressiveness and refusal of cares. Staff have noticed a change in the resident's sleeping pattern and that she has been more confused and not attending to her Activities of Daily Living. The Psychiatrist documented that the resident is controlled on [MEDICATION NAME], continues to wander, and is noted to be slightly better, redirectable, and not sleeping well, no acute symptoms noted. A GDR was not recommended because the resident was symptomatic and an increase in [MEDICATION NAME] (natural sleep aid) was recommended. The physician documented that he was in agreement and to refer to telepsychiatry for behaviors. The Antipsychotic and Dementia Review Sheet, dated 1/26/18, revealed that a GDR failed in (MONTH) (YEAR) and that a telepsychiatry consult was needed. Review of the 2/17/18 Psychiatrist consult request form revealed the facility Consultant SW documented that the resident had less aggressive behaviors over the last couple of months, was still requiring redirection, and can be very argumentative. The psychiatrist response was that the resident is labile, aggressive, compliant with medications, and sleep and appetite are variable. The recommendation was for no GDR due to the resident being symptomatic and to continue the same medications and follow-up as needed. The Department of Telepsychiatry Consult Report, dated 3/22/18, included that the resident has advanced dementia that has been steadily progressing and has a distant history of depression and anxiety. Staff use non-pharmacological strategies for her behaviors which are modestly effective. The resident is calmer with [MEDICATION NAME] but not frankly psychotic at that time. Discussed desired goal of minimizing poly pharmacy, however, the Nurse Practitioner (NP) would like to keep the current medication regimen because the resident has benefited from them thus far and the goal of care is comfort. The telepsychiatry recommendations included that if the resident has not been exhibiting psychotic symptoms for another month, consider slow GDR by decreasing by 0.25 mg weekly. Review of the Consulting Pharmacy Recommendation, dated 4/25/18, revealed that the resident continues on [MEDICATION NAME] with no GDR. The resident's mood and behavior scores both warrant a GDR at that time. Please consider [MEDICATION NAME] 0.5 mg twice daily. There was no documentation of a medical staff response. There are no documented GDR attempts in the medical record since (MONTH) (YEAR). When interviewed on 6/4/18 at 3:51 p.m., the Interim Assistant Director of Nursing (ADON) stated that the resident does not have any hallucinations or delusions and is usually easy to redirect. Interviews conducted on 6/5/18 included the following: a. At 10:36 a.m., the Interim ADON said that GDRs should be done as per the Pharmacy Consultant Recommendations. She stated she is not sure when or how often GDRs should be done, but thinks they should be done every three months. b. At 12:48 p.m., the NP stated that she started working at the facility about two weeks ago, and she does not like to see antipsychotics given when a resident has dementia unless they also have [MEDICAL CONDITION] or [MEDICAL CONDITION]. The NP said she has a stack of (MONTH) (YEAR) pharmacy recommendations to review and act on but has not had time yet. The NP stated that GDRs are required twice a year, and if the resident has not had one since (MONTH) (YEAR), it is well overdue. c. At 1:12 p.m., the Consultant Pharmacist said that she expects the medical staff to respond to her recommendations within 30 days. (10 NYCRR 415.12(l)(1))

Plan of Correction: ApprovedJuly 16, 2018

Resident #20, medical record was reviewed and updated was seen by provider on 6/8/18 and followed up with CHE (psychosocial services) for behavior monitoring.
The DON/Designee will conduct an audit on all residents medical records to include scheduled and PRN medications that are greater than 14 days.
The DON/ADON will complete weekly audits on PRN antipsychotics.
The DON will ensure GDR meetings are held monthly with the provider and IDT as per facility policy and procedure.
The DON will follow all recommendation closely to ensure that timely GDR take place.
Review of all residents monthly will be done by the Unit Manager and follow up audits will be conducted by the ADON.
The DON is responsible for compliance with drug regimen as it relates to GDR.
All nurses will be educated to the GDR process as it relates to the facilities policy and procedures.

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of seven residents reviewed for accidents, and five of six supply closets, the facility did not ensure that the residential environment remained as free of accident hazards as possible or that adequate supervision was provided to prevent accidents. The issues included use of a mechanical lift out of weight range for Resident #86, and lack of adequate, secure storage of razors. This is evidenced by the following: 1. Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/6/18, revealed that the resident was cognitively intact, totally dependent for transfer, and was a two-person physical assist. The current Comprehensive Care Plan, included that the resident was an extensive assist of one staff member for transfers, bed mobility and toileting. The current Certified Nursing Assistant (CNA) Kardex revealed that the resident required extensive assist of one staff member for transfers. The Physical Therapist Discharge Summary, dated 11/14/17, included that the resident was non-ambulatory, required extensive assistance with bed mobility with bilateral assist bars and extensive assistance for transfers. Observations on 5/30/18 at 10:37 a.m. revealed an Invacare Reliant RPS 350 sit to stand lift in the resident's room. In an interview at that time, CNA #1 stated that they use the sit to stand lift for the resident who was in the bathroom at that time. CNA #1 said that they were waiting for the resident to finish in the bathroom. When asked about the resident's weight, the CNA stated that he did not know for sure how much the resident weighed, but that he must be close to 350 pounds. He stated that at one point, the resident was stuck in the up position and they had to use a paperclip to release the lift (because the emergency pull tab was broken). A review of the medical record for the resident revealed that on 5/7/18 the resident weighed 391.8 pounds. A review of the Invacare Reliant RPS350 product manual directed in the Safety summary DO NOT exceed maximum weight limitation of the Stand-up Lift. The maximum weight limitation is 350 pounds regardless of any additional weight limitations on accessories. Further review of the manual revealed the statement, WARNING notices as used in this manual apply to hazards or unsafe practices which could result in serious bodily harm. Record review on 5/31/18 at 11:08 a.m. revealed the manufacturer's specifications (pages 4, 5, 16, and 17) for the Invacare 350 Stand-up Lift directed the following, In case of damage, DO NOT use equipment, DO NOT exceed maximum weight limitation of the Stand-up Lift. If any parts are worn replace immediately, and replace any defective parts immediately and ensure that the lift is not used until repairs are made. Interviews conducted on 5/31/18 included the following: a. At 12:53 p.m., the Director of Physical Therapy said that he makes the recommendations for the use of mechanical lifts, but not specifically which lift to use. He said he does not consider weight limits when making recommendations. The Director of Physical Therapy said he has never recommended what lift to use based on the resident's weight, just the sling size. b. At 1:07 p.m., the Interim Assistant Director of Nursing said that she has worked at the facility for four years and she does not recall the last in-service for the use of mechanical lifts. She said it should be done annually and as needed. c. At 1:25 p.m., the Licensed Practical Nurse (LPN) said that the only inservice training she remembers was with the sling sizes but not the lifts. The LPN said that it should be documented on the CNA Kardex what lift to use to transfer a resident or direct to use a lift with weight capacity of X pounds. d. At 1:32 p.m., CNA #1 said that she had worked at the facility for one month and she has not had training on the lifts. She said she knows how to use the lifts from her other job. e. At 1:36 p.m., CNA #2 said they never differentiate about the different lifts. He said he does not know the weight limit on a Redi-Stand. f. At 1:40 p.m., CNA #3 said that he has completed mandatory training in the last year for the lifts. He said that he uses the Invacare 350 Lift for the resident. He said the resident was close to 350 pounds, but he does not know how to differentiate for the bariatric resident. He said on the Care Card it directs to use the Redi-stand or Hoyer Lift. CNA #3 said that staff transfer the resident approximately four to five times a day. CNA #3 said if the staff do not have a lift, then they search for one. He said if staff cannot find a lift, then the resident is left comfortable in bed. CNA #3 said a lift needs to be safe. 2. When observed on 5/29/18 from 9:27 a.m. to 10:22 a.m., and at 3:54 p.m., the south hall supply closet on the third floor had a sign on the door that stated, Attention staff, the door must be locked at all times, (the same sign is on all the supply closet doors). The door was not locked and the closet contained various personal care items, including 39 twin blade razors and staff personal items such as backpacks and purses. Facility staff were observed going into the closet and not unlocking or locking it. Two residents were in the hallway wandering back and forth by the unlocked closet. Observations conducted on 5/30/18 included the following: a. Between 8:53 a.m. and 11:33 a.m., the supply closet on the second floor north hallway was found unlocked with 91 disposable razors inside. The supply closet on the first floor north hallway was found unlocked with disposable razors inside. In an interview at that time, the Director of Maintenance stated that the supply closet should be locked if there are razors inside. b. At 1:56 p.m., the third floor south end supply closet was unlocked and contained 39 razors. Two residents were wandering back and forth in the hallway. c. At 2:00 p.m., the third floor north end supply closet was unlocked and contained 40 razors. d. At 2:04 p.m., the second floor south end supply closet was unlocked and contained 110 razors, staff keys and personal property. Three residents were walking in the hallway. When interviewed on 6/1/18 at 2:31 p.m., the Interim Assistant Director of Nursing stated that supply closets were for storage of resident supplies, not staff items. She said they should be locked at all times. She said items like razors could be dangerous to the residents. (10NYCRR: 415.12(h), 415.29, 415.29(a), 415.29(b), 415.29(i)(1))

Plan of Correction: ApprovedJuly 15, 2018

The facility will ensure that residents environment remain free from hazards and accidents, each resident will receive adequate supervision and assistance to prevent accidents.
Resident #86 CCP will be reviewed and revised as needed. Therapy referral made and therapy started seeing the resident on 6/20/18. All nursing staff will be educated by staff educator on the use of mechanical lifts in regards to weight limitations and proper operating guidelines and the maintenance of them. Audits will be conducted on all residents who require a mechanical lift comprehensive care plan and closet care plan will be revised and reviewed as needed. The responsibility of all audits will be from the DON, ADON, and Unit Managers. The audits will continue weekly and brought to the QAPI committee for review. Safety issues for mechanical lifts will be logged in the unit specific maintenance book and will be removed from the unit for repairs. All nursing staff will have an in-service training in regards to mechanicals lifts and all new hires will on hiring as well. An in-service is schedule for 7/2/18.
All supply closest will be audited weekly for 4 weeks and monthly for 4 months and on going randomly to ensure all supply closets are locked. All staff will be educated on the importance of having all doors locked that have personal items. The staff will also be educated on not storing their personal items within the supply closet. Unit managers, supervisors, ADON, and DON will do daily rounds to ensure that all supply closets are locked. The DON or designee will do periodic audits to ensure compliance. The DON is responsible for compliance.

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

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident observed for incontinence care, one of one legionella environmental program, one of one medical waste program, one of six supply closets, one of three dining observations, and one of one laundry room, the facility did not ensure that proper infection control procedures were followed. Specifically, there was improper incontinence care and lack of glove changing and handwashing (Resident #17), lack of an adequate assessment, sampling, and management of potable water system, lack of documentation of medical waste disposal, lack of sanitary storage of resident care supplies, bare hand food handling (Resident #17). This is evidenced by the following: 1. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/3/18, revealed that the resident had severely impaired cognition and was totally dependent on staff for toileting. The 3/7/18 Comprehensive Care Plan and the 6/1/18 Certified Nursing Assistant (CNA) Kardex included total assist of one staff to provide peri-care and directed to use barrier cream after each incontinent episode. When observed on 5/29/18 at 9:08 a.m., an odor of urine was noted upon entering the resident's room. The resident gave approval to check for incontinence and was found to be incontinent of a large amount of urine and feces. The CNA came into the room with a breakfast tray and did not check for incontinence before attempting to feed the resident. The CNA said that night shift gets the resident washed and dressed but they did not do it that day. On 5/29/18 at 10:03 a.m., the CNA returned to do morning care on the resident, but she did not have a mechanical lift so she left to do care on another resident. At 10:28 a.m., the CNA returned to do care bringing her own bag with her that she said contained personal care products that she has purchased and uses on all her residents. The CNA said there are not enough linens so she only has one towel, no washclothes or disposable cloths to wash the resident. She stated that she arrived for work at 7:30 a.m. and has not done incontinence care on the resident. She said she believes the night shift do their last rounds at 6:00 a.m. The CNA donned two pair of gloves and shaved the resident's face using shaving cream she took from her bag. She washed and dried the resident's axilla (armpits). She took deodorant from her bag and applied it on the resident. The CNA cleaned the resident's perineum with the end of the towel in a scrubbing motion seven times without using a new surface. There was a copious amount of black liquid stool in the perineal area. The CNA took the basin of water into the bathroom to get clean water but used the same area of the towel to again clean the perineum of stool in a scrubbing manner. The CNA then got another clean basin of water and again using the same surface of the towel, continued to clean the perineum in a scrubbing motion. The resident was rolled to the side and the feces was cleaned from the buttocks with the same towel. A dressing on an open area had fallen off the posterior right thigh. No barrier cream was applied. Without changing gloves or washing hands, the CNA applied the resident's Attends and clothing. The CNA touched various items in the resident's room including the privacy curtain, bed controls, fall mat, call bell, and overbed table. She placed the deodorant and shaving cream that she used on the resident into her private bag and rinsed and dried the wash basins. She gathered dirty linens and left the room to dispose of them in the hallway and then removed her gloves and washed her hands. When interviewed on 5/31/18 at 12:59 p.m., the CNA stated that she is not worried about carrying the bag of personal care items from room to room because she does not put it on the bed. She said she knows to wash a resident's perineum from front to back. She stated that if there was more linen and disposable wipes, she might have done a better job washing the resident. She said that she should have removed her gloves sooner than she did. During an interview on 6/1/18 at 1:13 p.m., the Interim Assistant Director of Nursing (ADON) stated that she expects staff to wash the resident's perineum from front to back, folding the washcloth each time or they could cause urinary tract infections. She said it is standard practice to use barrier cream with incontinence care. The Interim ADON said the staff should remove gloves after cleaning a dirty area. She said personal care items should not be carried from room to room, and she was not aware it was being done. The (MONTH) 2010 facility policy, Handwashing, included to wash hands after contact with body fluids or excretions and if moving from a contaminated body site to a clean body site during patient care. 2. On 6/1/18 at 8:45 a.m., the Director of Maintenance (DM) was interviewed with regard to the facility Legionella testing and management program. The DM stated that a company had come out for Legionella, but he was not sure if they took water samples or not. The DM stated that he was not sure if a facility risk assessment was conducted or if they have a sampling and management plan. Further interview with the facility Administrator revealed a corporate maintenance person was taking care of the Legionella program. The Administrator said she was not sure if samples had been collected in (YEAR) or if a facility risk assessment had been performed. Documentation provided by the Administrator showed one set of ten water samples was taken for Legionella; however, there was no further records provided to show if samples were taken in (YEAR), or that a facility risk assessment for Legionella had been performed. A review of the facility Legionella policy, dated 9/16/16, revealed the following: An Environmental Assessment will be performed using the NYSDOH form . the facility will conduct surveillance on the potable water system by sampling for Legionella quarterly for the year (YEAR) . records pertaining to environmental assessments, sampling and management plan, including sampling results will be retained by the DM for a period of three years. 3. Observations on 6/5/18 at 9:15 a.m. revealed 14 1/2 boxes with biohazard markings stored in the basement medical waste storage room. The boxes stated: Max. Weight 55 lbs, and the most current waste pickup sheet showed a date of 9/6/17. The Director of Maintenance stated to his knowledge, medical waste had not been picked up since then, but the Director of Housekeeping was in charge of medical waste. When interviewed on 6/6/18 at 12:08 p.m., the Administrator said that they have a new medical waste company, and the old company stopped picking up in (MONTH) (YEAR), and she was not sure why they stopped picking it up. 4. Observations on 5/29/18 at 1:18 p.m. revealed the following resident care items were left on the floor under the shelving in the supply closet next to room [ROOM NUMBER] (third floor): a bag of briefs, a bottle of shampoo, a washcloth, a toothbrush, a tube of toothpaste, a comb, and socks. The floor was soiled with dust and debris in the area of the items noted. 5. Observations on 5/29/18 from 12:56 p.m. to 1:16 p.m. revealed that a Licensed Practical Nurse (LPN) was using her bare hands to feed a sandwich to a resident in the third floor dining room. When interviewed on 6/5/18 at 11:57 a.m., the LPN said she had been taught not to feed residents while wearing gloves. She said it was not ideal to touch the resident's food with her bare hands. She said she did not know it was not allowed. (10 NYCRR 415.19(b)(4) & 415.29(j)(1))

Plan of Correction: ApprovedJuly 31, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17 medical record and CCP were reviewed and updated.
The CNA was educated on proper hand washing, donning gloves and perineal care. All nursing staff was in serviced on proper handling of resident food items during meal times. Continued staff education will be ongoing to ensure compliance.
The staff educator will provide education regarding proper perineal care to all CNA's. The ADON will conduct random weekly audits to ensure compliance. All CNA?s will be educated if a resident has a dressing that has been soiled during care to notify the nurse, so the nurse can change the dressing immediately. The nurses will alternate CNA?s weekly to audit ADL for compliance. The CNAs was educated that personal hygiene products cannot be brought into the facility for resident personal care.
The facility will conduct a facility risk assessment for Legionella using the NYSDOH form and will conduct quarterly potable water system sampling going forward. All records will be maintained per facility policy. The facility policy and procedure will be reviewed and updated as necessary. A Legionella and Sampling Management Plan was developed and it signifies that if there is ever samples >30% than it will be reported to the Department of Health and steps will be taken to ensure staff and resident safety. All nursing staff will be educated on policies and procedures in regards to Legionella Disease and what to do if a resident was ever diagnosed with [REDACTED].
The DON will ensure compliance of the audits and continued education of all nursing staff.
All audits will be conducted by Maintenance Director to ensure compliance.
The biohazard medical waste was picked up on 6/6/2018 by the facilities new vendor and will continue to be picked up monthly. The Director of Housekeeping, who is responsible for continued monthly medical waste pickup, was educated on the proper timeliness of scheduling monthly pickups.
The supplies left on the floor in room [ROOM NUMBER] was picked up and stored properly. The housekeeping staff was alerted to clean the floor in room [ROOM NUMBER].
All nursing staff were reeducated on the proper handling of resident food items.
An audit will be completed weekly random during meal times by the diet tech and all audits will be brought to the QAPI committee.
The DON and Administrator is responsible for compliance.

FF11 483.80(d)(1)(2):INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

REGULATION: §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that- (i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #29) of five residents reviewed for immunizations, the facility did not provide documentation that the resident received the influenza (flu) and/or pneumococcal (pneumonia) immunizations or documentation regarding medical contraindication or refusal of immunizations. This is evidenced by the following: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 3/29/18, revealed the resident was cognitively intact, and the influenza and pneumococcal vaccinations were not given at the facility because they were not offered. Review of a facility policy, Immunizations: Pneumococcal Vaccination of Residents, dated 2/1/17, directed that all residents should receive the pneumococcal vaccine if they are [AGE] years of age or older, or younger than [AGE] years with underlying conditions that are associated with increased susceptibility to infection or increased for serious disease and its complications. Each resident's pneumococcal immunization status will be determined upon admission, or soon afterwards, and will be documented in the resident's medical record. All residents with undocumented or unknown pneumococcal vaccination status will be offered the vaccine. Every attempt will be made to obtain these records from the discharging hospital or family representative. The MDS Coordinator will notify the Director of Nursing (DON) within five days of admission whenever vaccinations have not been given as required or a resident refuses the vaccination. Review of the electronic medical record for immunizations revealed [MEDICATION NAME] skin tests (used to determine exposure to [MEDICAL CONDITION]) were done on 12/21/17 and 1/4/18. The areas on the immunization record for influenza and pneumococcal were blank. Interviews conducted on 6/5/18 included the following: a. At 10:41 a.m., the Registered Nurse Manager (RNM) said if the vaccination history is not available in the discharge record, he will check with the resident or family. The RNM said there was an admission check list in use that included determining vaccination history. The RNM said he was not sure if any follow up was in place to determine if the vaccination history was obtained. He said the primary physician could be called. b. At 12:05 p.m., the MDS Coordinator said she would ask the resident or a family member if the vaccinations were given and if not, she would check hospital discharge information. She said if this information was still unavailable, she would advise the physician and follow up regarding administering both vaccinations. She said that the resident was admitted during the flu season. c. At 12:11 p.m., the medical records secretary reviewed the medical record (hard chart) and said there was no documentation of immunizations on file. d. At 12:23 p.m., the DON said she expects the nurses to obtain the immunization history upon admission. She said staff can review the medical record and interview the resident, family and/or primary care physician regarding the resident's immunization history. The DON said if the information cannot be obtained, staff are to notify the physician who will decide whether to give the vaccinations. (10 NYCRR 415.19(a)(3))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (Resident #29) of three residents reviewed for immunizations, the facility did not provide documentation that the resident had received influenza and pneumococcal immunizations or was not given the immunizations due to medical contraindications or refusal. Specifically, the facility did not complete the resident's immunization history per the Plan of Correction. This is evidenced by the following: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 3/29/18, revealed the resident was cognitively intact, and the influenza and pneumococcal vaccinations were not given at the facility because they were not offered. Interviews with the Infection Control/Licensed Practical Nurse (LPN) and LPN/Acting Nurse Manager (LPN/NM) #1 on 8/16/18 revealed the following: a. At 9:50 a.m., the Infection Control LPN and LPN/NM #1 said they had not received any education or training regarding immunizations. The Infection Control/LPN said she had just reviewed the resident's medical record and there was no information regarding administration of the flu vaccines. LPN/NM #1 said she also reviewed the chart and there was no immunization history other than administration of a purified protein derivative (PPD skin test to check for [MEDICAL CONDITION]). The Infection Control/LPN said immunization logs and/or histories could be located in the medical record or in the overflow, or there may be no record. b. At 10:28 a.m., LPN/NM #2 said she had not received any training regarding immunizations. She said the previous Director of Nursing (DON) had not provided her with any training or audits. She said nothing was done. c. At 9:59 a.m., the Infection Control/LPN said the policy and procedure for Infection Control/Immunizations was not distributed until 8/13/18. When interviewed on 8/17/18 at 10:18 a.m., the Administrator said that she thought the previous education nurse had updated the resident's medical record. At that time, the DON said that she and the Infection Control/LPN had worked on a new system for immunizations that week. (10 NYCRR 415.19(a)(3))

Plan of Correction: ApprovedSeptember 10, 2018

The facility will ensure that the resident either received the Influenza and Pneumococcal immunizations or did not receive the Influenza and Pneumococcal immunization due to medical contraindications or refusal, and that the resident previous history is obtained.
Resident #29 medical records were reviewed, all immunizations were updated as warranted.
The nursing staff will be educated that all new admissions will be offered pneumococcal vaccinations for age appropriate residents and for the influenza vaccinations will be offered during Flu season upon admission. If resident has had vaccines, medical records will be obtained from PCP. When the resident refuses vaccines, the nurse will document appropriately in the residents' medical record. The Infection control program was reviewed with infection control nurse. All nursing staff will be educated on proper administration of vaccines and obtaining prior immunization history of all new admits. An audit of all residents will be completed by the infection control nurse to review residents were lacking any immunizations. The audits will be continued monthly and for all new admissions and current residents.
The nursing staff will be educated that all residents will be given a PPD unless contraindicated, then a chest x-ray will be obtained to rule out exposure.
The staff will be educated on the admission checklist to ensure compliance of the admission process.
The DON/Designee will do random audits of immunizations.
The DON is responsible for compliance.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey 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: June 6, 2018
Corrected date: July 20, 2018

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 investigations (#NY 165 and #NY 820), it was determined that for one (Resident #453) of seven residents reviewed for accidents, the facility did not thoroughly investigate an abrasion to the resident's forehead sustained during the provision of care to rule out abuse, neglect, or mistreatment. This is evidenced by the following: Review of the policy and procedure, Incident and Accident Reporting and Investigation, effective 4/19/11, revealed that an investigation is necessary when the cause of an incident is not clear. As a part of this investigation, written statements should be obtained from all witnesses, the Nurse Manager or Supervisor will write a summary of the investigation, and the Accident and Incident Review Committee will review incidents daily, or the next business day after the weekend. Resident #453 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/19/18, revealed the resident had severely impaired cognition. The Incident and Accident (I&A) Reports, dated 2/13/18, revealed that while being assisted with care by two staff members, the resident sustained [REDACTED]. The facility investigation did not contain statements from all staff who witnessed the incident, a summary of the supervisor's investigation of the event, or interventions to prevent reoccurrence. There was no documented evidence that the I&A Reports had been reviewed by the Director of Nursing (DON) or Administrator. Interviews conducted on 6/5/18 included the following: a. At 1:35 p.m., the DON stated that the Nurse Manager, Supervisor, or Team Leader could initiate an I&A Report, and she would expect whomever was involved with the initial event to do so. She stated that the Unit Manager was responsible for conducting the investigation, and it should include statements from all staff on the shift at the time of the incident and a note should be entered into the medical record. The DON said that the I&A Report would then come to her for review to ensure the investigation was complete. She stated that the investigation for the incident on 2/13/18 was not complete. b. At 1:40 p.m., the Administrator stated that she would expect all documents that are required for the I&A Report to be included with the investigation. She said that she reviews the incident reports after they have been reviewed by the DON. c. At 2:00 p.m., the Registered Nurse Manger (RNM) stated that he completes his portion of the I&A Report and then it goes to the DON. He said the DON adds interventions and signs the document. He stated that he felt the primary caregiver's statement was enough since he was involved in the incident. He said the incident happened while the primary aide and another Certified Nursing Assistant (CNA) were providing care to the resident. He said that he believed the second CNA was agreeable to the primary CNA's version of what happened, but the CNA assisting him with care should have also filled out a statement. The RNM stated that he should have checked the resident's room for anything that could have been a hazard and obtained a statement from the second CNA involved. The RNM said that would have helped to complete the investigation and helped to rule out abuse, neglect, or mistreatment. The RNM said that the investigation was not complete and was missing a few parts. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedJuly 28, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action Taken For Those Residents Affected:
A full investigation was completed for resident #453. Resident #453 was sent to hospital day of the incident for further evaluation and did not return to facility. The RNM was reeducated on the policy and procedure of filling out A&I reports completely and the need for collecting all components to rule out any abuse, neglect, or mistreatment. The RNM was instructed to review the incidenct to rule out abuse, neglect or mistreatment of [REDACTED].
Corrective Action Taken For Those Residents Potentially Affected:
The facility recognizes that all residents have the potential to be affected however, during a full record review of all A&I?s during the past 6 months no residents were affected during this deficient practice. The RNM involved in the incident was reeducated in the process of filling out A&I reports and completing all parts prior to handing them to the Director of Nursing for review.
Systematic Monitoring:
A full review of all A&I?s within the past 6 months to ensure that all parts are included and completed appropriately. A new A&I report and log was developed to ensure that all sections of the report are completed. The RNM failed to complete the A&I process, obtaining statements from all parties involved, investigating, and implementing interventions to prevent reoccurrence, and providing a summary. The DON will continue with reeducating staff on the updated policy and procedure for A&I's and ensuring that the process is followed. The staff educator or designee will in-service all nurses on the process of an accident/incident investigation completely annually and ongoing.
Quality Assurance Monitoring:
The facility created a log as an audit tool to monitor and track all A&I?s to ensure completeness and accuracy of all parts of the investigation. This will include but is not limited to final review of Director of Nursing and the Administrator. The audits will be done weekly for 8 weeks and then monthly for 6 months. All audits will be brought to the QAPI committee for review and from there it will be determined if continued monitoring will be necessary.
The Director of Nursing is responsible for compliance of this deficiency.

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Recertification Survey, it was determined that for two of two medication rooms, one of three medication carts, one of six supply closets, and one of one basement supply room reviewed for medication storage, the facility did not ensure that all drugs and biologicals were securely stored in accordance with state and federal laws. The issues involved opened and undated medications on the first and third floors, expired medications on the second and third floors, cleaning agent stored in an unlocked supply closet on the third floor, and medication bottles observed on the floor in the basement central supply room. This is evidenced by the following: The undated facility policy, Storage of Medications, directed that the facility should not use discontinued or outdated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. Drugs for external use, as well as poisons, shall be clearly marked and stored separately from regular medications. 1. The first floor south end medication cart was inspected on 5/30/18 at 2:19 p.m. and contained two Basaglar (long acting insulin) Kwik pens that were open and in use, but were not dated. When interviewed at that time, Licensed Practical Nurse (LPN) #1 stated that the insulin pens should be dated when they are opened because they are only good for 28 days once opened. 2. During an observation on 5/30/18 at 2:28 p.m., the second-floor medication room contained two bottles of [MEDICATION NAME] (medication for chest pain) that expired on 4/30/18 and 5/27/18 and one box containing three [MEDICATION NAME] suppositories (laxative) that expired in (MONTH) (YEAR). 3. In an observation on 5/30/18 at 2:55 p.m., the third-floor medication room contained one [MEDICATION NAME] suppository that expired in (MONTH) (YEAR), one vial of [MEDICATION NAME] (treatment for [REDACTED]. When interviewed at that time, LPN #2 said that expired medications should be thrown away and that the pneumococcal vaccine should have been dated when it was opened. 4. During observations on 5/29/18 at 9:27 a.m., at 9:53 a.m., at 10:22 a.m., and at 3:54 p.m., and on 5/30/18 at 1:56 p.m., the supply closet on the south hall of the third floor was unlocked. The closet had one 21-ounce spray can of 3M trouble shooter baseboard stripper. The can contained the following warning: Danger! Causes skin burns, contents under pressure, harmful if inhaled, causes eye irritation. Contents included 2-[MEDICATION NAME], petroleum gases, and liquefied sweetened [MEDICATION NAME]. Precautions: avoid eye contact, do not get on skin or clothing, avoid breathing of vapors, mists or spray. Use only with adequate ventilation. Exposure to heat or sun can cause bursting, do not swallow. Keep out of reach of children. Note to physicians: exposure may increase [MEDICAL CONDITION] (heart) irritability, do not administer sympathomimetic drugs unless absolutely necessary. When interviewed on 6/1/18 at 2:31 p.m., the Interim Assistant Director of Nursing stated that 3M trouble shooter baseboard stripper should not be stored in the supply closet and the closet should be kept locked. She said that medications like insulin should be dated when they are opened and all medications should be discarded when they are expired. 5. During an observation on 5/30/18 at 1:31 p.m., a bottle of aspirin and a bottle of Vitamin B1 were observed on the floor in the basement central supply room in the corner under where the ceiling had leaked and rotted through the ceiling grid leaving debris on the floor. (10 NYCRR 415.18(d)(e)(1-4))Based on observations and interviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two of three medication rooms reviewed for medication storage, the facility did not ensure that all drugs and biologicals were securely stored. Specifically, medication rooms on the second floor and third floor were unlocked and unattended. This is evidenced by the following: During an observation on 8/13/18 at 11:48 a.m., the medication room on the second floor was unlocked and unattended. There was a full sharps container located on the shelf that contained used syringes. Observations conducted on 8/16/18 included the following: a. At 9:35 a.m., the medication room door on the second floor was unlocked and unattended. There were two residents sitting in the foyer in front of the nurses' station at that time. b. At 2:45 p.m., the medication room door on the third floor was unlocked and unattended. At that time, there were five residents who were sitting in the foyer directly across from the nurses' station and another resident was ambulating down the hall. When interviewed on 8/13/18 at 11:55 a.m., the second floor Licensed Practical Nurse Manager stated that she recently entered the medication room and she was responsible for it being unlocked. She stated that she does not remember if she checked to see if the door was closed all the way. She stated that the medication room should be locked when unattended. Interviews conducted on 8/16/18 included the following: a. At 9:35 a.m., the Director of Nursing stated that it was her expectation that the medication room be locked at all times except when occupied. b. At 10:30 a.m., the third floor Licensed Practical Nurse Manager said that it was her expectation that the medication room be locked at all times unless attended. Additionally, the facility was unable to provide documentation that the initial audit was conducted, education was provided, and an audit tool was developed per the Plan of Correction. (10 NYCRR 415.18(d)(e)(1-4))

Plan of Correction: ApprovedSeptember 10, 2018

1. The two insulin pens were removed from the first floor south medication cart and disposed of per facility policy.
2. The second floor medication room outdated medicine were disposed of per facility policy.
3. All outdated medication in the third floor medication room were disposed of per facility policy.
4. The 3M trouble shooter baseboard stripper was removed from the supply closet and placed in the housekeeping supply room.
5. The bottle of aspirin and vitamin b1 was disposed of and the floor was cleaned up of the debris.
Staff educator will provide education for all nursing on proper handling and storage of drugs and biologicals. A complete audit will be completed by DON and ADON on medication carts and storage areas for compliance. A monthly audit of all med rooms and carts will be done for all medications are discarded appropriate by unit managers, supervisors, ADON and DON. All housekeeping staff were in-serviced by housekeeping director on storage of chemicals. The housekeeping will conduct weekly rounds for proper storage of all housekeeping chemicals.
The DON, Housekeeping Director, and Administrator is responsible for compliance.

FF11 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (first and third floors) of three residential sleeping floors and one of one basement, the facility did not maintain an effective pest control program. Specifically, there were sightings of mice, mouse droppings, sightings of fruit flies, and pest harborage areas. This is evidenced by the following: 1. Observations conducted on 5/29/18 included the following: a. At 2:06 p.m., there were mouse droppings in the bathroom of Resident room [ROOM NUMBER] along the baseboard behind the toilet. There was also a small hole approximately 1-inch in diameter through the wall in the corner of the bathroom behind the toilet. b. At 3:35 p.m., there were multiple openings in the suspended ceiling tiles throughout the basement main kitchen. There was an approximately 4-inch x 8-inch opening with bowed ceiling tiles from water damage. When interviewed at that time, the Director of Maintenance said there was a leak from an overflowing sink in the first floor clean utility room. Further observations revealed hundreds of mouse droppings on top of the stainless steel hood directly above the tilt skillet, plate warmer, and a cart of hamburger buns. c. At 3:42 p.m., there were multiple small brown mouse droppings on the floor in the basement dietary dry foods storage room. Droppings were also on unopened boxes of food and on the tiles above the suspended ceiling. d. At 3:50 p.m., there were dozens of small brown fruit flies on the wall and around the garbage can in the basement employee break room. Also in the break room, there was an approximately 1.5-inch square opening into the wall by the floor next to the refrigerator. There were dozens of small brown mouse droppings on the floor near the vending machines. 2. In an observation on 6/5/18 at 8:40 a.m., a mouse ran across the surveyor's foot while standing in the doorway to the Director of Maintenance's office in the basement. At that time the Director of Maintenance stated, Was that a mouse? Further observations revealed the mouse had entered the building through the double doors leading to the loading dock which had been opened for a bread delivery, and the outside bay door was open. A review of the facility pest sighting logs on the first floor revealed that since 3/7/18 there had been 24 sightings of mice. Of those, 12 were in (MONTH) and 7 for June, as of 6/5/18. 3. During the exit conference on 6/6/18 at 12:45 p.m., the Administrator stated that she could not produce any of the pest control vendor reports at that time. The facility did provide a contract with a pest control vendor, signed 12/1/17, which revealed that the facility would pay for each service individually. (10 NYCRR: 415.29(j)(1), 415.29(j)(5), 415.29(j)(6)(i))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a Post Survey Revisit completed on 8/17/18, it was determined that for two (first and third floors) of three resident sleeping floors and one of one basement, the facility did not maintain an effective pest control program. Specifically, there were sightings of mice, mouse droppings, flies, and pest harborage areas. This is evidenced by the following: Observations conducted on 8/13/18 at 10:02 a.m., revealed mouse droppings in the basement dry storage room along the baseboards, on boxes of diced pears, on boxes of water, on top of the wrapped cans of chicken noodle soup, on a can of cream style corn, on a can of diced tomatoes, on cans of tomato paste, on cans of tomato sauce, on a plastic wrapped can of tomato soup, on cans of mandarin oranges and on a box or orange juice. Observations on 8/14/18 between 11:15 and 11:43 a.m. revealed the following: a. More than 60 small brown flies in the first floor North shower room. In an interview at that time, the Nurse Manager stated that the flies need to be promptly reported to maintenance. b. In the first floor South shower room there were small brown flies in the air and on the walls. c. In Resident room [ROOM NUMBER] there were two small black flies near the sink. Observations on 8/15/18 at 9:25 a.m. revealed small brown flies all over in the second floor Soiled Utility room. Observations on 8/16/18 in the Main Kitchen revealed that on top of the stainless-steel exhaust hood located above the cooking appliance, there were dozens of mouse droppings. Also, above the suspended ceiling there were numerous mouse droppings on the ceiling tiles. In an observation on 8/16/18 at 9:03 a.m. in the basement employee breakroom, there was a live mouse stuck in a glue trap and dozens of mouse droppings on the floor. Observations on 8/16/18 at 2:03 p.m. in Resident room [ROOM NUMBER], revealed several dozen small brown flies all over a meal tray left on the overbed table. Flies were observed on the juice cup, bowl of cobbler, as well as on and in the sandwich bag. There were also several dozen flies observed on the privacy curtain and the overbed light. When interviewed on 8/13/18 at 8:45 a.m., the Administrator stated that they have not yet completed any of the audits. During an observation and interview on 8/16/18 at 9:12 a.m., a dietary worker was observed entering the dry storage room. When interviewed at that time, the dietary worker said that they see mice all the time, but it is better. In an interview on 8/17/18 at 9:17 a.m., the Director of Maintenance stated that they did not have a signed contract with a pest control vendor, but they have been coming in weekly. A review of the facility documentation revealed that the pest control vendor did not have a signed contract to provide services to the facility. Also, during the pest control visits that were provided, the vendor had been targeting and treating mice only. There was no documentation that the vendor had provided treatment for [REDACTED]. Additionally, the facility did not provide any documentation that the education or audits had been completed per the Plan of Correction. (10 NYCRR 415.29 (j)(1)(5))

Plan of Correction: ApprovedSeptember 10, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** There were no residents harmed as a result of this deficient tag. The facility recognizes that all residents could have been effected.
1. a. room [ROOM NUMBER] bathroom was cleaned and the hole was covered by 1-hour fire rated caulk.
b. The openings in the ceiling were covered by ceiling tiles. The bowed ceiling tile was replace with a new ceiling tile. The stainless steel hood was cleaned. The tilt skillet, plate warmer were cleaned and the hamburger buns were thrown out as a precaution even though there were no mouse droppings present.
c. The dietary dry food storage room was cleaned of all mouse droppings, the food with the mouse droppings was discarded and the ceiling tiles were cleaned.
d. The fruit flies were removed. The employee break room was cleaned of all mouse droppings. The hole in the wall next to the refrigerator was filled by 1- hour fire rating caulk.
2. The facility has obtained a new pest control company to come in weekly. A log will be maintained for times the pest control company comes in and what was done and that the pest control log that is currently in use on each floor will be reviewed.
3. The Administrator will maintain a copy of the contract of the current pest control company and the Maintenance Director will maintain all logs of when the pest control company is in the building and what was done.

(NAME) Martin, an independent outside consultant, has been retained by the facility for the required compliance with the statement of deficiencies directed plan of correction.
1) A complete assessment of the causative factors was completed at the QA meeting held (MONTH) 28th (YEAR). The following issues were identified that contribute to the issues identified for the deficiency.
a) Back loading dock area needs a cleaning.
b) Over growth outside.
C) Construction next to facility.
2) Identify the specific steps/interactions undertaken or proposed to eliminate and correct the causative factors identified during the assessment.
a) The facility held a QA Committee meeting on (MONTH) 28th (YEAR) to review the deficiencies.
b) The loading dock area will be cleared of any and all debris and storage.
c) Grounds will be kept clean and free from over growth.
d) Weekly audits will be completed every week for 90 days on then monthly thereafter of dock area and the ground to assure they are clear of debris and overgrowth.
e) The facility will contract with new extermination company.
3) Identify the routine triggers or parameters the facility will implement for the above deficiencies that will signal or alert all staff of an evolving problem or deficient practice situation. Indicate how this system will be carried out.
a) Our triggers will be identified during daily rounds and weekly audits.
b) Any negative findings will result in counseling and corrective action.
C) Any negative findings will be reported to the administrator.
4) Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance.
a) The director of maintenance will make daily rounds and weekly audits and bring all findings to the administrator and the QA Committee for review and any needed corrective action
An outside consultant, (NAME) Martin, educated the following targeted staff: the director of maintenance/interim housekeeping director, director of dietary, and the administrator on the Pest Management article on 7/20/2018. All facility policy and procedures related to pest control were reviewed and updated accordingly to reflect new procedures implemented. The Director of Maintenance, Director of Housekeeping, Director of Dietary will re-educate their staff on the procedures set into place from this educational inservice.
The following items were reviewed:
1) How to identify interior and exterior ?hot spots? within the facility
2) Ensuring food preparation areas are clean
3) Outside cleanliness of the facility (i.e., trees, bushes, grass trimmed)
4) Storage and Receiving (dock area) is kept clean and empty of any garbage, boxes, as well as keeping anything stored enclosed in covered containers to keep any pests out. Cardboard boxes should be discarded.
5) Checking all holes in walls and under doors for any cracks
6) Checking all shipments that come in for any pests
7) Frequent monitoring of any plumbing issues that may cause leaks and/or standing water
8) Making sure all areas are clean of any debris
9) Ensuring that all hot spots, storage/receiving areas are kept clean and to make any necessary repairs to doors, cracks to deter any pests from entering the facility.
An audit sheet has been developed to conduct a full house audit on all issues that were identified through this deficient practice. Any area that is found needing repair will be logged on the audit sheet and will be repaired as quickly as possible. The Maintenance Director will conduct the audit weekly and will bring the audit to the QAPI committee for review and continued monitoring.
The Director of Maintenance, Director of Housekeeping, Director of Dietary, and the Administrator is responsible for compliance.

ZT1N 415.26:ORGANIZATION AND ADMINISTRATION

REGULATION:

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one fire alarm system, the facility governing authority did not ensure compliance with all applicable Federal, State, and local laws, rules, and regulations. Specifically, a fire alarm panel replacement project commenced without approval from the New York State Bureau of Architectural and Engineering Review to add an essential piece of equipment to the facility. This is evidenced by the following: 1. Observations on 6/5/18 at 1:39 p.m. revealed two fire alarm panels mounted to the wall in the basement Telephone/Fire Alarm room. When interviewed at that time, the Director of Maintenance (DM) revealed that one of the panels is the newer one, and the project to switch over to the new panel began more than a year ago. Further interview with the DM revealed a former vendor had begun the project and now the current vendor is supposed to finish it. The Administrator stated that the fire alarm system panel upgrade was in the works, and she was not aware of a construction notice being submitted. Observations throughout the building revealed the fire alarm system serves all three floors and the basement. 2. On 6/6/18 a review of the New York State Department of Health's (NYSDOH) Electronic Certificate of Need database revealed that there was no limited review application for replacement of the fire alarm panel approved by the NYSDOH, or the submission of a construction notice. Part 710.1, Approval of Medical Facility Construction, requires: (1) a limited review to be completed for the erection, building, acquisition, alteration, reconstruction, improvement, extension or modification of a medical facility, including its equipment and services. (2) As a part of the application required for approval of the project, the applicant shall give the following assurances: that the applicant will obtain the approval of the commissioner of all required submissions. (10 NYCRR: 710.1(c)(5)(ii), 710.1(c)(8)(ii)(f)(2), 415.26(b))Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one of one fire alarm system the facility governing authority did not ensure compliance with all applicable Federal, State, and local laws, rules, and regulations. Specifically, a fire alarm panel replacement project commenced without approval from the New York State Bureau of Architectural and Engineering Review to add an essential piece of equipment to the facility. The findings are: A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed that the Administrator would complete an Architect/Engineers Certificate of Construction Notice, submit, and obtain approval prior to replacement of the fire alarm panel. The project would be uploaded into the New York State Electronic Certificate of Need (NYSECON) by 7/31/18, and the Administrator was the responsible party, with a completion date of 7/31/18. On 8/13/18 at 2:12 p.m. a review of the New York State Department of Health's (NYSDOH) NYSECON database revealed that there was no limited review application for replacement of the fire alarm panel approved by the NYSDOH, or the submission of a construction notice by the facility. Observations on 8/16/18 at 12:25 p.m. revealed two fire alarm panels mounted to the wall in the basement Telephone/Fire Alarm room. Observations throughout the building revealed the fire alarm system serves all three floors and the basement. When interviewed at that time, the Director of Maintenance revealed one is a newer panel they are upgrading to. The Administrator stated that the fire alarm system panel upgrade was still going to happen and that the construction notice was submitted. Further review of documents provided by the Administrator revealed that the facility had begun the construction notice process but had not completed it. The notice had not yet been assigned a construction notice number. There was no construction notice application, no architect/engineers certificate of construction notice, and no safety plan. Part 710.1, Approval of Medical Facility Construction, requires: (1) a limited review to be completed for the erection, building, acquisition, alteration, reconstruction, improvement, extension or modification of a medical facility, including its equipment and services. (2) As a part of the application required for approval of the project, the applicant shall give the following assurances: that the applicant will obtain the approval of the commissioner of all required submissions. (10 NYCRR: 710.1 (c)(5)(ii), 710.1 (c)(8)(ii)(f)(2), 415.26(b))

Plan of Correction: ApprovedSeptember 12, 2018

The vendor has been contacted to obtain a quote for proposed work. The administrator will complete Architect/engineers certificate of construction notice and submit, obtain approval prior to replacement of fire alarm panel. The Administrator will ensure that any current and future projects that require a construction notice, CON, or limited review will be submitted and approved prior to any project starting. Any current and future projects will be reviewed by the QAPI committee to ensure project is not affecting the residents. The Administrator is responsible for all compliance. The project will be uploaded into the NYSECON by 7/31/2018.

FF11 483.40(d):PROVISION OF MEDICALLY RELATED SOCIAL SERVICE

REGULATION: §483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #94) of two residents reviewed for hospice services, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The issue involved the lack of timely follow through of a physician's orders [REDACTED]. This is evidenced by the following: The undated facility policy, Hospice Program, revealed that once it is felt that the resident would benefit from hospice services, the medical staff is contacted for an order for [REDACTED]. Resident #94 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/16/18, revealed the resident had severely impaired cognition and was totally dependent on staff for all Activities of Daily Living. Physician orders, dated 5/9/18, included a hospice consultation. The written order was signed as checked by three nurses with the third nurse signing and dating on 5/11/18. There was no documentation in the medical record regarding hospice until 5/24/18 when a progress note revealed that the interdisciplinary team met and discussed the resident's medical status. It was decided that Social Work would follow up with the resident's guardian to get approval for a hospice consult at that time. A communication note, dated 5/25/18 and signed by the SW, revealed that the SW had spoken to the resident's guardian regarding the resident's decline in health and the recommendation of a hospice referral. The guardian was educated about what hospice entails and agreed with the hospice referral. There was no further documentation in the medical record regarding a hospice referral. Following surveyor intervention, the resident was seen by the Medical Director on 6/1/18 with orders written for palliative care measures, discontined [MEDICATION NAME] (anti-psychotic medication), ordered [MEDICATION NAME] (anti-anxiety medication), and an order indicating that medications could be crushed as needed until a hospice evaluation could be completed on 6/4/18. When interviewed on 6/1/18 at 10:12 a.m., the Director of Nursing (DON) stated that once a physician's orders [REDACTED]. The DON said that the Unit Manager was responsible for contacting Social Work regarding a medical order. During an interview on 6/1/18 at 10:20 a.m., the resident's assigned SW stated she was not aware that there was a physician's orders [REDACTED]. The SW said that the resident was discussed with the interdisciplinary team on 5/24/18, and she called the guardian after that meeting. The SW said that she had called the hospice agency on 5/25/18, had not heard back from them, and has not had time to call again that week. When asked how medical orders are typically brought to the SW's attention, the SW stated that it was usually the physician or Nurse Practitioner themselves. The SW said that she was aware there was talk of a hospice referral but not aware there was an actual physician's orders [REDACTED]. The SW said that it does not usually take six days, and she should have called the hospice agency again by now. When interviewed on 6/1/18 at 10:25 a.m., the acting Unit Manager stated that when an order is received for Social Work, the first nurse taking the order off should have either taken the triplicate piece or written a notification of change memo to the SW regarding the recommendation. The second and third nurse signing the order should have double checked to see that the notification was made to Social Work. When interviewed on 6/1/18 at 1:33 p.m., the Medical Director stated that he had spoken to the hospice nurse earlier that day, and the hospice evaluation was scheduled to take place on 6/4/18. The Medical Director stated that there should not have been any delay in obtaining a Hospice evaluation after it was ordered. The Medical Director said that he had also written orders for palliative care measures for the resident. When interviewed on 6/4/18 at 2:09 p.m., the Director of Social Work stated that there was a delay in the hospice referral process for this resident. (10 NYCRR 415.5(g)(1)(i-xv))

Plan of Correction: ApprovedJuly 12, 2018

If Hospice is needed or recommended for a resident by IDT or Physician:
? The physician/nursing will discuss this plan first and relay message to social work
? Social Work will then talk to resident or responsible party regarding recommendation and potentially setting up hospice meeting and making hospice referral
? If resident or responsible party is in agreement with a hospice meeting, social work will then arrange a meeting with hospice and resident/responsible party
? Social work will then notify IDT when hospice meeting is

The SW responsible for the care of resident #94 was educated regarding the hospice referral process and timeliness of the hospice referral.
A full house audit was completed of residents who had orders in PCC for a hospice evaluation.

The policy for hospice was reviewed. The policy incudes appropriate response time in regards to the physician?s order being placed in PCC and the hospice referral being made to ensure and maintain the highest practicable physical, mental and psychosocial well-being of each resident. All social workers and nurse managers was educated on the referral process of hospice.

The facility will develop an audit tool to monitor and ensure compliance with the policy for Hospice. The audit will include ensuring timely response for a hospice referral once a physician?s order is entered and continued follow up to ensure a meeting is scheduled and held within a timely manner. The Director of Social Work or designee will be responsible for completing these audits weekly for 12 weeks and then monthly for 9 months. The Director of Social Work is responsible for compliance and will report findings at the QAPI monthly for follow up and review.

FF11 483.75(g)(2)(ii):QAPI/QAA IMPROVEMENT ACTIVITIES

REGULATION: §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that the facility did not ensure a Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility had continuing deficiencies in the areas of Food Procurement, Store/Prepare/Served-Sanitary (F812), Accommodation of Needs (F558), Environment (F584), Minimum Data Set Assessment accuracy (F641), Activities of Daily Living (F677), Respiratory Care (F695), Medication Storage (F761), Flu and Pneumococcal Immunizations (F883), Essential Equipment/Safe Operating Condition (F908), Corridor Handrails (F924), Pest Control (F925), Establishment of Emergency Program (E001), Egress (K211), Doors with Self-closing Devices (K223), Aisle, corridor or ramp width (K232), Discharge from Exits (K271), Emergency Lighting (K291), Vertical Openings (K311), Hazardous Areas (K321), Fire Alarm System (K345), Utilities - gas and electric (K511), Elevators (K531), Essential Electric Systems (K916), Electric System maintenance and testing (K918), and Power Cords (K920). This is evidenced by the following: Cross reference F812: Food Procurement, Store/Prepare/Served-Sanitary The facility failed to conduct weekly onsite kitchen audit inspections which included, but was not limited to, sanitation food service distribution visual observations and equipment observations that could cause a food safety violation. This resulted in an imminent risk to residents' health and safety. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said the facility had not started or completed any of the Federal or Life Safety Code audits that were stated in the Plan of Correction. She stated the Director of Nursing (DON) had been terminated because she found out that she had not been doing anything. She said she believed some education had been done with staff, but did not know how much. She said they have a relatively new maintenance person who has started working on some of the issues, but she did not know what had been done or what was left to do. When interviewed on 8/13/18 at 11:49 a.m. and 12:40 p.m., the Administrator said the DON and herself had written the Plan of Correction. She said the QAA committee consists of herself and all the department heads (maintenance, therapy, Social Work (SW), Activities, DON, Housekeeping, and the Medical Director). She said they had not had a QAA meeting yet. She said the only education she could find had six staff signatures, and they had no other documentation of staff being educated. The Administrator said they did not have the policies completed by the consultant and had no educational outlines. She stated she was ultimately responsible for the Plan of Correction. The Administrator said the date certain for the Plan of Correction was the date she thought the facility would be in compliance. She stated the RN staff educator had reduced her hours. She checked her e-mail denoting who had received a copy of the Plan of Correction and the staff educator had been omitted. When asked how the staff educator could be responsible for education when she had no knowledge, the Administrator responded, She can not. Interviews conducted on 8/16/18 included the following: a. At 10:41 a.m., Nurse Manager #1 said she received a copy of the P(NAME) but did not get to read it all. She said they were not given any instructions, outlines, audits, or guidance to provide education. Nurse Manager #1 said she was unsure if the Nurse Managers were part of Quality Assurance and did not know when the last meeting was held. b. At 11:10 a.m., Nurse Manager #2 said Nurse Managers are not part of the QAA team and have never attended a QAA meeting. She said they had no direction for audits or education. c. At 1:33 p.m., Nurse Manager #3 said she was not aware of what QAA means or what the committee does. d. Interviews with seven Certified Nursing Assistants, two Housekeepers, and one Licensed Practical Nurse between 9:43 a.m. and 3:55 p.m., revealed that they were not aware of the QAA committee, the committee's role, and/or how to contact them. Interviews conducted on 8/17/18 included the following: a. At 8:37 a.m., the Social Work Director said she has been at the facility for four years and is part of the QAA committee. After reviewing her calendar, she said the last QAA meeting was held on 6/20/18. She said since the (MONTH) Recertification Survey they had not been told to change anything and she had not received any guidance or auditing tools. b. At 9:03 a.m., the Director of Therapy said they were not part of the QAA program right now but they did attend one meeting in June. The Director of Therapy said they did go over the P(NAME) at that meeting but education and audits were not discussed. c. At 12:24 p.m., the Medical Director said he started at the facility two months ago and is part of the QAA program. He said he did attend a meeting in (MONTH) but could not remember anything that was discussed. He said that he was not aware of the facility's Statement of Deficiencies or Plan of Correction. He said that was a missing link. He stated that he wants to know what deficiencies the facility received. He said he was not aware the facility did not complete the P(NAME). When interviewed on 8/17/18 at 10:18 a.m., the Administrator said ultimately she is responsible for the QAA program. She said the way to ensure progress toward correction or if improvement was achieved and sustained would be identified through the use of audits. She said the assessments, tasks, work list, audits, and education were not completed prior to 8/13/18 as stated in the Plan of Correction. (10 NYCRR 415.27(a-c))

Plan of Correction: ApprovedSeptember 10, 2018

Corrective Action Taken for Those Residents Affected and for Those Residents Having Potential to be Affected-
The facility respectfully recognizes all residents as having potential to be affected and it was determined that there was no negative outcome due to the deficient practice.
The facility has initiated the weekly onsite kitchen audit inspections, including sanitation food service distribution visual observations and equipment observations that could cause a food safety violation.
The facility has hired a new Director of Nursing.
The facility has hired a new Director of Housekeeping.
The facility has hired a second full-time floor tech.
The facility employs a full-time staff educator.
The facility held a QA meeting on 8/24/18 and again on 9/6/18.
All education for the Plan of Correction will be completed by the Consultant. The Consultant will provide documentation regarding the education in-services to the administrator and the staff educator for use with newly hired staff.
The (MONTH) statement of deficiencies was distributed to all management staff, on 9/5/18 and was reviewed at the QA meeting on 9/6/18.
The administrator was educated regarding her responsibility to ensure the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically her responsibility to ensure the facility complied with the P(NAME) submitted to the DOH for both the Health and Life Safety Code Surveys.
Systemic Monitoring-
The policy for Quality Assurance Committee was reviewed revised and updated to include, the facility will hold QA meeting the last Friday of every month minus one winter month, members of the QA committee, the function and purpose of the QA committee. The Consultant will be responsible to in-service all staff regarding the policy.
Quality Assurance Monitoring-
The Consultant in conjunction with the facility will develop an audit tool to monitor and ensure compliance with the policy for Quality Assurance Monitoring. The audit will include the facility is meeting monthly as scheduled, that the facility maintains records of the QA meeting, that the staff understand the function and purpose of the QA committee and who the members of the committee are. The Staff Educator or designee will be responsible to complete these audits weekly for 4 weeks and then monthly for 3 months, at which time it will be reviewed for continued frequency guidance at QA. The Staff Educator will report findings at the QACM monthly for follow up and review.
Person Responsible for the Correction of this Deficiency- Administrator
Date of Completion- 10/12/18
Layla Kuek, RN is an Independent Consultant. Mrs. (NAME REDACTED) Kuek, has been retained by the facility for required compliance with the Statement of Deficiencies Directed Plan of Correction and Directed In-Services.
A. The causative factors that may have contributed to the issue identified is lack of education.
B. The steps/interventions undertaken or proposed to eliminate and correct the causative factors identified during the assessment phase is staff in-servicing or education.
C. The routine triggers or parameters the facility will implement for the above deficiency, that will signal or alert all staff of an evolving problem or deficient practice situation. This system will be carried out by the facility by ensuring the monthly QAPI meeting occurs.
D. The facility will measure whether efforts are successful or unsuccessful in maintaining compliance through QAPI.
A. Mandatory In-Servicing For F 867 will be conducted on 9/17/18 at 10:00am and 2:00pm, 9/18/18 at 10:30am, 9/19/18 at 10:00am and 2:00pm, 9/20/18 at 10:30am, 9/21/18 at 10:30am and 3:30pm, 9/25/18 at 10:00am, and 9/27/18 at 10:00am. Each in-service will be approximately 60 minutes in length, depending on the length of the question and answer session at the end. The in-service will be given by Layla Kuek RN. Targeted staff will include all staff. Monitoring and Evaluation of the effectiveness of the program will be conducted facility audits that are completed by facility staff designated in the P(NAME). The Quality Assurance Audit findings will be reviewed monthly at the Quality Assurance Committee Meetings for follow up and guidance.
B. In-Service Outline- The policy for Quality Assurance Committee was reviewed revised and updated to include, the facility will hold QA meeting the last Friday of every month minus one winter month, members of the QA committee, the function and purpose of the QA committee. The Consultant will be responsible to in-service all staff regarding the policy.
Questions and Answer
Post Test

FF11 483.10(e)(3):REASONABLE ACCOMMODATIONS NEEDS/PREFERENCES

REGULATION: §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 2 (Residents #67 and #17) of 32 residents reviewed for accommodation of needs, the facility did not provide the residents with services to meet the residents' needs. Specifically, call bells were out of reach. This is evidenced by the following: 1. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 3/3/18, revealed that the resident had severely impaired cognition. During an observation on 5/30/18 at 1:37 p.m., the resident was in bed, turned to her right side. The call bell was under a large pillow under the resident's head. When asked at that time if she knew where her call bell was, the resident moved her right arm around the bed covers and said she could not find it. On 5/30/18 at 3:04 p.m., the resident's bed was in the high position, and the call bell was still under her pillow. The surveyor intervened and brought Certified Nursing Assistant (CNA) #1 into the room. When interviewed at that time, CNA #1 stated that the resident can use the call bell and it should be positioned where she can reach it. CNA #1 then removed the resident's call bell from under the pillow, clipped it to the linen in her lap, and lowered the bed to a low position. When observed on 6/1/18 at 7:34 a.m., the resident was in bed awake, and the call bell was out of reach tucked under the resident's large pillow under her head. CNA #2 walked into the resident's room, said she had already done her walking rounds at the beginning of the shift, and did not notice that the call bell was out of reach. She said it was out of the ordinary for the call bell to be out of the resident's reach. 2. Resident #67 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/28/18, revealed that the resident had moderately impaired cognition. During an observation on 5/29/18 at 4:00 p.m., the resident was lying in bed awake, and the call bell was strung up over the headboard of the bed, out of reach of the resident. During interviews on 5/29/18 at 4:05 p.m., CNA #1 said that the resident can usually use the call bell and it should be within her reach. At that time, the Licensed Practical Nurse (LPN) came into the room, stated the resident can use the call bell, and it should be in reach. The LPN moved the call bell onto the resident's lap and clipped it to the sheet. When interviewed on 6/5/18 at 2:27 p.m., the Interim Assistant Director of Nursing stated that Residents #17 and #67 can use call bells and they should be within reach. (10 NYCRR 415.5(e)(1))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (Resident #35) of three residents reviewed for accommodation of needs, the facility did not provide the resident with services to meet the resident's needs. Specifically, the resident's call bell was out of reach. This is evidenced by the following: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/10/18, revealed that the resident had moderately impaired cognition, required total assistance from staff for all Activities of Daily Living, and had limited Range of Motion of bilateral lower extremities. When observed on 8/15/18 at 2:10 p.m., the resident was lying in bed on his left side on an air mattress with a splint on his left hand. The call bell was on the floor. The resident asked the surveyor to retrieve the call bell. The clip on the call bell cord appeared broken and did not clip securely to the blanket. When interviewed at that time, Certified Nursing Assistant (CNA) #1 stated that the resident was able to use the call bell and notified maintenance regarding the broken call bell clip. During observations on 8/16/18, the resident was in his bed asleep at 9:45 a.m., and awake at 10:05 a.m. with his call bell clipped to the sheet above his head on his right side. When the resident was asked at 10:05 a.m. if he was able to reach his call bell, the resident said he was unable to locate the call bell. When the resident was told the location of the call bell, he demonstrated that he was unable to reach the call bell. At that time, CNA #2 stated that they had problems with the resident's call bell clip and would often find it on the floor. CNA #2 moved the call bell lower on the bed and when the resident stated he still could not reach it, CNA #2 then moved it to his chest where his right hand was resting and clipped it to his sheet. Additionally, when interviewed on 8/17/18 at 10:18 a.m., the Administrator and Director of Nursing said that the full house review of call bells, the development of the call bell audit tool, and education of staff had not been completed as per the Plan of Correction from the 6/6/18 Recertification Survey. (10 NYCRR 415.5(e)(1))

Plan of Correction: ApprovedSeptember 10, 2018

Corrective Action Taken For Those Residents Affected:
Resident #17 was assessed by the Director of Nursing and the Unit Manager and it was determined that there were no negative outcomes to the deficient practice. The call bell was clipped to their bed linen to remain within reach. The nursing staff responsible for resident # 17 was reeducated in the importance of safety to ensure resident is able to have the call bell within reach at all times while in the room and to have the bed at the correct height according to their care plan.
Resident #62 was assessed by the Director of Nursing and the Unit Manager and it was determined that there were no negative outcomes to the deficient practice. The nursing staff responsible for resident #62 was reeducated in the importance of safety to ensure the resident is able to have the call bell within reach at all times while in the room.

Corrective Action Taken For Those Residents Potentially Affected:
The facility recognizes all residents have the potential to be affected and it was determined that no negative outcomes were found from the deficient practice. A full house review of resident call bells was conducted to ensure they all had clips on the cords and they were within reach and the beds were at the correct height for safety according to their individualized care plan. Staff was educated accordingly.

Systematic Monitoring:
The policy and procedure was reviewed, found not necessary to update at this time, and used to educate the staff on the importance of maintaining call bell being within reach and beds being at the correct height. The facility educator or designee will be responsible for educating all staff who assist with resident call bells and bed height by (MONTH) 30, (YEAR).
Quality Assurance Monitoring:
The facility will develop an audit tool to ensure compliance with the policy and procedure of call bell location on the bed and bed height. The audit tool will represent all residents to be reviewed for call bell and appropriate bed height. This audit will be conducted weekly for 8 weeks and then monthly for 3 months. The Director of Nursing, nurse manager or designee will be responsible for completing the audit. The Administrator will be responsible for reporting the audits at the QAPI committee meetings for review and from there it will be determined if continued auditing is necessary.

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three dining rooms observed, the facility staff did not provide care in a manner that enhanced each resident's dignity. The issues involved the lack of a dignified dining experience (Resident #90) and staff were standing up over residents during meals while assisting with feeding (Residents #17 and #72). This is evidenced by the following: 1. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/8/18, revealed the resident had severely impaired cognition and required supervision and set up for eating. The current Comprehensive Care Plan (CCP) and Certified Nursing Assistant (CNA) Kardex included a diet of no added salt and regular consistency with thin liquids. During observations in the unit dining room on 5/29/18 from 12:32 p.m. through 1:13 p.m., and on 6/1/18 from 12:30 p.m. through 12:46 p.m., the resident was eating food items including rice with pork and gravy, and cooked spinach with his hands and apple crisp by picking up the bowl and eating directly from it with his mouth and hands. The resident was not seen using utensils at any time. The resident was approached by staff and asked if he wanted his sandwich and if he wanted help. The resident loudly replied, No. The resident was observed on 5/30/18 at 1:28 p.m., in his room lying in bed with his lunch tray on overbed table with the remains of his lunch on the tray including mashed potatoes with gravy and corn. When interviewed on 6/4/18 at 2:53 p.m., the resident's assigned CNA said that when the resident eats, he feels around on the tray with his hand and eats with his hands. The CNA stated that she was not sure if the resident was totally blind. The CNA said that the resident does not use utensils and will not accept assistance. When interviewed on 6/1/18 at 1:10 p.m., the Diet Technician (DT) stated that the resident gets sandwiches and snacks three times daily and eats them well because they are finger foods. The DT said that it is not dignified for the resident to be eating with his hands and his mouth and that she could give him more finger foods. 2. Resident #72 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/1/18, revealed that the resident had severely impaired cognition and was totally dependent on staff for eating. Review of the 4/23/18 CCP and the 6/5/18 CNA Kardex revealed the resident needs the total assist of one staff for eating. When observed on 5/29/18 from 12:37 p.m. to 1:16 p.m., and on 6/1/18 from 8:21 a.m. to 8:40 a.m., the CNA was standing to feed the resident and at times, holding the resident's head in her left hand while feeding her with the spoon in her right hand. 3. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/3/18, revealed that the resident had severely impaired cognition and was totally dependent on staff for eating. Review of the 3/7/18 CCP revealed that the resident required one staff for limited assistance with eating, and the 4/27/18 CNA Kardex revealed the resident needed set up and encouragement to eat. When observed in the third floor dining room on 5/29/18 from 12:37 p.m. to 1:16 p.m., the Licensed Practical Nurse (LPN) was standing while feeding the resident. When interviewed on 6/1/18 at 1:24 p.m., the DT stated that staff are supposed to sit and feed residents at eye level. When interviewed on 6/5/18 at 11:57 a.m., the LPN said that the staff should be sitting down while feeding the residents. (10 NYCRR 415.5(a))

Plan of Correction: ApprovedJuly 13, 2018

Corrective Action Taken For Those Residents Affected:
For resident #90, the care plan was reviewed and revised to ensure that the meal provided will be finger foods and provide utensils at all meals according to resident preferences at all meal times. Staff will be educated to offer and provide assistance as tolerated and as needed. Education will be provided to staff regarding appropriate hand hygiene for the resident prior to meal times.
The CNA feeding resident #17 was reeducated on the proper feeding techniques and that at no point is it acceptable to hold a resident?s head while assisting them while they?re eating.
The LPN feeding resident #72 was reeducated that while assisting a resident during meal times it is necessary to sit and remain eye level with the resident.

Corrective Action Taken For Those Residents Potentially Affected:
The facility recognizes all residents have the potential to be affected and it was determined that no negative outcomes were found from the deficient practice.
A full review was conducted of all residents who are care planned for assistance while feeding. All nursing staff will be reeducated on their responsibility with assisting residents during meal times.

Systematic Monitoring:
The policy and procedure was reviewed, found not necessary to update at this time, and used to educate the staff on the importance of maintaining dignity while dining. The facility educator or designee will be responsible for educating all staff who assist with resident feeding by (MONTH) 30, (YEAR).
Quality Assurance Monitoring:
The facility will develop an audit tool to ensure compliance with the policy and procedure of feeding a resident. The audit tool will represent all staff members who assist with feeding have been randomly audited to ensure proper technique. This audit will be conducted weekly for 8 weeks and then monthly for 3 months. The Director of Nursing or designee will be responsible for completing the audit. The Administrator will be responsible for reporting the audits at the QAPI committee meetings for review and from there it will be determined if continued auditing is necessary.

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 362), it was determined that for one (Resident #16) of two residents reviewed for respiratory care, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. Specifically, a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine was not applied, respiratory equipment and supplies were not maintained, and the respiratory care plan did not reflect the resident's current respiratory status. This is evidenced by the following: Resident #16 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/6/18, revealed the resident had moderately impaired cognition, required supervision with personal hygiene and special respiratory treatments including [MEDICAL CONDITION]. The facility policy, [MEDICAL CONDITION]/ [MEDICAL CONDITION] (Bilevel Positive Airway Pressure) Support, dated 2/4/18, revealed the purpose was to provide the spontaneously breathing resident with continuous positive airway pressure, with or without oxygen, and to promote comfort and safety. The policy included to review and follow manufacture's instructions for [MEDICAL CONDITION] machine set up. The current Comprehensive Care Plan (CCP), with an initiated date of 10/11/17, included breathing patterns were ineffective related to sleep apnea. Interventions included [MEDICAL CONDITION] as ordered at 10 millimeters (mm), administer respiratory treatments, and monitor respiratory status. The Sleep Center Report, dated 2/8/17, included the resident was a regular [MEDICAL CONDITION] user and needed a new mask and other supplies. There was no documentation in the medical record regarding new supplies. Physician orders, dated 3/16/18 and 5/3/18, included [MEDICAL CONDITION] at 10 mm, on at bedtime and off in the morning. The order included to rinse the mask and dry prior to applying the mask, fill the container with sterile water, and check the filter at bedtime. The start date of the order was 7/30/17. The report from the Sleep Center, dated 3/28/18, included the resident's equipment was beyond dirty. The equipment needed to be cleaned and replaced often. The mask was moldy, the resident had severe sleep apnea and needed to be tested . The treatment plan included new disposable supplies immediately. A physician order, dated 4/6/18, included a sleep study for [MEDICAL CONDITION]. A physician order, dated 5/30/18, included to place the [MEDICAL CONDITION] on hold. A prescription, dated 5/31/18, included [MEDICAL CONDITION] machine settings per Respiratory Therapy. The resident's room was observed intermittently throughout the survey, from 5/29/18 through 6/1/18, and there was no [MEDICAL CONDITION] machine in the room. An observation in the afternoon of 6/1/18, the resident's [MEDICAL CONDITION] machine was in a plastic bag at the nurses' station. The tubing was attached to the [MEDICAL CONDITION] machine, there was no mask, and the humidifier chamber was dry without sediment. When interviewed on 5/29/18 at 2:03 p.m., the resident stated the [MEDICAL CONDITION] machine was taken by the Director of Nursing, and it was supposed to be brought back when it was replaced. He stated it has been gone for three weeks. The resident stated the Nurse Manager (NM) was aware and was supposed to get his machine back to him. The resident stated he cannot use a full face mask and has not used one in a couple of years. He stated a sleep study was scheduled but then had to be rescheduled. Interviews conducted on 6/1/18 included the following: a. At 1:08 p.m., a Licensed Practical Nurse (LPN) stated the humidifier chamber of the [MEDICAL CONDITION] should be cleaned every couple of days and the mask every day. b. At 2:40 p.m., the Director of Medical Records, responsible for scheduling outside appointments, stated the resident was scheduled for a sleep study on 6/26/18. She stated his machine was at the facility and presented a [MEDICAL CONDITION] machine in a plastic bag. c. At 2:34 p.m., the LPN NM stated the resident had a [MEDICAL CONDITION] machine but needed a new one. The LPN NM stated she had faxed the script to the medical supplier a couple of hours ago. She stated the resident was refusing to wear the mask. The LPN NM said she did not know how often the mask should be replaced but thought it should be cleaned weekly. The LPN NM stated the Registered Nurses developed the CCP, and she would expect the care plan to address the use and care of a [MEDICAL CONDITION] machine. The LPN NM stated it was reported that the resident refused to wear the [MEDICAL CONDITION]. When asked if the resident continued to wear the [MEDICAL CONDITION] after the sleep center visit on 3/28/18, she stated she did not know. The Treatment Administration Records (TAR) for (MONTH) (YEAR) and (MONTH) (YEAR), revealed an entry for the [MEDICAL CONDITION] machine per the physician order [REDACTED]. The LPN NM stated an order was obtained on 5/30/18 placing the resident's [MEDICAL CONDITION] on hold. She said staff should not be signing off the [MEDICAL CONDITION] if it was not used. When interviewed on 6/4/18 at 10:27 a.m., the Director of Nursing stated the provision of care for the [MEDICAL CONDITION] machine should be on the TAR. She stated the maintenance and care of a [MEDICAL CONDITION] machine was more than just rinsing the mask. (10 NYCRR 415.12(k)(6))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (Resident #16) of three residents reviewed for respiratory care, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. Specifically, a Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine was not applied correctly, staff were unaware of how to check the machine for verification, and education and audits were not completed per the Plan of Correction. This is evidenced by the following: Resident #16 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/6/18, revealed the resident had moderately impaired cognition and special respiratory treatments including [MEDICAL CONDITION]. Physician orders, dated 7/30/18, include [MEDICAL CONDITION] at 10 millimeters, on at bedtime and off in the morning. The Comprehensive Care Plan, dated 6/18/18, included breathing patterns are ineffective related to sleep apnea. The goal was the resident will demonstrate an effective respiratory rate, depth, and pattern and have no stated discomfort verbalized. Approaches included [MEDICAL CONDITION] as ordered and to monitor the treatment. A nursing note, dated 6/26/18, revealed the resident returned from the sleep clinic with a prescription for a new [MEDICAL CONDITION] machine. A nursing note, dated 7/19/18, revealed the company representative brought a new [MEDICAL CONDITION] machine to the resident and demonstrated how to set up the machine and clean the filter. When observed on 8/13/18 at 10:55 a.m., the resident was sitting in his room, and the [MEDICAL CONDITION] machine was on the side table. The resident said he had the [MEDICAL CONDITION] on the previous night, but he has not worn it every night because it falls apart and no one knows how to fix it. He stated the rubber part where the nose piece goes falls right out, and where the straps connect that breaks apart too. The resident demonstrated how that happened. He said he has been waiting about a month for a new mask but it has not come yet. The surveyor checked the [MEDICAL CONDITION] sleep summary which revealed that the resident used the [MEDICAL CONDITION] machine for 9 hours and 15 minutes the previous night, the seal of the mask was poor, and the humidification was good. When interviewed on 8/13/18 at 11:05 a.m., the Licensed Practical Nurse (LPN) Manager said she was not aware there was a problem with the resident's mask, and she did not know the resident was waiting for a new mask. The LPN Manager said she received some education regarding [MEDICAL CONDITION] machines, but did not know she could check the sleep summary on the face of the machine to know how effective the seal of the mask was for the previous night. At 2:59 p.m., the LPN Manager said she found the new mask that was delivered in the supply room. The packaging was unopened, undated, and did not identify the resident. The LPN Manager said she did not know how long it had been in the supply room. When interviewed on 8/13/18 at 3:31 p.m., the evening LPN said the resident's mask does come apart at times, the nose piece crumbles apart and falls off all the time. She said the resident had been telling her about it for awhile. She said the resident was waiting for a new mask. She said she was unaware that she could check the sleep summary on the machine to determine the effectiveness of the seal of the mask. Review of the education for [MEDICAL CONDITION]/[MEDICAL CONDITION], dated 7/19/18, revealed the signatures of six nurses. There was no education outline. An additional five LPNs were interviewed on 8/13/18 at 11:24 a.m., 12:08 p.m., 2:45 p.m., on 8/14/18 at 10:50 a.m., and on 8/16/18 at 10:22 a.m. Four LPNs said they had not received any education regarding [MEDICAL CONDITIONS], and one LPN said that he had received a brochure regarding [MEDICAL CONDITION]. When interviewed on 8/14/18 at 10:54 a.m., the Registered Nurse (RN) said that effective mid-July she was no longer the Staff Educator. The RN said she did not have any input regarding the Plan of Correction (P(NAME)) the facility submitted, nor did she receive a copy of the P(NAME). The RN said she had no knowledge of who was responsible to educate the staff per the P(NAME). When interviewed on 8/17/18 at 10:18 a.m., the Administrator said they did not complete education for the nurses regarding Respiratory Care, and no audits were conducted or audit tolls developed. (10 NYCRR 415.12(k)(6))

Plan of Correction: ApprovedSeptember 10, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 16's care plan was reviewed and updated on 6/10/18. Per physician the sleep study was no longer needed new [MEDICAL CONDITION] was ordered and is being used per physician order. After a facility wide review only two residents had the potential to be affected as they require a [MEDICAL CONDITION] or [MEDICAL CONDITION] at this time. The other two residents care plan, physician orders, and machine were reviewed for accuracy and proper operation. The DON and/or ADON will conduct weekly audits for 8 weeks on MARs and TARs for compliance and then monthly for 4 months. Education will be provided to all nurses regarding proper use of and care of of [MEDICAL CONDITION] and [MEDICAL CONDITION] equipment per facility policy by the staff educator or designee. The DON is responsible for compliance.

FF11 483.55(b)(1)-(5):ROUTINE/EMERGENCY DENTAL SRVCS IN NFS

REGULATION: §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility- §483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: July 20, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey it was determined that for one (Resident #35) of three residents reviewed for dental services, the facility did not provide or obtain routine dental services to meet the needs of each resident. Specifically, the resident had not been seen by a dentist since (YEAR). This is evidenced by the following: The undated facility policy, Dental Services, directed the dentist comes to the facility monthly and a list is kept and updated by the Minimum Data Set (MDS) Assessment nurse. Resident #35 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Dental Evaluation, dated 10/26/16, revealed the resident was seen for an oral exam and had retained roots, multiple broken and/or missing teeth and his oral health was fair. The MDS Assessment, dated 4/10/18, revealed the resident had moderately impaired cognition and no dental issues. During an observation on 5/29/18 at 11:09 a.m., the resident had visible broken teeth and root tips. When interviewed at that time, the resident stated he needed dentures but did not think the facility had someone to take care of that. During an interview on 6/5/18 at 8:34 a.m., the Registered Nurse MDS Coordinator said that the Nurse Managers track when residents are due for dental evaluations and send her a list. The MDS Coordinator stated residents are seen annually. She said the resident has not been seen by the dentist since (YEAR). She stated the dentist was due in that week and she would place the resident on the list to be seen. (10 NYCRR 415.17 (a-d))

Plan of Correction: ApprovedJuly 16, 2018

Resident # 35 medical record was reviewed and a referral was placed for dental services. A full house audit was conducted to ensure that all new and current residents have seen a dentist. All new admissions will be provided with the dental consult within 3 days of admission or referral for next scheduled dental service day. An audit will be completed to determine a schedule for 6 month rotation for all residents. The MDS Coordinator will be in serviced and counseled by DON on assessments and accurate documentation. All audits will be completed by the DON or designee and presented to the QAPI committee for review and from there it will be determined if continued auditing will be necessary. The DON is responsible for compliance.

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

REGULATION: ACCURACY OF ASSESSMENTS

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for three (first, second, and third floors) of three resident sleeping floors and one of one basement, the facility did not properly provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, the facility did not complete their written Plan of Correction by correcting all of the physical environment issues cited during the Recertification Survey of 6/6/18, several similar physical environment issues were observed in other areas of the building, staff were not educated, and the facility did not complete audits of the physical environment to ensure compliance with the P(NAME). This is evidenced by, but not limited to, the following: A review of the Pkan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the facility statement included the following: a. The housekeeping staff were re-educated on how to properly care for the facility to promote a homelike environment for the residents. b. The first floor shower room ceiling tiles were replaced. c. The first floor employee bathroom sink was repaired. d. The hole in Resident room [ROOM NUMBER] was repaired. e. Resident Room # 217 was cleaned up, urinal emptied, and floor mopped. f. The janitor's closet next to room [ROOM NUMBER] slop sink was cleaned out with wet/dry vacuum. Plumber was contacted for repair work to be done. g. Resident room [ROOM NUMBER]'s floor had been mopped. h. The second floor dining room cove base was replaced. The heating unit was replaced back on to the wall. i. On the second floor the floors have been cleaned by the housekeeping staff, communal area laminate flooring had been replaced. j. Resident room [ROOM NUMBER] the brown spots were cleaned from the walls inside the bathroom, under the sink, on the doorframe, heating unit, and the lower wall outside of the bathroom. The corners and edges of the bathroom were scraped and cleaned as well. The scrapes were repaired. k. Resident room [ROOM NUMBER] the wall behind the headboard was repaired. l. The linen has come from different vendors and the type of linen can be different. A plan of purchasing more linens on a consistent monthly basis to make sure we have that three day supply of emergency linen. m. A weekly documented inspection of all linen will be conducted to ensure linen is not dingy, dirty, or stained. The Administrator and Director of Maintenance were listed as responsible for compliance. The above listed items (a-e) were not corrected and/or completed. Observations and interviews conducted during the Post Survey Revisit between 8/13/18 and 8/17/18 revealed the following: Basement 1. In an observation on 8/13/18 at 10:08 a.m. in the wheelchair room there were seven stained and bowed ceiling tiles. 2. In an observation on 8/14/18 at 11:24 a.m., the kitchen dishroom had an area of missing floor tiles, 16 inches wide x 16 inches long, and standing water had accumulated. When interviewed at that time, the Director of Food Services said that was the same area cited during survey, it had been repaired but the tiles broke because they were not the right kind. There were pieces of broken tile in the water. She said the Director of Maintenance needed to get the right type of tile to make the repair and that he needed to lay the tile when the area was dry. 3. In an observation on 8/16/18 at 8:50 a.m., the men's bathroom had turn knobs on the faucet rather than wrist blade style valve handles. First Floor 1. In an observation on 8/14/18 at 11:19 a.m. in the first floor North Hall shower room revealed water leaking out of the ceiling into the shower stall, and there were more than 60 small black flies on the walls and ceiling of the shower room. The drain grate in the shower stall was approximately 1/4 plugged with hair and debris. In an interview at that time, Nurse Manager (NM) #1 stated that one resident (resident in room [ROOM NUMBER]) had a shower in that shower room (North Hall) that morning. NM #1 stated that he was not aware of the leak in the ceiling and that staff should log it into the maintenance book. NM #1 said that maintenance should be notified immediately of the flies and leak. When the surveyor asked NM #1 about the drain grate in the shower, he replied, Yep that looks hairy. NM #1 stated that all residents on the first floor have to use the shower room in the North Hall. 2. In an observation on 8/17/18 at 10:08 a.m. in Resident room [ROOM NUMBER], the sink alcove had two areas approximately 6 inches in diameter, and around the soap dispenser it was unsanded and there was unpainted joint compound. There were also white splatters and water streaks on the wall in the bathroom. There was a cobweb extending across the bathroom ceiling and brown material stuck to the floor by the bathroom doorframe. 3. In an observation on 8/17/18 at 10:17 a.m. in Resident room [ROOM NUMBER], there were vertical scratches in the wall paint covering an area 3 feet wide behind the bed. There was also yellow material on the floor around the perimeter of the room behind the beds as well as a Catchmaster rodent stick trap stuck to the wheelchair foot pedal which was on the floor in the corner of the room. 4. In an observation on 8/17/18 at 10:24 a.m. in Resident room [ROOM NUMBER], the piece of wood above the air conditioner had brown water stains on it. The wall next to the heating and air conditioning unit had a brownish red spill. The bathroom walls had white streaks and the wall base molding had gray material on it. 5. In an observation on 8/13/18 at 11:41 a.m., the first floor South shower room had the only shower head capped off. The tub was dirty and there was a dead bug inside. There were cracked green tiles around the tub. There were flies in the air and on the walls, and the caulk around the base of the toilet was brown and peeling away. 6. In an observation on 8/14/18 between 11:15 a.m. and 11:43 a.m. in Resident room [ROOM NUMBER] the wall by the door was chipped, the wall edge was damaged next to the sink, and there was unpainted joint compound near the sink. The floors were dirty, the walls were scuffed with black marks, the A bed was tipped to the side, and a damaged metal part was sticking out below the bed. 7. In an observation on 8/14/18 between 11:15 a.m. and 11:43 a.m. in the first floor clean utility room, the floor was scuffed and dirty, and there was a 1 foot x 3 feet ceiling tile missing above a cart of clean linens. 8. In an observation on 8/16/18 at 1:20 p.m. the first floor North shower room had a green whirlpool tub. In the tub was a dirty washcloth, three razors, a bottle of moisture blast Irish Spring shower gel, dust, and crumbs. There were 21 small brown flies observed. Second floor 1. In an observation on 8/13/18 at 9:05 a.m. on the second floor, corridor floors were visibly soiled and sticky. In an interview at that time, Maintenance Technician #1 stated that they are going to replace the floors. He said housekeeping cleans the floors and the floor techs buff and wax them. The Maintenance Technician stated that they clean the floors daily and they buff and wax them every two days. 2. In an observation on 8/14/18 at 10:09 a.m., the bathtub in the second floor shower room located in the South Hall had pieces of mop strings, stains, and debris in the tub. There was a housekeeping cart stored right next to the tub. In an interview at that time, Housekeeper #1 stated that they do not dump the mop buckets in the bathtub and that they clean the tubs every other day. Housekeeper #1 stated that it did not look like they had cleaned that tub in the last two days. 3. In an observation on 8/14/18 at 11:44 a.m. in the bathroom of Resident room [ROOM NUMBER], there was a ceiling tile falling down as well as a plastic covered sign which read, Call don't fall which had hair, debris, and a white pasty substance stuck to it. Also, there were two spots on the wall approximately 8 inches x 12 inches of unsanded and unpainted joint compound. The soap dispenser was missing its cover and there was a ceiling tile which was brown around the outside edges and buckling. The wall had damage 1 inch high x 3 feet long, and there were two areas the paint was scraped off (4 inches wide x 10 inches long and the other was 2 inches wide x 8 inches long). Above the window air conditioner there was a board that had brown water stains on it with blackish gray mildew growing, also stuck to the board was a brown grass like substance. 4. In an observation on 8/14/18 at 11:58 a.m. in the bathroom of Resident room [ROOM NUMBER], there was a ceiling tile that had brown stains around the edges, in the corner of the bathroom just below the ceiling the wall paint was torn away, there were brown water streaks running down the wall and a patch of black mold like material was growing on the wall. There was a condom catheter and bag stored on the back of the toilet which had browning colored material on the bag. In an interview at that time, Licensed Practical Nurse (LPN) #1 stated that the item on the back of the toilet was a condom catheter and drainage bag. LPN #1 said it should not be there, it appears to be used and dirty. 5. In an observation on 8/17/18 at 10:44 a.m., in Resident room [ROOM NUMBER] there were gouges in the paint and wall between the beds and behind the B side bed. There were also two areas of unsanded and unpainted joint compound approximately 6 inches x 12 inches next to the sink. 6. In an observation on 8/17/18 at 11:00 a.m., the sink in the janitor's closet next to Resident room [ROOM NUMBER] was plugged and liquid waste was backing up to within 1 inch of the top of the sink basin. In an interview at that time, Housekeeper #1 stated the former Maintenance Director was fixing it but since he left nothing has been done. Housekeeper #1 said maintenance knows about it, it is in the maintenance book. When asked if the building looked clean, Housekeeper #1 stated some days it does, some days it does not. Housekeeper #1 said it is hard to say because, I am always here. Housekeeper #1 said it would help if we could work longer because there are two other shifts with no housekeeping. 7. In an observation on 8/14/18 at 10:15 a.m., Resident #100 was sitting by the second floor elevator and stated to the surveyor, look at the tub would you, and take a look at both. Resident #100 said it is disgusting here, the floors are filthy and there is scum everywhere. 8. In an observation on 8/14/18 at 11:42 a.m., the hallway floors had multiple cracks, scuff, grime, and chips missing. 9. In an observation on 8/14/18 at 11:43 a.m., the second floor North shower room had six stained ceiling tiles and pooled water on the floor of the shower stall, the shower head was laying on the floor and leaking, there was a soiled towel on the floor, the foot pedal for the trash can was broken, and there were two packets of A and D ointment on the floor. 10. In an observation on 8/17/18 at 10:55 a.m. in Resident room [ROOM NUMBER], the heating and air conditioning unit cover was falling off and heavily scuffed. There was a 2 inch wide gap around the window air conditioning unit which had been stuffed with a white brief. The shared bathroom with Resident room [ROOM NUMBER] had dirty floors, brown stains, and the ceiling tiles had brown stains on them. Third floor 1. In an observation on 8/17/18 at 11:32 a.m., Resident room [ROOM NUMBER] had gouges in the wallboard behind the headboard. 2. In an observation and interview on 8/16/18 at 1:43 p.m. in Resident room [ROOM NUMBER], Certified Nursing Assistant (CNA) #1 pointed to a urinal on the floor and said that should not be there, it is disgusting. CNA #1 then dumped the urinal and then tried to turn the water on but the water in the sink did not work. CNA #1 stated that she cannot rinse out the urinal. Further observation revealed a plastic container under the sink that had dirty grey/brown water in it about an inch deep with debris floating in it. 3. On 8/16/18 at 2:20 p.m., third floor CNA #2 stated that they wanted to make rounds but had no linen to do it. CNA #2 stated that CNA #3 called down to laundry one hour ago. CNA #3 stated that she called the front desk and asked them to have linen sent up. They have no towels or washcloths to care for the residents. CNA #3 stated that it is often like that, her and CNA #2 use whatever it is they have to care for the residents, such as a pillowcase, paper towels, or whatever was available. At the time, LPN #1 was observed going downstairs and returned with ten towels and washcloths. When asked by the surveyor why that is all she brought up, LPN #1 stated that they were loading some linen on the carts right now and would bring some up. At 3:56 p.m., the clean utility room was observed after a linen delivery. The cart contained 11 towels, 7 washcloths, 10 blankets, 6 resident gowns, 5 flat sheets, and 9 fitted sheets. 4. In an observation on 8/14/18 at 9:14 a.m. in Resident room [ROOM NUMBER], the floor mats on both sides of the door side bed had tears, frayed corners, and dirt with dried liquid substance on them. The soap dispenser in the bathroom was broken and a bag of soap was on the sink. In an interview at that time, CNA #5 stated it has been like that for a while, we have a lot of them like that. Further observations revealed the bedframe was dirty, the dial on the Gaymar Aire Twinmattress was dirty with built up brown substance on the dial air inlet cover and tubing connected to the mattress. The board around the air conditioner had mold on it. At the headboard of both beds the paint is peeling. 5. In an observation on 8/15/18 at 8:20 a.m., the couch across from the nurses' station had stains on the armrests and tears at the base of the couch approximately 2 inches x 12 inches. 6. In an observation on 8/15/18 at 8:23 a.m., the third floor South shower room trash can foot pedal was broken, the showerhead had been removed, and the valves were capped off. The bathtub was soiled with grime and stains. 7. In an observation on 8/15/18 at 8:44 a.m. in Resident room [ROOM NUMBER], the blue mattress was stained brown in the center and the floor was dirty. 8. In an observation on 8/15/18 at 8:50 a.m., the third floor North shower room had moldy pink, brown, and black on the floor grout at the base of the shower stall, there was no soap in the dispenser located in the shower stall and the cover was broken off, also the soap dispenser at the sink was not working. 9. In an observation on 8/15/18 at 8:58 a.m. in Resident room [ROOM NUMBER], the mirror above the sink was cracked and the bathroom exhaust fan was not working. 10. In an observation on 8/15/18 at 9:05 a.m., in Resident room [ROOM NUMBER] the top light in both overbed lights were not working, the heat register was totally pulled out of the wall with the cover off, there was a dirty bed sheet on the floor under the sink, the floors were dirty, the sink plumbing was leaking into a garbage can under the sink, the walls were scuffed and damaged. In the bathroom which was shared with Resident room [ROOM NUMBER], the ceiling exhaust fan was not working. 11. In an observation on 8/15/18 at 2:13 p.m., both housekeeping carts on the third floor had mop wringers that were heavily soiled with gray goopy material. In an interview at that time, Housekeeper #2 stated that it was the only one he could find to use. In a follow up interview at 2:32 p.m., the Director of Maintenance stated that the housekeepers are supposed to clean the mop buckets every night. He further stated that they are not supposed to use the mop bucket that Housekeeper #2 was using and that the mop bucket was unacceptable. 12. In an observation and interview on 8/16/18 at 9:10 a.m. in Resident room [ROOM NUMBER], the mattress had an oblong brown stain in the middle. At that time, CNA #6 stated others are like that. CNA #6 said that the bed was just made and she did not think much of it, it's just old. The surveyor also observed a brown splatter on the wall next to the bed. 13. In an observation on 8/16/18 at 2:31 p.m., the voce base molding by the elevator outside the dining room was peeling off. The rear elevator was not working. When interviewed at that time, the Director of Maintenance stated that the elevator was down because the wanderguard was not working so they locked it out. 14. In an observation on 8/17/18 at 11:23 a.m. in Resident room [ROOM NUMBER], the heating and air conditioning unit was pulled out of the wall, there were also many chips, scuffs and scrapes in the wall. The sink in the room had a leaking drain and there was a garbage can full of water underneath. There was also a ripped, dirty sheet on the floor. When interviewed on 8/13/18 at 8:45 a.m. and on 8/17/18 at 10:30 a.m., the Administrator stated that they had not completed any audits. She said there was no quality assurance audit tool developed for the environment, and she did not know why. She said there was no education provided. In an interview on 8/15/18 at 1:14 p.m., the Director of Maintenance stated that no weekly audits of the environment had been done. He said that he was working on it. In an interview on 8/15/18 at 1:20 p.m., the Director of Maintenance stated that the Corporate Compliance person, who was also the consultant listed in the Directed Plan of Correction resigned shortly after the Plan of Correction was approved. Interviews conducted on 8/16/18 included the following: a. At 8:06 a.m., Resident #77 stated that there are not enough towels, washcloths, or pillowcases. Resident #77 stated when you do not have a washcloth or towel to wash up with, then you smell. Resident #77 said the place is dirty, the floors are terrible dirty, and the sheets are always dirty. b. At 10:00 a.m., Resident #153 stated they do not have enough towels and washcloths, and if they do not have any, he does not wash up, that is it. Resident #153 also stated the facility is dirty and he would like to leave. The resident's wheelchair arm was observed to be torn exposing the foam and had been taped up. When asked about the wheelchair, the resident stated it looks bad. c. At 10:29 a.m., Resident #16 stated he does not always have enough towels and washcloths. He said that he gets the linen himself from the cart. He said if there are no linens on the cart, then he is in trouble and unable to wash up. Interviews conducted on 8/17/18 included the following: a. At 12:35 p.m., Housekeeper #2 stated that having the supplies that we need to clean would help. Housekeeper #2 said there was no roll out toweling or big garbage bags. b. At 12:48 p.m., Resident G was asked how he felt about his living environment. He stated that the facility does not have proper supplies for the residents. He said they constantly run out of sheets, pillowcases, and towels all the time. He said that the cleanliness around the facility could be better. He said he buys his own cleaning supplies to clean the bathroom because he shares a bathroom with two other residents who urinate all over the toilet seat and it usually smells. He also said that since he has been in the facility, he has reported to the administration that his bed does not work. He said that he is unable to change positions properly, and nothing has been done. c. At 12:57 p.m. LPN Nurse Manager #1 stated the facility could be cleaner. She said there are dirty walls that need to be repainted and the place needs new flooring. LPN Nurse Manager #1 said the facility needs to make the environment more homelike for the residents. She said the furniture is outdated, torn and dirty, the showers do not work, and there is not enough towels and washcloths or bed linen. LPN Nurse Manager #1 said that management has been made aware of these issues. d. At 1:30 p.m., the Laundry Supervisor was asked if they had a three day supply of laundry and he stated, No, it is more like a one day supply and we have to keep up with it. He said we do not have enough in the building for a three day reserve supply. The Laundry Supervisor stated that the day shift work 6:00 a.m. to 2:00 p.m., and he has a staff member staying until 4:00 p.m. The Laundry Supervisor then stated there was supposed to be someone who works 3:00 p.m. to 11:00 p.m. but that does not always happen. A review of facility documentation on 8/16/18 at 9:50 a.m. revealed that there were two room inspection forms title with the facility's former name. The first was for Resident room [ROOM NUMBER] and was dated 7/27/18, the second was for Resident room [ROOM NUMBER] and was dated 8/2/18. These were the only environmental audits provided. (10 NYCRR 415.29)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 820), it was determined that for three (first, second and third floors) of three residential sleeping floors and one of one basement, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. The issues involved excessive and loud overhead paging, floors were dirty, furniture was dirty or damaged, walls were dirty or damaged, there was standing water on the floor, lack of three-day supply of laundry, damaged bed and footboard, missing privacy curtain hooks, sinks leaking water and plumbing issues, broken and dirty handrails, and a broken soap dispenser. This is evidenced by, but not limited to, the following: 1. During the survey from 5/29/18 through 6/5/18, multiple loud overhead pages were heard on all units. When interviewed on 6/5/18 at 12:10 p.m., the Administrator said she was aware of excessive overhead paging. She stated she had addressed that with staff as overhead paging does not promote a homelike environment. 2. Observations conducted during the initial Life Safety Code tour of the resident environment on 5/29/18 from 9:00 a.m. to 2:35 p.m. revealed the following: a. The floors throughout the entire building (basement, third, second, and first floors corridors and resident rooms) were dirty, sticky, stained, had debris buildup along edges, and had broken, missing, and cracked sections. b. In Resident room [ROOM NUMBER], the footboard of the bed was bent, wobbly, and loosely secured. Additional observations and interviews on the first floor on 5/30/18 between 8:56 a.m. to 1:57 p.m. revealed the following: a. In Resident room [ROOM NUMBER], there was a deep brown dried spill on the floor (12 inch x 12-inch tile square) next to the resident's bed, the paint on the walls was chipped and scraped in multiple areas. b. Resident #93's wheelchair had visible food particles and stains on the cushion and along the edges of the wheelchair. When interviewed at that time, the resident said the chair is dirty and dusty. c. In Resident room [ROOM NUMBER] (door bed), the privacy curtain was missing several hooks and was drooping unevenly. The wall at the head of the bed was scraped through the blue paint, exposing the white drywall below. d. In the first floor shower room there were multiple brown stained ceiling tiles. e. In the first floor employee bathroom the sink drain was leaking and a there was a gray rectangular bin under the sink to catch the leaking water. f. Resident #98 said there are no pillowcases. She said she had to pull the top sheet up over the plastic pillow to rest her head. The resident said this was okay during the day but at night, it was a problem. The resident said the dried red stains on the floor next to her bed were jello and had been there for three to four days. She said she was worried about drawing ants because she had seen some in her room (none at that time). Additionally, the paint on the wall behind the headboard was scratched and chipped, exposing white drywall through blue paint. g. In Resident room [ROOM NUMBER], Certified Nursing Assistant (CNA) #1 brought a concentrator covered in a plastic bag in to the resident's room. As he pulled the plastic off, the outside surfaces of the concentrator were observed to be dirty with deep brown patches of dirt and dust. CNA #1 said the concentrator was supposed to be clean and ready to use because it had a tag on it. In an observation on 6/1/18 at 2:05 p.m., in Resident room [ROOM NUMBER] there was an empty orange juice carton on the floor behind the headboard and many pieces of broken up blue foam (resident had been discharged to the hospital). Interviews conducted on 6/5/18 included the following: a. At 8:30 a.m., a Registered Nurse Manager (RNM) and CNA #2 both said if there is a surface spill, like on a wheelchair, CNAs are to wipe it up. The RNM said if a more in depth cleaning was required, he would notify housekeeping. The RNM said he was not aware of the condition of Resident #93's wheelchair. At 8:36 a.m., the RNM and surveyor observed the resident's wheelchair, and the RNM said he would have the chair cleaned. b. At 8:32 a.m., Resident #93 said that his wheelchair had not been cleaned or repaired. The resident said it is dirty, nasty, and it should be cleaned. There was still visible food debris and chunks of food and stains and discolorations on the cushion and along the edges of the cushion. c. At 8:38 a.m., in Resident room [ROOM NUMBER] the same dried brown stains remained on the floor, and there were multiple gouges in the wall, a hole right through the dry wall, and noticeable brown drips running down the wall. d. At 8:59 a.m., the Director of Therapy said that Resident #93's wheelchair should be cleaned. e. At 1:15 p.m., the Director of Maintenance said if staff identify something that needs to be cleaned, repaired, or is unsafe, they can notify him, or document it in the housekeeping book at the nurses' station. f. At 2:44 p.m., CNA #1 went to Resident room [ROOM NUMBER] with the surveyor and said the resident had been on thickened liquids and the brown stain looked like dried coffee. CNA #1 looked at the walls and said it looked like something had been thrown at the wall and dripped down. There was a quarter size hole in the wall and CNA #1 stuck his finger in it, then said he had no idea how it happened. CNA #1 said he would notify housekeeping. A review of the housekeeping and maintenance log books did not reveal any entries for that room. In an observation on 6/6/18 at 8:20 a.m., the soap dispenser in the first floor employee restroom was broken and the bag of soap was lying in the sink basin. A review of the first floor maintenance log revealed an entry from 5/3/18 that documented the first floor staff bathroom soap dispenser was broken. At that time, the Director of Maintenance said that staff are heavy handed, and they keep breaking the dispensers because they are flimsy. Second Floor Observations and interviews conducted on 5/29/18 included the following: a. At 9:34 a.m., a wet floor sign had been placed on the hallway floors, and the floor was still sticky under foot. b. At 9:46 a.m., in Resident room [ROOM NUMBER] there was dried red liquid on the floor, and the resident said it had been there all week. There was also damage to the wall behind the headboard and there was black electrical tape on the bedframe. c. At 11:31 a.m., in Resident room [ROOM NUMBER] D there was a hole in the wall behind the door that was in the process of being patched, the repair was incomplete. d. At 12:54 p.m., in Resident room [ROOM NUMBER] there was a urine odor in the room, a urinal was set on the floor, and the floor was sticky. Observations conducted on 5/30/18 included the following: a. At 8:46 a.m., the slop sink in the janitor's closet next to Resident room [ROOM NUMBER] was backing up with a grayish black material. When interviewed at that time, the Director of Maintenance said he would call a plumber. He said that sink has been plugging up for a while, and a plumber came in who said that they would have to bust out the wall to fix it, so they are waiting on another estimate. The Director of Maintenance stated that he has reached out to multiple plumbers, but many will not come to the facility. He said the facility has several plumbing issues that are waiting to get fixed, but they wanted to group them together for repair at one time. He said he would have maintenance staff come up with a wet dry vacuum to get the water out of the sink. b. At 9:35 a.m., Resident Rooms #217 and #219 had dirty and sticky floors and damaged and peeling cove base molding. The floors had debris, brown shoe prints, and wheelchair tracks on the surfaces. c. In the second floor dining room there was a framed picture leaning on a window ledge with broken jagged glass, a heating unit was ripped out of the wall, the ceiling fan blades were loose, sagging down, covered in dust and were missing screws, the cove molding around the edges of the floor was damaged and pulling away from the wall, there were broken window blinds, and the floors were dirty and sticky. Observations and interviews conducted on 6/5/18 included the following: a. At 9:23 a.m., there was a couch in the communal area that was dirty, had torn cushions with exposed foam, and a broken zipper. Pieces of laminate were missing from the floor in the hallway. b. At 9:26 a.m., a Licensed Practical Nurse Manager said that whenever staff observe something in need of cleaning or repair, it should be documented in the maintenance or housekeeping log book. She said those departments are responsible for cleaning and making repairs. She looked at the floors with the surveyor, and then stated the dirty floors should have been entered in the housekeeping log book as it was not homelike. She said the handrails need a deep cleaning. c. At 2:07 p.m., a handrail was hanging loose, not secured to the wall with exposed nails. Third Floor Observations and interviews conducted on 5/29/18 from 9:00 a.m. to 2:35 p.m. during the Life Safety Tour included the following: a. In Resident room [ROOM NUMBER], there were brown spots all over the base of the walls inside the bathroom, under the sink, on the door and doorframe, on the heating unit, and on the lower section of the wall outside the bathroom. Additionally, the corners and edges of the floor were sticky and yellow, there were numerous scrapes on the walls, and brown debris on an electrical outlet. b. In Resident room [ROOM NUMBER] the latch to the door was missing. c. The heating register in the third-floor dining room was covered with tan debris and material. The wall in the dining room near the door marked office storage had multiple spots of debris splatter. Observations and interviews conducted on 5/29/18 included the following: a. At 8:57 a.m., in Resident room [ROOM NUMBER] the fall mats were dirty with dust and dirt. Scrapes were on the wall by the head of the bed where white drywall shows below blue paint. The floor was littered with cards, straw papers, and personal items. In the bathroom, there was a very dirty pink basin on the floor, and a denture cup on the sink was dirty with white and orange debris. b. At 9:14 a.m., in Resident room [ROOM NUMBER] the wall beside the heating and air conditioning (AC) unit was covered with drops of liquid. There was a small baseball sized hole in the wall to the left side of the heater/AC unit. There was an area behind the headboard with several 2 to 3 feet long gouges out of the wall, exposing dry wall. c. At 9:37 a.m., in Resident room [ROOM NUMBER] ten parts of the window blinds were broken off or missing, at the head of the bed the blue paint was scrapped off the panel that is nailed to the wall, about a 3 1/2 foot x 2 1/2 foot area (white drywall/paint underneath is visible). The sink vanity veneer is missing on the bottom and right edges, leaving bare wood and rough edges. d. At 11:14 a.m., in Resident room [ROOM NUMBER] there was a strong fecal odor in the room. e. At 2:06 p.m., in Resident room [ROOM NUMBER] there were mouse droppings on the floor in the bathroom and a portion of the vanity sink basin was broken. Basement a. An observation on 5/30/18 at 1:31 p.m. revealed the ceiling in the Central Supply room had water damage, and there was an area where the ceiling grid had rusted through. b. In an observation on 5/30/18 at 1:50 p.m., the women's bathroom located in the basement had drips of blood on the floor in front of the first toilet. The second toilet was filled with feces and used sanitary napkins, and the toilet tank top had been placed over the bowl. The Director of Maintenance stated that was nasty and left the bathroom. When interviewed at 2:11 p.m., the Director of Maintenance said housekeeping was responsible to clean the bathrooms in the basement. c. On 6/5/18 at 10:35 a.m., the floors in the hallway throughout the basement were dirty with shoe prints, wheel tracks, dirt and debris. There was standing water in the hallway outside the kitchen dishroom, paint and tiles were missing from the floors, and there were many cracked, broken, and pitted tiles in the kitchen dishroom. d. An observation on 6/6/18 at 8:45 a.m. revealed a duct fan above the washing machines in the basement Laundry room was covered in lint and dust. In an interview at that time, the Director of Maintenance stated that the fan did not work, and when asked why it did not work, he said that it had built up with dust and burned the electric motor out. Laundry Observations and interviews conducted on 6/1/18 included the following: a. At 1:15 p.m., when asked about the gray dingy towels, LPN #2 said she would not wipe her face on them. Observations on the first, second, and third floors revealed gray, dingy, stained towels. b. At 2:06 p.m., the Director of Housekeeping said the facility does not have a three day supply of linen. When specifically asked about the different shades of color of the linen, she said she thought that was related to purchasing from several different vendors. She said the facility does the laundry. c. From 2:58 p.m. to 3:25 p.m. on floors one through three, there were multiple randomly selected washcloths and towels that were noted to be dingy, grey and have brown stains. Observations and interviews conducted on 6/4/18 included the following: a. At 11:15 a.m., the Infection Control Nurse said there has been an issue with dingy stained towels and washcloths for some time. She said there was no documentation from housekeeping addressing the concern. She said the issue had been discussed in morning report but there had not been any administrative follow-up. b. At 9:32 a.m., CNA #5 said she did not have any clothing protectors for use at breakfast and had been directed to use paper towels to protect the resident's clothes. c. At 2:53 p.m., CNA #6 said she can not wash residents' hands before meals because there are no disposable washcloths or regular washcloths to use. Observations and interviews conducted on 6/6/18 included the following: a. At 8:50 a.m. in the laundry, there was gray duct tape holding the seal in place around the door to a dryer. b. At 10:36 a.m., CNA #4 said he receives ten towels for personal care. He stated that he hides towels so he can have them for other shifts. He said if he needed more washcloths, he would have to ask the Housekeeping Director for disposable washcloths. c. At 10:41 a.m., the Director of Housekeeping said that there is no emergency supply of laundry for the facility. She said dryers are currently broken, 20 towels had been delivered to the second floor for personal care, and there were no towels or washcloths for the first and third floors. d. At 11:08 a.m., CNA #2 said she has run out of towels for the day. (10 NYCRR: 415.29, 415.29(b), 415.29(d), 415.29(h)(1), 415.29(i), 415.29(j), 415.5(h)(1-5))

Plan of Correction: ApprovedAugust 2, 2018

Plan of correction not approved or not required

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made during the Life Safety Code Survey, it was determined that for two (first and second floors) of three resident use floors, the facility did not properly maintain corridor width. Specifically, furniture that was stored in corridors was not affixed, and the corridor width was reduced to less than 6 feet. The findings are: 1. Observation on 5/29/18 at 12:04 p.m. revealed an overbed table and armchair were stored in the corridor outside of Resident room [ROOM NUMBER]. The armchair was pulled into the middle of the corridor reducing the usable egress width. 2. Observations on 5/30/18 at 9:20 a.m. revealed two sitting chairs stored in the egress corridor outside Resident room [ROOM NUMBER]. Neither of the chairs were affixed to the floor or wall. 3. Observations conducted on 5/30/18 at 11:42 a.m. revealed two walkers and two rolling walkers stored in the egress corridor leading to the marked exit from the Physical Therapy Gym. These walkers created a pinch point of less than 48 inches. 4. Observations on 5/30/18 at 2:50 p.m. revealed a sitting chair stored in the egress corridor adjacent to the first-floor copy room. The chair was not affixed to the floor or wall. 5. Observations on 6/5/18 at 11:11 a.m. revealed a sitting chair stored in the egress corridor outside Resident room [ROOM NUMBER]. The chair was not affixed to the floor or wall. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.3.4(5))**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two (second and third floors) of three resident use floors, the facility did not properly maintain corridor width. Specifically, the facility did not complete their written Plan of Correction, items were stored in egress corridors limiting usable width, and furniture was stored in corridors that was not properly affixed. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed sitting chairs in the second-floor corridor were removed, all staff would be educated on having the corridors clear from obstruction, a whole house audit would be done to ensure corridors are clear of furniture and any obstructions to egress width. The audits will be completed for eight weeks and monthly for three months. The Administrator was responsible for compliance, and the completion date was 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 9:01 a.m. revealed a sitting chair in the egress corridor outside Resident room [ROOM NUMBER] (second floor) and the chair was not affixed to the floor or the wall. 4. Observations on 8/14/18 at 11:55 a.m. revealed a sitting chair in the egress corridor outside Resident room [ROOM NUMBER] (second floor) and the chair was not affixed to the floor or the wall. Additionally, there was a bed stored in the corridor outside room [ROOM NUMBER] near the exit door, which limited the usable width to 4 feet 3 inches. 5. Observations on 8/17/18 at 8:53 a.m. revealed a blue sitting chair in the egress corridor outside the thirrd floor activities room and the chair was not affixed to the floor or the wall. 6. There was no documentation provided by the Administrator to show that a facility wide audit and weekly audits had been performed for egress width and furniture stored in corridors. There was no documentation to show that staff had been educated regarding that deficiency. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.3.4(5))

Plan of Correction: ApprovedSeptember 14, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All residents were affected based off of this deficient practice.
1. The over bed table and arm chair was removed from the hallway outside of room [ROOM NUMBER].
2. The two sitting chairs stored in the egress corridor outside room [ROOM NUMBER] was removed.
3. The two walkers and two rolling walkers stored in the egress corridor by exit in physical therapy gym were removed.
4. The sitting chair outside first floor copy room was removed.
5. The sitting chair outside room [ROOM NUMBER] was removed.
All staff will be educated on having the corridors clear from obstruction. A whole house audit will be done to ensure all corridors are clear of furniture and any obstructions to egress width. They will be completed for 8 weeks and monthly for 3 months. The audits will be brought to the QAPI committee and from there it will be decided if continued auditing will be necessary.
The Administrator is responsible for compliance.

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: August 17, 2018
Corrected date: October 22, 2018

Citation Details

Based on observations, interview, and record review conducted during the Life Safety Code Survey, it was determined that for one (center stairwell) of three exit stairwells, the facility did not properly maintain exit discharge pathways. Specifically, a pathway was too steep and did not include handrails. The findings are: Observations conducted in the presence of the Director of Maintenance on 5/29/18 at 9:35 a.m. revealed the exit discharge pathway from the center stairwell extended down a small downward sloping section of sidewalk on the northwest corner of the property. An interview with the Director of Maintenance revealed there has been no work done yet to correct the exit pathway from the previous survey, but contractors are working on it and are going to regrade and widen it. A review of the Statement of Deficiencies from the Life Safety Survey concluding on 4/17/17 revealed the slope of the exit discharge pathway (sidewalk) from the center stairwell was measured by the surveyor to be approximately 2 1/2 inches of fall in 20 inches of horizontal run. Additionally, the side slope of this pathway was measured to be 1 1/8 inches of fall over 24 inches. The downward sloping section of the sidewalk did not have handrails. The measurements were obtained by using a 24-inch level and a tape measure. Upon conclusion of the 4/17/17 survey, the facility applied for and was granted a time-limited waiver to correct this issue, which expires on 6/15/18. The facility Administrator stated in an interview on 6/5/18 that a contractor might be coming that week and that the project will be done by (MONTH) 15th. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 19.2.7, 7.1.6.3, 7.1.7.2, 7.2.2.4, 7.2.5, 7.2.5.4)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on [DATE], it was determined that for one (center stairwell) of three exit stairwells, the facility did not properly maintain exit discharge pathways. Specifically, the facility did not complete their written Plan of Correction, and a pathway was too steep and did not include handrails. The findings are: 1. A review of the Plan of Correction submitted by the facility from the survey of [DATE] revealed that the facility Administrator requested another time-limited waiver until [DATE] from the Department of Health as the contractor selected was unable to complete the project prior to the (MONTH) 15, (YEAR) deadline. 2. Observations conducted in the presence of the Director of Maintenance on [DATE] at 8:40 a.m. revealed the exit discharge pathway from the center stairwell extended down a small downward sloping section of sidewalk on the northwest corner of the property. When interviewed at that time, the Director of Maintenance revealed the work has not been done yet because the former contractor backed out, but knew a contractor was coming in to regrade the area and do the work. A review of the statement of deficiency from the Life Safety Survey concluding on [DATE] revealed the slope of the exit discharge pathway (sidewalk) from the center stairwell was measured by the surveyor to be approximately 2 ,[DATE] half inches of fall in 20 inches of horizontal run. Additionally, the side slope of this pathway was measured to be 1 ,[DATE] inches of fall over 24 inches. The downward sloping section of the sidewalk did not have handrails. The measurements were obtained by using a 24-inch level and a tape measure. Upon conclusion of the [DATE] survey, the facility applied for and was granted a time-limited waiver to correct that issue, which expired on [DATE]. Upon conclusion of the [DATE] Recertification Survey a waiver extension was requested through [DATE]. When interviewed on [DATE] at 9:15 a.m., the Administrator said that they have requested another waiver extension. Review of the New York State Department of Health Bureau of Architecture and Engineering Review waivers website revealed approval of a waiver extension has not yet been granted by Centers for Medicaid and Medicaid Services. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 19.2.7, 7.1.6.3, 7.1.7.2, 7.2.2.4, 7.2.5, 7.2.5.4)

Plan of Correction: ApprovedSeptember 14, 2018

The facility administrator requested another time-limited waiver until 8/10/2018 from the DOH as the contractor selected was unable to complete the project prior to the (MONTH) 15, (YEAR) deadline.

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for one of one basement, the facility did not properly maintain doors that are designed to be self-closing. Specifically, doors were obstructed, damaged, and/or not self-closing. The findings are: Observations on 5/31/18 at 2:25 p.m. revealed the self-closing mechanism to one of the two doors to the basement laundry room was disabled and disconnected from the door frame. The laundry room contained natural gas dryers and a significant amount of clean and soiled linens. In an interview at that time, the Director of Maintenance stated he was not sure how the mechanism had been broken. Additionally, the door to the soiled holding side of the laundry room was stuck on the door frame and would not automatically close and fully latch into the frame. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.2.2.7, 7.2.1.8.2)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one of one basement the facility did not properly maintain doors that are designed to be self-closing. Specifically, the facility did not complete their written Plan of Correction and a door closing device was damaged. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the laundry room door had been repaired so it does close and latch properly and audits will continue monthly. The Administrator and Director of Maintenance were responsible for compliance, and the completion date was 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that the audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 9:15 a.m. and again on 8/16/18 at 8:40 a.m. revealed the self-closing mechanism to one of the two doors to the basement laundry room was disabled and disconnected from the doorframe. The laundry room contained natural gas dryers and a significant amount of clean and soiled linens. 4. There was no documentation provided by the Administrator or Director of Maintenance to show the laundry room door had ever been repaired, nor was there documentation to show monthly audits including that door had been performed. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.2.2.7, 7.2.1.8.2)

Plan of Correction: ApprovedSeptember 10, 2018

Based on this deficiency no residents had the potential to be affected. The laundry room door have been repaired so it does close and latch properly. A whole house audit was done on all doors with a self-closing mechanism and audits will continue monthly. Based off of the audit parts have been ordered and awaiting delivery to ensure timely repairs on all doors will be completed. All self-closing doors have been audited by the Maintenance Director or designee to ensure self-closing and latching capabilities. All audits will be reported to the QAPI committee for review. The Administrator and Director of Maintenance is responsible for compliance.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview conducted during the Life Safety Code Survey, it was determined that for two (second and third floors) of three floors, the facility did not properly maintain electrical equipment. Specifically, unapproved plug extenders were in use and power strips and extension cords were connected in series (daisy-chained). The findings include: 1. Observations on 5/29/18 at 1:49 p.m. revealed that in the third floor Staff Educator's Office there was an extension cord providing power to a plug strip which was in turn providing power to computer equipment. In an interview at that time, the Director of Maintenance stated that the extension cord had probably been there since the old Staff Educator was there. 2. Observations on 5/30/18 at 8:50 a.m. revealed a green extension cord attached to a television near the bed closest to the window in Resident room [ROOM NUMBER]. 3. Observations on 5/30/18 at 9:10 a.m. revealed there was a six outlet plug adaptor attached to a duplex outlet in the Director of Housekeeping (DH) office (second floor). When interviewed at that time, the DH stated that the plug adaptor was hardwired. Further observations revealed the adaptor was plugged into (not hardwired) into the duplex electrical receptacle. The 2012 edition of NFPA 99, Health Care Facilities Code, requires all adaptors, extension cords, and attachment plugs to be listed for their purpose. The 2011 edition of NFPA 70, National Electric Code, states flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. The survey and certification letter 14-46-LSC issued by the Centers for Medicare and Medicaid Services requires power strips used in conjunction with non-patient care related electrical equipment to be UL-1363 (relocatable power taps). Power strips used in conjunction with patient care related electrical equipment must be UL-1363-A or UL- -1 (special purpose relocatable power taps). Power strips cannot be 'daisy chained.' (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.2.4.2, 10.2.4.2.1, 10.2.4.2.2; 2011 NFPA 70: 400.8; CMS S&C: 14-46-LSC)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two (first and second floors) of three resident sleeping floors, the facility did not properly maintain electrical equipment. Specifically, the facility did not complete their written Plan of Correction, power strips were connected in series (daisy-chained), and patient care related electrical equipment was plugged into unapproved power strips. The findings include: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed education was provided for all staff on appropriate use of power strips in a health care facility. The Director of Maintenance will do a full house audit of all non-allowable power cords/extension cords, the Administrator was responsible for compliance. 2. Observations on 8/14/18 at 11:50 a.m., revealed two power strips connected in series under the bed in Resident room [ROOM NUMBER]. 3. Observations on 8/16/18 at 8:35 a.m., revealed a [MEDICAL CONDITION] machine, a nebulizer, and an oxygen concentrator were all plugged into an unapproved power strip near the B-bed in Resident room [ROOM NUMBER]. The markings on the powerstrip did not show UL-1363A or UL- -1. 4. Observations on 8/17/18 at 10:35 a.m., revealed the power lead for the A-bed in Resident room [ROOM NUMBER] was plugged into an unapproved powerstrip. Additionally, there were two powerstrips connected in series near the B-bed in room [ROOM NUMBER] and the bed controls and an oxygen concentrator were into the powerstrips. The markings on the power strips did not show UL-1363A or UL- -1. 5. Observations on 8/17/18 at 10:35 a.m., revealed the power lead for the B-bed controls and an electric air mattress pump in Resident room [ROOM NUMBER] were plugged into an unapproved power strip. The markings on the power strip did not show UL-1363A or UL- -1. 6. There was no documentation provided by the Administrator or Director of Maintenance to show that all staff were educated with regard to appropriate use of power strips, nor was there documentation to show that a facility wide audit for power strips was conducted. The 2012 edition of NFPA 99, Health Care Facilities Code, requires all adaptors, extension cords, and attachment plugs to be listed for their purpose. The 2011 edition of NFPA 70, National Electric Code, states flexible cords and cables shall not be used as a substitute for fixed wiring of a structure. The survey and certification letter 14-46-LSC issued by the Centers for Medicare and Medicaid Services requires power strips used in conjunction with non-patient care related electrical equipment to be UL-1363 (relocatable power taps). Power strips used in conjunction with patient care related electrical equipment must be UL-1363-A or UL- -1 (special purpose relocatable power taps). Power strips cannot be 'daisy chained.' (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.2.4.2, 10.2.4.2.1, 10.2.4.2.2; 2011 NFPA 70: 400.8; CMS S&C: 14-46-LSC)

Plan of Correction: ApprovedSeptember 10, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The extension cord in the third floor staff educator?s office was removed.
The green extension cord in room [ROOM NUMBER] was removed.
The six outlet plug adapter was removed from the Director of Housekeeping office.
No residents were affected by this deficient practice but have the potential to be affected.
Education was provided for all staff on the appropriate use of power strips in a health care facility by the staff educator. The Director of Maintenance will do a full house audit of all non-allowable power cords/extension cords then have an audit completed quarterly. All audits and education documentation will be presented to the QAPI committee and the needs for more frequent auditing and/or education will then be determined. The Administrator is responsible for compliance.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: August 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews during the Life Safety Code Survey, it was determined that for two (first and second floors) of three resident use floors, the facility did not properly maintain patient care related electrical equipment (PCREE). Specifically, PCREE was damaged, left in use, and not being maintained per manufacturer's specifications. The findings are: 1. Observations on 5/29/18 at 2:22 p.m. revealed a Contemporary Products, Inc. Model 6260 Aspirator on a crash cart in the second floor dining room. The unit was marked with a biomedical contractor sticker that stated FAIL, and the pressure gauge read 95psi (pounds per square inch). An interview with the Director of Maintenance revealed they do not use that contractor anymore. Further review of the inspection checklist on the crash cart revealed a signoff by a Licensed Practical Nurse on 5/28/18. The Director of Nursing (DON) stated that she does not see how it (Suction Machine second floor dining room) would be in working order, since the plug has no ground and there is no glass on the gauge. The DON then stated that they would send someone to get a suction machine from another floor. 2. A review of facility records, provided by the Director of Maintenance on 5/30/18 at 10:00 a.m. revealed that on 4/30/18 the Contemporary Products Inc. model 6260 suction machine in the second floor dining room had failed its inspection by the biomedical contractor because it needed a new gauge and plug. Further observations and record review on 5/30/18 between 10:30 a.m. and 10:43 a.m. revealed the following. a. Invacare 450 lift, control number 1011, found on the third floor by Resident room [ROOM NUMBER] was also on the list of items which failed the 4/30/18 biomedical inspection because it needed a new control box and leg spreader assembly. b. Invacare Reliant RPS350 sit to stand lift, control number 1010, was found in Resident room [ROOM NUMBER] and had failed the biomedical inspection on 4/30/18 because it needed an emergency pull on the [MEDICATION NAME]. In an interview at that time, Certified Nursing Assistant (CNA) #1 stated that the emergency pull tab was broken, but there was a second way to use the emergency switch. CNA #1 stated that staff use the sit to stand lift for Resident #86 and sometimes you have to hit the box to get it to work. CNA #1 then stated that at one-point Resident #86 had gotten stuck in the up position and they had to use a paperclip to get the stand to release. c. Invacare Reliant RPS350 sit to stand lift, control number 1018 was in the first floor shower room and had failed the biomedical inspection on 4/30/18 because it needed new casters and the leg spreader assembly was broken. 3. In an interview on 5/30/18 at 2:52 p.m., the Director of Maintenance stated that none of the lifts should be on the floor, they should be downstairs for repair. 4. In an interview on 5/30/18 at 4:52 p.m., the Administrator stated that approval was not given to repair the lifts because she said she was talking to corporate to get approval. 5. An interview with the Administrator on 5/31/18 at 9:19 a.m. revealed that she had contacted the corporate office by email on 4/30/18 and on that same day corporate asked how many lifts they have and how many they needed. The Administrator reported that she told corporate that all lifts did not pass the inspection. She said because a piece of equipment fails does not mean it is not safe. She said the contractor fails a piece of equipment if it does not meet manufactures specifications, maintenance makes the determination if the equipment is safe. The Administrator said that all equipment was tagged and taken out of service after the inspection, but it appears that staff were still using the lifts after they failed and were tagged. Corporate contacted the Administrator verbally and they were told to rent equipment. The Administrator contacted a vendor but was unable to rent any equipment because of the facility's past reputation. The Administrator then stated that they would need six lifts and three stands, but only got one lift and one stand. She said the reason that they did not get six lifts and three stands was because corporate only approved two. The Administrator stated that they had decided they needed six lifts and three stands because they wanted to replace all stands and lifts that failed the inspection, not because they were determined to be unsafe. 6. Record review on 5/31/18 at 11:08 a.m. revealed the manufacturer's specifications (pages 4, 5, 16, and 17) for the Invacare 350 stand up lift stated the following: In case of damage, DO NOT use equipment, DO NOT exceed maximum weight limitation of the stand up lift. If any parts are worn replace immediately, and replace any defective parts immediately and ensure that the lift is not used until repairs are made. 7. In an interview on 5/30/18 at 11:17 a.m., the President of Omnicor, (vendor who inspected the patient care equipment) stated that when an item fails, they use the user manual and determine if the items meet manufacturer's specifications. The President stated that if a piece of equipment fails, it does not mean that it is not safe. If the manual states that an item can not be used if damaged, then they would take that into account. 8. In an interview on 5/31/18 at 1:00 p.m. when asked did you take the lifts out of service when they were identified as having problems, the Director of Maintenance stated yes, they were all brought back down to the basement. He said he was not sure how they got back up on the floors. The Director of Maintenance then stated that some were taken out of service, and he was not sure which were left in service. He said someone could have come down there and brought them back upstairs. The ones that were taken out service had a sign on them that read do not use or out of service. 9. In an interview on 5/31/18 at 2:22 p.m., an Invacare Technical Support Representative stated that if a lift fails its inspection, then it should not be used. The emergency pull [MEDICATION NAME] needs to be in place, and in his opinion he would pull it out of service. The leg spreaders must be able to open and lock or close and lock. The 2012 edition of NFPA 99, Standard for Health Care Facilities, requires facilities to establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. A permanent file of instruction and maintenance manuals shall be maintained and be accessible. A record shall be maintained of the tests required by this chapter and associated repairs or modifications. All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.5.2.1.1, 10.5.2.1.2, 10.5.3.1.2, 10.5.6.1.1, 10.5.6.2.1)

Plan of Correction: ApprovedJuly 18, 2018

It was determined that no residents have been affected but all residents have potential to be affected by this deficient practice.
1. The suction machine on the second floor crash cart was removed from the crash cart and replaced with a working suction machine.
2. The suction machine was brought down to the Maintenance Office to be sent out to the Biomedical contractor for repairs.
a. The Invacare 450 lift, control number 1011, was removed off of the floor and tagged for non-operational use. Another 450 lb lift was purchased, inspected and placed in circulation for use.
b. The Invacare sit to stand lift was removed off of the floor and tagged for non-operational use. Another sit to stand lift was purchased, inspected and placed into circulation for use.
c. The Invacare sit to stand lift control number 1018 was pulled from the floor by maintenance and tagged for non-operational use. The biomedical contractor called to come and repair/inspect all equipment.
3. All equipment that did not pass inspection was removed from the floor and tagged for non-operational use and placed downstairs for maintenance to repair and/or contact biomedical contractor to come and repair.
4. Corporate gave approval and three lifts arrived within the facility to safe resident transfers.
5. Any and all equipment that needs repairs are to be repaired by maintenance and if maintenance cannot repair the equipment then a contractor will be called to do work on the equipment.
6. Education will be provided by the staff educator and the maintenance director on the procedure for safe resident transfers with any mechanical lift and what to do when it has been identified there is an issue with the lifts or any equipment. It must be placed in the maintenance log and reported immediately to the maintenance department for immediate remediation.
7. The biomedical contractor has been contacted to come and repair/inspect any equipment in house.
8-9. All equipment that failed inspection were immediately removed from the floors and tagged for non-operational use. Until repairs have been made to satisfy all manufacture guidelines on proper operation of all equipment.
Education will be provided by 8/10/2018 for all staff on the proper use of all equipment and procedures on how and what to do if it is identified there is an issue with any equipment. Facility policy and procedures will be reviewed and revised as necessary for maintenance and testing of all patient care related electrical equipment. A whole house audit of the patient care related electrical equipment will be completed by the Maintenance Director and then will continue with quarterly audits to ensure all equipment is inspected for 12 months and then yearly after that. The audits will be brought to the QAPI committee for review and from there it will be determined if auditing needs to be increased. The Maintenance Director is responsible for compliance.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 18, 2018
Corrected date: October 22, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for one of one emergency generator, the facility did not properly maintain the emergency power system. Specifically, there was no remote annunciator for the emergency power source (generator). The findings are: Observations on 6/1/18 at 10:25 a.m. revealed a three phase 170 kilowatt Onan brand natural gas-powered emergency generator in the basement boiler room. The generator was observed to have gauges showing: AC volts, Amps, water temperature, oil pressure, and run-hours. An interview with the Director of Maintenance on 6/5/18 at 1:50 p.m. revealed he was not aware of an annunciator panel for the generator. The 1999 edition of NFPA 99, Health Care Facilities Code, requires a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 6.4.1.1.17, 6.5.1)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one of one emergency generator, the facility did not properly maintain the emergency power system. Specifically, the facility did not complete their written Plan of Correction and there was no remote annunciator for the emergency power source (generator). The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the Director of Maintenance had already contacted the generator vendor to come out on 7/3/18 and do yearly maintenance and testing of the generator. The vendor will assist in installing a remote annunciator for the generator. The Director of Maintenance will then be responsible to keep a monthly audit of ensuring the remote annunciator is working properly and the completion date was 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that the audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 10:25 a.m. revealed a 3-phase 170-kilowatt Onan brand natural gas-powered emergency generator in the basement boiler room. The generator was observed to have gauges showing: AC volts, Amps, water temperature, oil pressure, and run-hours. When interviewed at that time, the Director of Maintenance revealed there was no remote annunciator for the generator but Penn Power will be putting one in. 4. There was no documentation provided by the Administrator or Director of Maintenance to show that a generator vendor had come out to the facility, nor was there documentation to show that a remote annunciator had been installed. The 1999 edition of NFPA 99, Health Care Facilities Code, requires a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 6.4.1.1.17, 6.5.1)Based on observations, an interview, and record review conducted during the 2nd Post Survey Revisit completed on 10/18/18, it was determined that for one of one emergency generator, the facility did not properly maintain the emergency power system. Specifically, the facility did not complete their written Plan of Correction, and there was no compliant remote annunciator for the emergency power source (generator). The findings are: A review of the Plan of Correction submitted by the facility from the 1st Post Survey Revisit of 8/17/18, revealed that the facility contracted with a generator vendor to install a remote annunciator beginning 9/17/18 and to be completed by 9/21/18. The 2012 edition of NFPA 99: Health Care Facilities Code states that a remote, common audible alarm shall be provided that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. Individual alarm indication to annunciate any of the following conditions listed shall be battery powered, shall be visually indicated, shall have additional contacts of circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occur, and shall have a lamp test switch to test the operation of all alarm lamps: Overcrank, low water temperature, high engine temperature pre-alarm, high engine temperature, low lube oil pressure pre-alarm, low lube oil pressure, over speed, low fuel main tank, low coolant level, control switch not in automatic position, low cranking voltage, contacts for local and remote audible alarm, audible alarm silencing switch, air shutdown damper when used. Observations on 10/15/18 at 1:15 p.m. revealed a Kohler remote annunciator on the wall across from the first floor nurses' station. The panel had a single light with the word fault printed next to the light and an audible sounder. In an observation on 10/17/18 at 8:41 a.m. there was a portable generator on wheels located outside on the lawn next to the Administrator's office. In an interview on 10/16/18 at 1:00 p.m., a representative from the vendor who installed the temporary generator and remote annunciator stated that the temporary generator has a temporary annunciator which will alarm if the generator is on or if there is a fault with the generator. He said the temporary annunciator would not indicate the source of the fault. He said staff would have to go out to the generator to find out the fault condition. He said the portable generator will only support the remote annunciator that was installed, it will not support a full (compliant) annunciator panel. The representative from the vendor said the facility's generator in house will not support an annunciator panel. He said the facility could get new hardware to add to the generator so it would support a remote annunciator, but it would take about six months. In further interviews at that time, the Facility's Director stated that he was not aware that a temporary generator was not compliant. When the surveyor asked why the facility did not obtain a time limited waiver, the Facility's Director stated that he did not know. He said that would have been up to the former Administrator. The Facility's Director stated, I had to do what I had to do to get an annunciator installed. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 6.4.1.1.17, 6.5.1)

Plan of Correction: ApprovedOctober 19, 2018

There were no residents directly affected by this deficient practice. The Director of Maintenance has already contacted the facilities generator vendor to come out on 7/3/18 and do yearly maintenance and testing of the generator. The vendor will also assist in installing a remote annunciator for the generator. The Director of Maintenance will then be responsible to keep a monthly audit of ensuring the remote annunciator is working properly. All audits will be brought to QAPI for review.

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for one of one emergency generator, the facility did not properly conduct or make records of runs and inspections. Specifically, monthly full load runs were performed for less than 30 minutes, load runs were conducted more than 40 days apart, records of runs were inaccurate or incomplete, and annual thirrd party inspections were not occurring. The findings are: 1. On 6/1/18 at 9:38 a.m., the surveyor was provided with documentation of generator runs and inspections. The records listed the generator and weeks one through four and monthly but did not specify which were actual runs or visual inspections. Additionally, there was nothing to indicate which runs took place under full load and the visual inspection log showed only meter readings from 5/1/18 through 5/28/18. When interviewed at that time, the Director of Maintenance (DM) stated that the full load runs are listed as monthly on the log sheets. The load run recorded on 5/1/18 showed a duration of 22 minutes, and the load run on 3/17/18 showed a duration of 15 minutes. The log sheets also showed greater than 40 days between load runs (4/1/18 to 5/21/18). Further review of the log sheets showed that all monthly load runs were left blank for the section that records the kilowatt percentage (KW%) and every weekly and monthly generator run/inspection had identically recorded numbers for: AC Amps, AC Volts, Oil Pressure, and Water Temperature. When interviewed at that time, the Director of Maintenance stated that he had never been taught how to do the KW%, that some of the weekly recordings were only visual inspections. When asked why AC Amps, AC Volts, Oil Pressure, and Water Temperature were recorded on visual inspections (not actual runs), the DM stated that this was the way he was shown how do it. 2. Observations in the presence of the Director of Maintenance on 6/1/18 at 10:25 a.m. revealed a three phase 170-kilowatt Onan brand natural gas-powered emergency generator in the basement boiler room. The generator was observed to have gauges showing: AC volts, Amps, water temperature, oil pressure, and run-hours. When interviewed, the DM stated that he thinks a vendor comes in to service the generator, but he was not sure the last time they were in. During a phone interview, a representative from the generator service vendor stated they should have come out in (MONTH) for service but the bill was not paid and the contract was not renewed. The 2010 edition of NFPA 110, Standard for Emergency and Standby Power Systems, requires a permanent record of the emergency power system inspections, tests, exercising, operation, and repairs shall be maintained and readily available. The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer. emergency power systems, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. The 2012 edition of NFPA 99, Health Care Facilities Code requires generator sets to be tested 12 times per year at intervals not to exceed 40 days. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.1.1, 9.1.3.1; 2010 NFPA 110: 8.3.4, 8.3.4.1, 8.4.1; 2012 NFPA 99: 6.4.4.1.4)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one of one emergency generator the facility did not properly conduct or make records of runs and inspections. Specifically, the facility did not complete their written Plan of Correction, monthly full load runs were not performed under full load, weekly inspections were not occurring, records of runs were incomplete, and annual third party maintenance was not occurring. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the Director of Maintenance had already contacted the generator vendor to come out on 7/3/18 and do an initial full load testing and from there the Maintenance Director would do the monthly testing and will keep an audit log sheet that will clearly state what was a visual inspection and monthly full load run. The vendor had been paid, a new contract had been created, and the vendor was coming out 7/3/18 to do a full inspection of the generator. The vendor will also educate the Director of Maintenance to ensure proper maintenance of the generator. The Director of Maintenance and the Administrator were responsible for completion by 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that the audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations in the presence of the Director of Maintenance (DM) on 8/15/18 at 9:38 a.m. revealed a 3-phase 170-kilowatt Onan brand natural gas-powered emergency generator in the basement boiler room. The generator was observed to have gauges showing: AC volts, Amps, water temperature, oil pressure, and run-hours. When interviewed at that time, the Director of Maintenance stated that the generator vendor has been contacted and they are on the list, but they have not come in yet. 4. On 8/16/18 at 10:35 a.m., the surveyor was provided with documentation of generator runs and inspections. The records listed only two generator runs (6/25/18 and 7/24/18) but did not specify if they were performed under full load or if they were visual inspections. The log sheet was not completed in the sections for the hour meter start and stop times and there was no documentation of weekly visual inspections. When interviewed at that time, the Director of Maintenance revealed the two generator runs were not under full load and he was not aware of the requirement for visual inspections. 5. There was no documentation provided by the Administrator or Director of Maintenance to show that the generator vendor had come out on 7/3/18 to perform full load testing, no documentation that the Maintenance Director was educated regarding the generator, and there was no documentation that a contract with a generator vendor was created. The 2010 edition of NFPA 110, Standard for Emergency and Standby Power Systems, requires a permanent record of the emergency power system inspections, tests, exercising, operation, and repairs shall be maintained and readily available. The permanent record shall include the following: (1) The date of the maintenance report (2) Identification of the servicing personnel (3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced (4) Testing of any repair for the time as recommended by the manufacturer. Emergency power systems, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. The 2012 edition of NFPA 99, Health Care Facilities Code requires generator sets to be tested 12 times per year at intervals not to exceed 40 days. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.1.1, 9.1.3.1; 2010 NFPA 110: 8.3.4, 8.3.4.1, 8.4.1; 2012 NFPA 99: 6.4.4.1.4)

Plan of Correction: ApprovedSeptember 14, 2018

It was determined that no residents were affected by this deficient practice. The Director of Maintenance has contacted the generator vendor to come on 7/3/18 and do an initial full load testing and from there the maintenance director will do monthly testing and will keep an audit log sheet that will clearly state what is a visual inspection and monthly full load run.
The vendor has been paid, a new contract has been created, and is coming out on 7/3/18 to do a full inspection of the generator. The vendor will also assist in providing updated forms for the Director of Maintenance to use in accurately documenting runs and inspections. The vendor will also educate the Director of Maintenance to ensure proper maintenance of the generator that all full load runs shall be performed at intervals not exceeding 40 days and no less than 30 minutes.
The Director of Maintenance will bring all audits to the QAPI committee for review and continued auditing. The Director of Maintenance and the Administrator is responsible for completion of audits.

K307 NFPA 101:ELEVATORS

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for two of two elevators, the facility did not maintain the firefighter recall system. Specifically, the facility did not conduct monthly firefighter recall tests. The findings include: Observations on 6/5/18 at 3:45 p.m. revealed the facility was three stories with a basement and has two elevators that serve all levels. Further observations revealed that outside the first floor elevators are red key buttons for Fire Recall, and the in-car firefighter service is to be used by the fire department to control the elevators in the event of a fire. When interviewed at that time, the Director of Maintenance (DM) revealed he does not have elevator recall keys and does not do any testing of the elevator firefighter recall service. The DM stated further that he is not aware of a third party inspection for the elevators. There was no documentation provided by the facility to show that the firefighter recall service was being tested on a monthly basis or city elevator inspection certificates. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.3, 9.4.6.1, 9.4.6.2)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two of two elevators the facility did not maintain the fire fighter recall system. Specifically, the facility did not complete their written Plan of Correction and the facility did not conduct monthly firefighter recall tests. The findings include: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the Director of Maintenance contacted the elevator company to have them come in and do the yearly inspections and the monthly firefighter recall inspection of both the front and the back elevator. Audits will be done monthly for six months. The Director of Maintenance and the Administrator were responsible for all audits and the completion date was 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that the audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/15/18 at 12:05 p.m., revealed the facility had three stories with a basement and had two elevators that serve all levels. Further observations revealed that outside the first floor elevators are red key buttons for 'Fire Recall' and in-car firefighter service to be used by the fire department to control the elevators in the event of a fire. When interviewed at that time, the Director of Maintenance (DM) said he does not have elevator recall keys and was not aware of the elevator firefighter recall service. The DM stated that he would contact the elevator vendor and discuss it with them. 4. There was no documentation provided by the Director of Maintenance or the Administrator to show that the firefighter recall service had ever been or was being tested on a monthly basis. There was no documentation that the elevator company had been contacted to perform the testing or that monthly audits were being performed. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.3, 9.4.6.1, 9.4.6.2)

Plan of Correction: ApprovedSeptember 10, 2018

No residents were directly affected however all residents had the potential to be effected by this deficient practice. The Director of Maintenance contacted the elevator company to have them come in and do the yearly inspection and the monthly firefighter recall inspection of both the front and the back elevator. The Director of Maintenance is responsible to ensure all audits and documented inspections of the elevator are placed in a binder and accurate. The audits will be done monthly for 6 months and brought to the QAPI committee. From there the QAPI committee will determine if auditing needs to continue. The Director of Maintenance and the Administrator is responsible for all audits.

K307 NFPA 101:EMERGENCY LIGHTING

REGULATION: Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for one of one battery powered emergency light provided at generator equipment locations, the facility did not perform the required annual testing. The findings are: Observations on 6/1/18 at 10:10 a.m. revealed a battery powered emergency lighting fixture attached to the wall in the basement generator room. An interview with the Director of Maintenance (DM) revealed testing of the light is recorded on the generator logs. Review of the generator logs revealed a section titled Yearly 90 Minute Light Test. This section was completed and initialed by the DM on the (MONTH) (YEAR) record as having run from 8:00 a.m. to 9:00 a.m. When interviewed at that time, the DM stated that it needed to be run another 1/2-hour. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.9.1, 7.9.3.1.1)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one of one battery powered emergency light the facility did not perform the required annual testing. Specifically, the facility did not complete their written Plan of Correction and did not document testing of an emergency light. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey revealed the generator vendor had been contacted and will be coming in for a full audit of battery powered emergency light in the generator room, and it will be tested for a duration of 90 minutes and documented. The Director of Maintenance and Administrator are responsible for compliance by 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/15/18 at 9:38 a.m. revealed a battery powered emergency lighting fixture attached to the wall in the basement generator room. An interview with the Director of Maintenance at that time revealed he tested the emergency light the previous week with the federal surveyor for about 30 minutes but did not document anything. He said that the generator vendor had been contacted and the facility was on the list, but they have not come in yet. 4. Document review on 8/16/18 at 10:40 a.m. revealed the log sheets for the generator runs included a section for documenting testing of the emergency lighting. Each section was not completed for the runs that took place on 6/25/18 and 7/24/18. 5. The Administrator or Director of Maintenance were unable to provide documentation that showed the battery powered emergency light in the generator room had been tested for 90 minutes. There was no documentation to show the generator vendor had come into the facility to audit the battery powered emergency light. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.9.1, 7.9.3.1.1)

Plan of Correction: ApprovedSeptember 14, 2018

The Generator vendor has been contacted and will be coming in for a full audit of the battery powered emergency light in the basement generator room and it will be tested for a duration of 90 minutes and documented. The Maintenance Director will continue to conduct the audits yearly thereafter. The Director of Maintenance is responsible for this audit to be completed and keep up to date. The audit will be brought to the QAPI Committee for review. The Director of Maintenance and Administrator is responsible for compliance.

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on interviews and record review conducted during the emergency preparedness review in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not complete a Hazard Vulnerability Assessment (HVA), have a written communications plan, have mutual aid agreements, have documentation of staff training, or conduct a full-scale community based drill. The findings are: 1. On 5/30/18 at 9:20 a.m., the Administrator provided the surveyors with the facility emergency preparedness plan (EPP) for review, which was signed off as being last revised (MONTH) (YEAR). The EPP did not include a documented facility and community based risk assessment utilizing an all-hazards approach, nor did the EPP contain a communications plan. The EPP binder contained an outdated mutual aid plan from 8/3/11, and page 21 of the plan listed the facility by the prior name When interviewed at that time, the Director of Maintenance revealed he has had some involvement with the EPP, but doesn't remember doing an HVA. The facility did not provide any documentation to show that a full-scale community or facility based drill was conducted within the last year, nor was there documentation to show that staff had been trained with regards to emergency preparedness. 2. When interviewed on 6/5/18 at 10:08 a.m., the Administrator said she was not sure if the facility had done and HVA and would need to look. She said the facility is not currently part of the Greater Rochester Mutual Aid Plan and there was no comprehensive EPP inservice. (42 CFR 483.73(a)(1) - Emergency Preparedness)Based on an interview and record review conducted during the Post-Survey Revisit completed on 8/17/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not complete their written Plan of Correction, did not conduct staff training, and did not conduct a full-scale community-based emergency preparedness drill. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed that the facility would participate in a community or facility based full scale drill, and staff would be educated on emergency preparedness procedures by the Maintenance Director or designee, and the Administrator was responsible for the completion by 8/11/18. 2. When interviewed on 8/14/18 at 3:30 p.m., the Maintenance Director said that since he has been at the facility there has been no full-scale emergency preparedness drill. When interviewed on 8/15/18 at 9:10 a.m., the Administrator said they have not performed a full-scale emergency preparedness drill yet, but there was one coming up in (MONTH) that they plan on doing. 3. There was no documentation provided by the Administrator or Director of Maintenance to show that a full-scale emergency preparedness drill had been performed. There was no documentation to show that staff had been educated on the emergency preparedness plan. (42 CFR 483.73(a)(1) - Emergency Preparedness)

Plan of Correction: ApprovedSeptember 14, 2018

As a result of the deficient practice all residents have the potential to be affected. The facility joined the Greater Rochester Mutual Aid Plan and the Administrator has attended the annual meeting on (MONTH) 22, (YEAR). A hazard vulnerability assessment (HVA) will be completed by (MONTH) 3, (YEAR).The facilities emergency preparedness plan will be reviewed and updated as necessary to include a communications plan and based on the HVA a plan will be made for address each risk area. The facility will participate in a community or facility based full scale drill and the staff will be educated on emergency preparedness procedures by the Maintenance Director or designee. All audits/reports will be brought to the QAPI committee for review. This will be ongoing. The Administrator is the responsible party.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 22, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for three (first, second, and third floors) of three resident sleeping floors and one of one basement, the facility did not properly maintain the fire alarm system. Specifically, fire alarm annunciator panels required occupants to go to the basement main fire alarm panel to read where the actual fire location would be in the event that the building fire alarm was activated. The findings are: Observations and interviews on 6/6/18 from 10:00 a.m. to 10:30 a.m. revealed the following: A wall mounted fire alarm system annunciator panel was located in the first-floor main lobby. An interview with an inspector from the City of Rochester Fire Marshal's Office (RFMO) revealed the annunciator panel will read Go To Basement when the fire alarm is activated, and that is not OK because it is not always a feasible option for the firemen to go to the basement to see where the alarm is pulled. The RFMO also stated that he was at the facility because there were concerns brought to his attention from the local fire department that responded to the building over the weekend. Further observations in the basement revealed there are two fire alarm panels on the wall and are wired such that they operate on a bypass. When the fire alarm is activated, the old panel sends signals to the newer panel which will show the actual location of the fire, and the annunciator panels are connected to the old panel. The RFMO stated that if the issue (fire) is in the basement, then all controls should be upstairs in an accessible area and the old panel needs to be eliminated. The 2010 edition of NFPA 72, National Fire Alarm and Signaling Code, requires: 1) All required annunciation means shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation. 2) Visible annunciators shall be capable of displaying all zones in alarm. 3) System defects and malfunctions shall be corrected. 4) The property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.4.1, 9.6.1.3; 2010 NFPA 72: 10.16.3.2, 10.16.4, 14.2.1.2.2, 14.2.2.1)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for three (first, second, and third floors) of three resident sleeping floors and one of one basement, the facility did not properly maintain the fire alarm system. Specifically, the facility did not complete their written Plan of Correction and the fire alarm annunciator panels required occupants to go to the basement main fire alarm panel to read where the actual fire location would be in the event that the building fire alarm was activated. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed Solution One would repair all annunciator panels so they will read appropriately and the main fire panel will be relocated to the first floor. All repairs will be completed by 8/11/18 and if not, then a time limited waiver would be requested. The Maintenance Director and the Administrator were responsible for compliance. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that the audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. During an interview on 8/13/18 at 9:29 a.m., the Director of Maintenance stated that they are buying a new fire alarm panel and are still working off both panels in the basement, but they are compliant. 4. When interviewed on 8/14/18 at 9:20 a.m., the Administrator said there are still two fire alarm panels and they can not work independently. The Administrator stated that Solution One (fire alarm vendor) said they have to remove both and have one panel to work the entire building. 5. Observations and interviews on 8/16/18 from 12:10 p.m. to 12:28 p.m. revealed the following: wall mounted fire alarm system annunciator panels were located in the first floor main lobby and on the second and third floors near the nurses' stations. Further observations in the basement revealed there are two fire alarm panels on the wall and are wired such that they operate on a bypass. When the fire alarm is activated, the old panel sends signals to the newer panel which will show the actual location of the fire, and the annunciator panels are connected to the old panel. Further observations at that time, during a planned fire drill involving activation of the fire alarm pull station on the third floor, revealed the annunciator panel in the first floor lobby displayed messages including: one of one new panel basement, and did not show the exact location of the fire. Further observations in the basement revealed the new fire alarm panel displayed the message: third floor center. When interviewed at that time, the Administrator stated the panels and the annunciators are not communicating properly. 6. During record review on 8/15/18 at 1:35 p.m., the fire alarm service vendor report, dated 6/27/18, read 'fire marshal wants keypads in front vestibule that will control both systems, we will quote.' An interview with a technician from the fire alarm service vendor revealed the remote annunciators will not show alarms from the second or third floors, and that you have to look at the new panel in the basement. 7. There was no documentation provided by the Administrator or Director of Maintenance to show that the main fire alarm panel was relocated to the first floor or repaired, nor was there documentation to show that the facility had applied for a time-limited waiver for that issue. The 2010 edition of NFPA 72, National Fire Alarm and Signaling Code, requires: 1) All required annunciation means shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation. 2) Visible annunciators shall be capable of displaying all zones in alarm. 3) System defects and malfunctions shall be corrected. 4) The property or building or system owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.4.1, 9.6.1.3; 2010 NFPA 72: 10.16.3.2, 10.16.4, 14.2.1.2.2, 14.2.2.1)

Plan of Correction: ApprovedSeptember 14, 2018

No residents were directly affected but all residents have the potential to be affected by this deficient practice. Solution One was contacted and came in and inspected the panels and will repair all annunciator panels so they will read appropriately and the main fire panel will be relocated to the first floor. All repairs will be completed by 8/11/2018 and if not then a time limited waiver will be requested. The Maintenance Director will then keep a log book to maintain all fire alarm inspection, testing, and maintenance of the fire alarm systems. All audits completed will be brought to the QAPI committee for review and continued auditing. The Maintenance Director and Administrator is responsible for compliance.

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: August 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain operating features. Specifically, employees were not familiar with established fire procedures, and there were no records of fire drills conducted prior to 11/30/17. The findings are: 1. Observations and interviews conducted on 5/31/18 from 10:30 a.m. to 11:17 a.m. revealed the following: a. Licensed Practical Nurse (LPN) #1 was standing in the south end hallway of the third floor and told the surveyor she could smell smoke. The surveyor agreed that there was a smell of smoke. LPN #1 did not report that to anyone but went to the far end (away from the nursing station) and shouted she could not smell smoke at that end. She continued to pass her medications. At that time, LPN #2 came down to the south hall and said she smelled smoke. After walking around the hallway for a while, she told the Interim Assistant Director of Nursing (ADON) who then walked around saying she could not smell anything because she has allergies [REDACTED]. b. The Interim ADON called a voice page of Code Red to the third-floor nursing station. The staff then began to put residents into the unit dining. Within one minute, the Director of Maintenance (DM), DON and Administrator responded to the floor. All residents on the third floor were behind closed doors one minute later (total of 11 minutes after detecting the smell of smoke). Smoke doors at both ends of the hallways had been closed and staff were stationed behind the doors. No fire alarm had been pulled. The DM checked the fire alarm pull station by the nursing station. c. The DM said he would go to the basement to get a ladder and check the ceiling. The DM returned to the third floor with a ladder and checked the ceiling in the hallway outside the Staff Educator's office. d. Twenty one minutes after the smell of smoke was detected, the surveyor intervened and asked the DM if he had pulled the fire alarm. He said the fire alarm should have been pulled as soon as the smoke smell was detected and proceeded to pull the fire alarm. e. The Administrator stated that if staff smell smoke, she expects staff to pull the fire alarm, call code red three times, and say the nurses' station or location of the fire. She said that would have alerted administrative staff (Administrator and DON), one nurse and one CNA to respond to the fire floor. She said the receptionist would then read the fire panel and call 911. She said by pulling the fire alarm, the fire department was automatically alerted to a fire. She said there is a fire alarm box by each nursing station, and the staff could have checked to tell them what floor the fire alarm was pulled from, if it had been pulled. She said she was not aware how long it took to call Code Red, but that it should have been called immediately. f. The Interim ADON stated that she would expect that if staff smell smoke, if they do not know where it is from to call Code Red immediately. She said if they know where the smoke is, like from equipment, she expects them to call maintenance. She said that before she called the Code Red, she called the front desk and told the receptionist that she was about to call Code Red. g. The front desk receptionist said the Interim ADON called her to let her know she was going to call a Code Red on the third floor by the desk. She said she did not do anything until later when the Administrator told her to call the fire department, and she called 911. 2. On 5/31/18 between 4:33 p.m. and 4:40 p.m. several staff members were asked what they would do if they smelled smoke. The answers were as follows: a. CNA #1 stated that you locate the location of the smoke, if you find the fire call Code Red, and tag the location. If you can not find the smoke, you still call Code Red. You would then wait for maintenance to call the fire department. CNA #1 then stated you would call maintenance and one of the higher ups would call the fire department. b. LPN #1 stated that you call Code Red, then call the front desk and tell them where you are smelling the smoke from. LPN #1 then stated that you would find the source and yell it out loud and go to the loud speaker. LPN #1 said she believes the front desk calls the fire department, and then stated you could also pull the fire alarm. LPN #1 then stated she would call Code Red and just pull the fire alarm. If you heard someone else call Code Red, then notify the front desk so they can call the fire department. c. CNA #2 and CNA #3 stated that you find the source of the smoke, then go to the charge nurse so they can overhead page, and then tag the door. They said the Supervisor or Charge Nurse would call the fire department if the fire alarms were not going off. They said staff would only pull the alarm if they saw an actual fire. CNA #2 then stated she would pull the alarm if she saw fire, probably not the best thing to do but she would do it. When asked why it would not be the best thing to do, she replied because of the building and all. 3. A review of the facility fire procedures on 5/31/18 at 4:15 p.m. revealed that the code word for fire was Code Red. The general policy and procedure for fire reads as follows: Upon discovering a fire, and if the alarm has not been sounded, then pull the nearest pull box alarm to the fire and to next notify the Administrator and Director of Nursing. The facility fire procedures also follow the acronym R.A.C.E., which were written as: Remove anyone in room, Activate the fire alarm, Close all remaining doors and windows in the fire zone placing residents in rooms, Evacuate as directed by person in charge. The response to hearing Code Red being called out is staff in the immediate area activate the fire alarm 4. On 6/1/18 at 9:01 a.m., the Director of Maintenance (DM) provided the surveyor with fire drill reports. The records showed no fire drills were conducted before 11/30/17. When interviewed, the DM stated that he had started back at the facility in (MONTH) of (YEAR) and could not find any drill reports before he started. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.7.1.2, 19.7.1.6, 19.7.1.8, 19.7.2.3.3)

Plan of Correction: ApprovedJuly 18, 2018

There were no residents affected but all residents have the potential of being affected. All staff will be re-educated on fire procedures by 8/11/2018. The facility has a new Director of Maintenance and a fire drill was already completed on 6/27/18 during the 7-3 shift. Fire drill will be conducted quarterly on each shift under varying conditions and times. An audit tool will be created to capture staff knowledge and understanding of all fire procedures. The audit will be done weekly on random shifts for 8 weeks and then quarterly to capture any new staff. All audits and documentation of fire drills and fire procedures will be brought to the QAPI committee for review. The Director of Maintenance and the Administrator is responsible for all audits.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for three (first, second, and third floors) of three resident use floors and one of one basement, the facility did not properly maintain hazardous areas. Specifically, doors to hazardous areas were damaged, were not self-closing, and/or did not properly latch. The findings are: 1. Observations on 5/29/18 at 1:30 p.m. revealed that the door to the third floor clean linen room would positively not latch when closed. 2. Observations on 5/30/18 at 8:45 a.m. revealed the door to the second floor soiled utility room would not automatically close and latch into the frame. The door was equipped with a self-closing device, but stopped approximately 1.5 inches short of full closing. 3. Observations on 5/31/18 at 9:55 a.m. revealed that the door to the soiled utility room across from the first floor resident lounge had tape across the strike plate, which prevented the door from latching when closed. 4. Observations on 5/31/18 at 2:25 p.m. revealed the self-closing mechanism to one of the two doors to the basement laundry room was disabled and disconnected from the door frame. The laundry room contained natural gas dryers and a significant amount of clean and soiled linens. In an interview at that time, the Director of Maintenance stated he was not sure how the mechanism had been broken. Additionally, the door to the soiled holding side of the laundry room was stuck on the door frame and would not automatically close and fully latch into the frame. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.2.1, 19.3.2.1.3, 19.3.2.1.5)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (second floor) of three resident use floors and one of one basement, the facility did not properly maintain hazardous areas. Specifically, the facility did not complete their written Plan of Correction, doors to hazardous areas were damaged, were not self-closing, and/or did not properly latch. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the second-floor soiled utility room self-closing device was repaired to close fully and latch. The basement laundry room door self-closing mechanism was repaired to ensure full closure. The Director of Maintenance will conduct audits monthly for five months. The Director of Maintenance was responsible for compliance by 8/11/18. 2. When interviewed 8/13/18 at 8:45 a.m., the Administrator said that audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 9:25 a.m. and again on 8/15/18 at 9:21 a.m., revealed the door to the second-floor soiled utility room would not automatically close and latch into the frame. The door was equipped with a self-closing device but stopped short of full closure leaving an approximately 1/8 to 1/2-inch gap between the lower half of the door and frame. The soiled utility room was approximately 100 square feet and contained two carts and three bins of soiled linens. 4. Observations on 8/13/18 at 9:15 a.m. and again on 8/16/18 at 8:40 a.m. revealed the self-closing mechanism to one of the two doors to the basement laundry room was disabled and disconnected from the door frame. Additionally, the single door to the soiled side of the laundry room did not fully close and latch by itself when released. The laundry room contained natural gas dryers and a significant amount of clean and soiled linens. 5. An interview with the Director of Maintenance on 8/15/18 at 12:06 a.m. revealed there had been no separate door audits for hazardous areas. 6. There was no documentation provided by the Administrator or Director of Maintenance to show the laundry room door and second floor soiled utility room door had ever been repaired, and there was no documentation to show monthly audits including these doors had been performed. The audits provided by the facility on 8/15/18 at 10:26 a.m. consisted of maps of the first, second, and third floors only with the word 'good' written next to some rooms. The maps did not identify what the audit was looking for and the soiled utility room doors on each floor and the basement doors were not identified as being inspected on the maps. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.2.1, 19.3.2.1.3, 19.3.2.1.5)

Plan of Correction: ApprovedSeptember 10, 2018

No residents were directed affected by this deficient practice, however, all residents had the potential to be affected.
1. The door to the third floor clean linen room door latch was repaired to close properly.
2. The second floor soiled utility room self-closing device was repaired to close fully and latch.
3. The first floor dirty utility room tape was removed to ensure appropriate latching.
4. The basement laundry room door self-closing mechanism was repaired to ensure full closure.
The Director of Maintenance will conduct a full house audit to ensure that all doors will close fully and latch and continue the audit monthly for 5 months and present all findings to the QAPI committee. From there it will be determined it the audit will need to be continued.
The Director of Maintenance is responsible for compliance.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 22, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for three (first, second, and third floors) of three resident use floors and one of one basement, the facility did not properly maintain firerated doors. Specifically, firerated doors were not inspected annually per NFPA 80 and/or were not maintained according to their listings. The findings are: Observations during the initial tour of the facility on 5/29/18 and 5/30/18 revealed firerated doors to the exit stairwells on all three floors and the center exit stairwell to the basement. Further observations on 6/5/18 from 10:00 a.m. to 10:10 a.m. revealed firerating plates on the edges of fire doors were painted over such that the firerating could not be seen. The locations of these doors included, but were not limited to the following: first floor stairwell doors and the basement kitchen doors. An interview with the Director of Maintenance revealed he did not think a fire door inspection had been done. There was no documentation provided by the facility to show that an annual fire door inspection according to NFPA 80 had been performed. The 2010 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives, requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the Authority Having Jurisdiction. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.3.1, 8.3.3.1; 2010 NFPA 80: 5.2.1; CMS S&C 17-38-LSC)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for three (first, second, and third floors) of three resident use floors and one of one basement, the facility did not properly maintain firerated doors. Specifically, the facility did not complete their written Plan of Correction, firerated doors were not inspected annually per NFPA 80 and/or were not maintained according to their listings. The findings are: 1. A review of the Plan of Correction submitted by the facility from the survey of 6/6/18 revealed that Solution One (fire alarm vendor) had been contacted to come in and do an annual fire door inspection to satisfy NFPA 80, and any fire doors identified to have failed the inspection will be repaired by 8/11/18. If the fire doors cannot be completed by the listed date, then a time limited waiver request will be submitted. The Administrator and Director of Maintenance were responsible for compliance, and the completion date was 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that audits had not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 8:54 a.m. revealed firerated metal doors to the exit stairwells on all three floors and the center exit stairwell to the basement. Further observations revealed firerated metal tags attached to the door frames at the center stair (third floor, first floor by 123, and second floor by 223) were painted over such that the firerating could not be seen. The locations of these fire door assemblies included, but were not limited to the following: first, second, and third floor stairwells. At that time, an interview with the Director of Maintenance revealed they went around and cleaned off the metal tags on the doors, did an audit, but have not yet done the fire door inspections, and will be hiring a contractor to do the annual fire door inspection. There was no documentation provided by the facility to show that an annual fire door assembly inspection according to NFPA 80 had been performed. The 2010 edition of NFPA 80, Standard for Fire Doors and Other Opening Protectives, requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the Authority Having Jurisdiction. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.3.1, 8.3.3.1; 2010 NFPA 80: 5.2.1; CMS S&C 17-38-LSC)

Plan of Correction: ApprovedSeptember 14, 2018

Based on the deficient practice all residents had the potential to be affected. All exit stairwells for all three floors have had the paint removed from the fire rating plates on the edges of the doors. A whole house audit will be completed for all doors in the facility to ensure the fire rating plates are visible. The facility has a new Director of Maintenance and Solution One has been contacted to come in and do an annual fire door inspection to satisfy NFPA 80. If any fire doors identified to have failed the inspection will be repaired by 8/11/2018. If this correction of failed fire doors cannot be completed by the listed date, then a time-limited waiver request will be submitted. The Maintenance Director will then keep a binder to keep documentation of such inspections are completed. All audits/reports will be brought to the QAPI committee for review and if any issues have been identified it will be audits will continue. The Administrator and Maintenance Director are responsible for compliance.

K307 NFPA 101:OPERATING FEATURES - OTHER

REGULATION: Operating Features - Other List in the REMARKS section any LSC Section 18.7 and 19.7 Operating Features requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included in Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

Citation Details

Based on observations and interviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for one (Center Stair) of three exit stairwells, the facility did not properly maintain operating features. Specifically, a smoke control system was not properly maintained. The findings are: Observations conducted on 8/13/18 at 9:13 a.m. revealed that the engineered smoke control system hatch in the center stairwell at the roof level had two cinder blocks placed on top of the hatch at the latching side which prevented it from opening. When interviewed on 8/13/18 at 10:40 a.m., the Director of Maintenance stated that he was not aware that the bricks were there. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.7.6, 4.6.12.1)

Plan of Correction: ApprovedSeptember 10, 2018

Corrective Action Taken for Those Residents Affected and For Those Residents Having Potential to be Affected-
The facility respectfully recognizes all residents as having potential to be affected and it was determined that there was no negative outcome due to the deficient practice.
The two cinder blocks were removed from the top of the hatch in the center stairwell at the roof level.
An audit of all roof top hatches were inspected to ensure they were not obstructed from opening.
Maintenance staff were educated regarding the purpose of the hatch and its function as a smoke control system.
Systemic Monitoring-
The Director of Maintenance will be responsible to conduct weekly rounds to check the hatch to ensure it is functional and is not obstructed from opening.
The Consultant will educate all maintenance staff regarding the regulation for maintaining the operating features of the facility, specifically the smoke control system hatch.
Quality Assurance Monitoring-
The Consultant in conjunction with the facility will develop an audit tool to monitor and ensure compliance with ensuring the smoke control system hatch is not obstructed. The audit will include ensuring the weekly rounds are being completed, visualization of the hatch to check compliance, and that staff verbalize understanding regarding the regulation. The Director of Maintenance or designee will be responsible to complete these audits weekly for 4 weeks and then monthly for 3 months, at which time it will be reviewed for continued frequency guidance at QA. The Director of Maintenance will report findings at the QACM monthly for follow up and review.

Person Responsible for the Correction of this Deficiency- Director of Maintenance
Date of Completion- 10/12/18
Directed Quality Assurance
Layla Kuek, RN is an Independent Consultant. Mrs. (NAME REDACTED) Kuek, has been retained by the facility for required compliance with the Statement of Deficiencies Directed Plan of Correction and Directed In-Services.
a. The causative factors that may have contributed to the issue identified is lack of staff education, poor preventative maintenance and knowledge on how to do repairs.
b. The steps/interventions undertaken or proposed to eliminate and correct causative factors identified during the assessment phase is the bricks were removed, and it was observed that the string to pull the smoke vent open/closed was wrapped to prevent proper latching of smoke vent.
c. Routine triggers or parameters the facility will implement for the above deficiency that will signal or alert staff of an evolving problem or deficient practice situation is new staff, turnover of maintenance staff, conducting proper preventative maintenance rounds and having documentation to prove it.
d. How the facility will measure whether efforts are successful or unsuccessful in maintaining compliance is by developing audit tools that will be brought to QAPI for continued monitoring and compliance.
A. Mandatory In-Servicing For K 700 will be conducted on 9/17/18 at 10:00am and 2:00pm, 9/18/18 at 10:30am, 9/19/18 at 10:00am and 2:00pm, 9/20/18 at 10:30am, 9/21/18 at 10:30am and 3:30pm, 9/25/18 at 10:00am, and 9/27/18 at 10:00am. Each in-service will be approximately 60 minutes in length, depending on the length of the question and answer session at the end. The in-service will be given by Layla Kuek RN. Targeted staff will include all maintenance staff. Monitoring and Evaluation of the effectiveness of the program will be conducted facility audits that are completed by facility staff designated in the P(NAME). The Quality Assurance Audit findings will be reviewed monthly at the Quality Assurance Committee Meetings for follow up and guidance.
B. In-Service Outline- The Consultant will educate all maintenance staff regarding the regulation for maintaining the operating features of the facility, specifically the smoke control system hatch.
Questions and Answers
Post Test

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: August 11, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for three (first, second, and third floors) of three resident use floors and one of one basement, the facility did not properly maintain portable fire extinguishers. Specifically, extinguishers were inspected at intervals exceeding 30 days, were overdue on 6 year maintenance procedures, and/or were marked as having been inspected on dates in the future. The findings are: 1. Observations and interview conducted during the initial tour of the facility on 5/29/18 from 9:00 a.m. to 3:50 p.m. revealed the following: a. Fire extinguishers on the wall in the basement near the kitchen and in the basement employee break room had inspection cards that showed the last monthly inspection was on 4/1/18. b. Fire extinguishers at the top of the north stairwell and outside room [ROOM NUMBER] had inspection cards with written monthly inspection dates of 6/4/18 and were initialed ES. c. Fire extinguishers outside Rooms #310 and #301 had inspection cards with written monthly inspection dates of 6/28/18 and were initialed ES. d. A fire extinguisher at the loading dock had an inspection card with a written monthly inspection date of 6/11/18 and was initialed ES. e. A fire extinguisher in the second floor dining room had an inspection card with a written monthly inspection date of 6/13/18 and was initialed ES. f. A fire extinguisher next to Resident room [ROOM NUMBER] showed its last monthly inspection was dated 6/4/18 and was initialed ES. The 6/4/18 was written using slash marks rather than dashes like the rest of the dates listed on the card. g. In an interview with the Director of Maintenance (DM) he stated that he did not inspect the fire extinguishers. Further interview revealed he was not sure they were dated in (MONTH) and that he saw the wrong date on another fire extinguisher. The DM also stated that he thought someone put his initials on it, but it was not him, because he uses dashes (-) in his dates not slashes (/). 2. Observations on 5/30/18 from 8:46 a.m. to 1:55 p.m. revealed the following: a. The fire extinguishers outside Resident room [ROOM NUMBER] and outside the second floor nurses' station had six year maintenance collars and stickers showing the last procedures were conducted in (MONTH) of 2012 (more than six years prior). The Director of Maintenance stated in an interview that he has never looked for this and it is the first he has heard of it. b. A fire extinguisher outside Resident room [ROOM NUMBER] was marked with an inspection tag with a written and initialed date of 6/18/18. c. The fire extinguisher next to Resident room [ROOM NUMBER] showed that its last monthly inspection was dated 6/14/18, but it had been crossed out. When interviewed, the DM stated that a Maintenance Worker put the wrong date in. Further observation revealed the extinguisher next to Resident room [ROOM NUMBER] was inspected on 5/1/18 and 6/14/18. When asked by the surveyor if the fire extinguisher was also inspected on 5/14/18 even though it was inspected 5/1/18 and the Maintenance Worker just put the wrong date down, the DM stated yes. The surveyor then asked why it would have been inspected on 5/14/18 when it was already inspected on 5/1/18, and the Maintenance Director stated that he did not know, he would have to ask the Maintenance Worker that question. The Maintenance Director also stated that he did not know why the Maintenance Worker would put his initials on the inspection. d. The (MONTH) (YEAR) inspection was not documented on the fire extinguisher inspection card located in the basement elevator machine room. In an interview at that time, the DM stated that he missed it. The 2010 edition of NFPA 10, Standard for Portable Fire Extinguishers, lists the following: 1) Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals. 2) Where at least monthly manual inspections are conducted, the date the manual inspection was performed and the initials of the person performing the inspection shall be recorded. 3) Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method. 4) Every 6 years, stored pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to the applicable internal examination procedures as detailed in the manufacturer's service manual and this standard. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.5.12, 9.7.4.1; 2010 NFPA 10: 7.2.1.2, 7.2.4.3, 7.3.1.1.2, 7.3.1.2.1)

Plan of Correction: ApprovedJune 30, 2018

No residents were directly affected but all residents had the potential to be affected by this deficient practice.
1. A ? G. Rochester Fire Safety Company have been contacted to come in and conduct the 6 year maintenance on all fire extinguishers in the facility. After the inspection fresh monthly inspection tags will be placed and will be inspected by the maintenance director monthly going forward. The Director of Maintenance will create a map of all fire extinguishers throughout the facility so no fire extinguisher will go without inspection.
2. A ? D. Rochester Fire Safety Company have been contacted to come in and conduct the 6 year maintenance on all fire extinguishers in the facility. After the inspection fresh monthly inspection tags will be placed and will be inspected by the maintenance director monthly going forward. The Director of Maintenance will create a map of all fire extinguishers throughout the facility so no fire extinguisher will go without inspection.
The Director of Maintenance will educate all maintenance staff on the proper inspection process and is responsible for all fire extinguisher inspection audits are within 30 days. The audits will be conducted weekly for 3 months and then monthly for 6 months. All audits will be brought to the QAPI committee and from there it will be continued if necessary.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 6, 2018
Corrected date: August 11, 2018

Citation Details

Based on observations, interviews, and records reviews conducted during the Life Safety Code Survey, it was determined that for one of one automatic extinguishing system, the facility did not properly maintain the sprinkler system. Specifically, a backflow prevention device on the sprinkler system was not tested , a sprinkler was obstructed, and there was no documentation of quarterly sprinkler systems inspections/tests during most of (YEAR). The findings are: 1. Observations on 5/29/18 at 3:42 p.m. revealed sagging and stained ceiling tiles in the basement dietary dry food storage room, such that the damaged tiles were blocking a sprinkler in the room. 2. Record review on 6/1/18 at 8:33 a.m. revealed no quarterly sprinkler system inspection reports between 1/18/17 and 1/14/18. There was no additional documentation provided by the facility to show sprinkler inspections were performed between the aforementioned timeframe. 3. Observations on 6/5/18 at 8:40 a.m. revealed a backflow device attached to piping in the basement sprinkler room. The service vendor inspection tag on the device showed: 4-inch(NAME)Model 909 and had an expiration date of 3/31/17. The Director of Maintenance stated in an interview at that time that he had called a plumber to come in and do it. There was no further documentation provided by the facility to show the backflow device had been tested within the previous year. The 2011 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, requires:1) all backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer. 2) System components shall be inspected at intervals specified in the appropriate chapters. 3) All components and systems shall be tested to verify that they function as intended. The frequency of tests shall be in accordance with this standard. 4) Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.5.1, 9.7.5; 2011 NFPA 25: 13.6.2.1, 4.4, 4.5.1, 4.5.2, 5.1.1.2, 5.2.1.1.1)

Plan of Correction: ApprovedJuly 19, 2018

No residents were directly affected but had the potential to be affected by this deficient practice. The previous Director of Maintenance did not maintain adequate documentation to show sprinkler testing, inspection, maintenance is up to date.
1. The maintenance director replaced all ceiling tiles in the basement dietary dry food storage room and made sure there was nothing blocking the sprinkler in the room.
2. Solution One has been contacted and will be coming in on 7/2/2018 to start doing the quarterly sprinkler inspection to ensure the sprinkler system is up and running. The Director of Maintenance is responsible for obtaining and maintaining a binder of all inspections for the sprinkler system.
3. Solution One will also be conducting the backflow inspection on 7/2/2018.
The director of Maintenance is responsible for auditing all sprinkler heads to ensure they are free of corrosion, foreign materials, paint, physical damage, and installed in the appropriate orientation which will be completed during the walk through with Solution One on 7/2/2018 and then continued monthly thereafter by Maintenance Director or designee. All audits will be brought to the QAPI committee for review.

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

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 two (first and second floors) of three resident use floors and one of one basement, the facility did not properly maintain electrical installations. Specifically, there were damaged outlets and cover plates, a damaged power cord, a receptacle that lacked a weatherproof cover, and an electrical junction box that was missing a cover. The findings are: 1. Observations during the initial tour of the facility on 5/29/18 between 10:35 a.m. and 3:55 p.m. revealed the following: a. A duplex electrical receptacle located on the roof near an air handler lacked a weather proof cover. b. An electrical junction box on the wall in the basement kitchen dishroom was rusted and lacked a cover plate. 2. Observations on 5/30/18 from 9:25 a.m. to 10:40 a.m. revealed the following: a. A duplex electrical outlet cover was broken and located near the wardrobe in Resident room [ROOM NUMBER]. b. The outer sheathing to the power cord to the A-bed in Resident room [ROOM NUMBER] was pulled back exposing the underlying wires. c. There was a duplex outlet with a broken faceplate in Resident room [ROOM NUMBER]. 3. Observations on 6/5/18 at 10:30 a.m. revealed outer sheathing to the power cord to an air blower on the floor in the basement was pulled back exposing the underlying green, white, and black wires. A disclaimer on the outside of the blower read: Do Not Use if Worn or Damaged. 4. Observations on 6/6/18 at 8:45 a.m. revealed a 220 volt receptacle behind the washing machines in the basement was pulled out of the wall and hanging by the conduit. When interviewed, the Director of Maintenance stated that it looked like a 220 volt receptacle and he has more anchors to fix it. The 2011 edition of NFPA 70, National Electric Code, requires: 1) Electrical equipment shall be installed in a neat and workmanlike manner. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating. 2) Raceways, cable assemblies, boxes, cabinets, and fittings shall be securely fastened in place. 3) All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. 4) Receptacles installed in a wet location shall have an enclosure that is weatherproof whether or not the attachment plug cap is inserted. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.1.1, 9.1.2; 2011 NFPA 70: 110.12, 300.11, 314.28(c), 406.9)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two (first and third floors) of three resident use floors, the facility did not properly maintain electrical installations. Specifically, the facility did not complete their written Plan of Correction, there were damaged outlets and cover plates, an uncovered electrical junction, and a receptacle that lacked a weatherproof cover. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the duplex electrical receptacle on the roof had been replaced with a weather proof cover. The Director of Maintenance conducted a whole house audit on all plugs and outlets and would continue audits monthly. The Director of Maintenance and the Administrator were responsible for all audits, and the completion date was 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that the audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 10:36 a.m., revealed a duplex electrical receptacle located on the roof near an air handler lacked a weather proof cover. 4. Observations in the first floor dining room near the door to the courtyard on 8/13/18 at 1:46 p.m., revealed the cover plate for a duplex electrical outlet was broken and falling off. 5. Record review on 8/14/18 at 10:29 a.m., revealed audits for electrical outlets on floors one, two, and three and did not include the roof or the basement. 6. Observations on 8/17/18 at 10:20 a.m., revealed a cracked and broken cover plate for a duplex wall outlet in Resident room [ROOM NUMBER]. 7. Observations on 8/17/18 at 11:23 a.m., revealed the A-bed electrical cord in Resident room [ROOM NUMBER] was ripped near the power lead exposing the inner insulation around wires. The 2011 edition of NFPA 70, National Electric Code, requires: 1) Electrical equipment shall be installed in a neat and workmanlike manner. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating. 2) All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. 3) Receptacles installed in a wet location shall have an enclosure that is weatherproof whether or not the attachment plug cap is inserted. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.5.1.1, 9.1.2; 2011 NFPA 70: 110.12, 300.11, 314.28(c), 406.9)

Plan of Correction: ApprovedSeptember 10, 2018

No residents were affected but all residents had the potential to be affected in this deficient practice.
1. A. the duplex electrical receptacle on the roof has been replaced with a weather proof cover.
B. The electrical junction box on the wall in the basement was replaced and a cover plate was placed.
2. a. The duplex outlet cover box was replaced
b. The plug will be replaced for #105A bed.
c. The duplex outlet cover faceplate was replaced in room # 117.
3. The plug for the air blower was repaired to have the exposed wires covered.
4. The 220v receptacle was repaired to ensure electrical safety.
The Director of Maintenance conducted a whole house audit on all plugs and outlets and will continue the audits monthly. The findings will be reported to the QAPI committee. The Director of Maintenance and the Administrator is responsible for all audits.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 17, 2018
Corrected date: October 12, 2018

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 two (first and second floors) of three resident use floors and one of one basement, the facility did not properly maintain vertical openings between floors. Specifically, there were improperly sealed penetrations into vertical openings. The findings are: Observations on 5/30/18 at 1:45 p.m. revealed an approximately 2-foot x 4-foot penetration through the ceiling pan in the basement wheelchair room. The opening also penetrated through the first floor and into the second floor creating a chase, and there were several pipes going through the opening. In an interview at that time, the Director of Maintenance stated that the penetration must go through the first floor around Resident room [ROOM NUMBER] or #108. (10 NYCRR 415.29(a)(2), 711.2(a)(1);2012 NFPA 101: 19.3.1.1)Based on observations, interviews, and record reviews conducted during the Post Survey Revisit completed on 8/17/18, it was determined that for two (first and second floors) of three resident use floors and one of one basement, the facility did not properly maintain vertical openings between floors. Specifically, the facility did not complete their written Plan of Correction and there were improperly sealed penetrations into vertical openings. The findings are: 1. A review of the Plan of Correction submitted by the facility from the Recertification Survey of 6/6/18 revealed the 2 foot x 4 foot penetration through the ceiling would be covered by a 1-hour fire stopping fire system. A whole house audit would be conducted by the Maintenance Director for any other vertical openings between floors within the facility. The Maintenance Director was responsible for this compliance with completion date of 8/11/18. 2. When interviewed on 8/13/18 at 8:45 a.m., the Administrator said that audits have not been started or completed yet for Life Safety Code tags and it was unclear if staff education had been done. 3. Observations on 8/13/18 at 10:08 a.m. revealed an approximately 2-foot x 4-foot penetration through the ceiling pan in the basement wheelchair room. The opening also penetrated through the first floor and into the second floor creating a chase, and there were several pipes going through the opening. When interviewed at that time, the Director of Maintenance stated that the Federal Surveyor that was in the previous week said they could just put a sprinkler in there. The Director of Maintenance said that he has no documentation that there was a full building audit for vertical penetrations. 4. There was no documentation provided by the Administrator or Director of Maintenance to show ceiling penetration were repaired, or that a full house audit for improperly sealed vertical openings was performed. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.1.1)

Plan of Correction: ApprovedSeptember 10, 2018

All of the residents are potentially affected by this deficient practice. The 2 foot by 4 foot penetration through the ceiling will be covered by a 1-hour fire stopping system. A whole house audit will be conducted by the Maintenance Director for any other vertical openings between floors within the facility. For any vertical openings between floors that are discovered will be properly sealed with at least 1-hour fire rated caulking. The audit will be conducted monthly going forward presented to the QAPI committee. The Maintenance Director is responsible for this compliance.