Pontiac Nursing Home
April 21, 2021 Certification/complaint Survey

Standard Health Citations

FF11 483.20(e)(1)(2):COORDINATION OF PASARR AND ASSESSMENTS

REGULATION: §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: June 9, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not incorporate the recommendations from the Pre-Admission Screening and Resident Review (PASRR) Level II determination into a resident's assessments and care planning for 1 of 1 resident (Resident #35) reviewed. Specifically, there was no documentation Resident #35's Level II Mental Health Screen recommendations for weekly behavioral counseling were followed and the resident's comprehensive care plan (CCP) was not specific to meet the resident's emotional and behavioral needs. Findings include: Resident #35 had [DIAGNOSES REDACTED]. The 3/24/21 Minimum Data Set (MDS) assessment documented the resident was not evaluated by Level II PASRR, was cognitively intact, had disorganized thinking, minimal depression symptoms of moving or speaking slowly or being restless half of the days in the previous two weeks, and required extensive assistance with most ADLs. Hospital records documented the resident was hospitalized between 1/21/21 and 3/18/21 for depression, suicidal thoughts, [MEDICAL CONDITION], and COVID-19. The 3/12/21 Level II PASRR documented the resident had been living in a nursing facility for over a year and recently had a change in mental status, which led to a hospitalization . The resident had a history of [REDACTED]. When first admitted to the hospital, the resident had thoughts of self-harm. The resident met the PASRR inclusion criteria for serious mental illness and needed hospitalization and the resident's day to day life was impacted by the illness. Recommendations included the resident receive ongoing psychiatric consultations and medication management by a psychiatrist or licensed prescriber; recovery-oriented clinical counseling focused on goal achievement by overcoming barriers due to the individual's mental illness; and therapeutic group interventions. Given the resident's current stability, psychiatric appointments were recommended every 10-12 weeks to monitor psychiatric symptoms. The resident would benefit from weekly counseling to treat psychiatric symptoms, counseling to help with depression and developing coping skills, and treating post-traumatic stress disorder ([MEDICAL CONDITION]). The resident would also benefit from recreational and therapy groups to have more activities and opportunities to interact with others. The 3/2021 and 4/2021 physician orders did not include documentation for orders for mental health practitioner consults. The comprehensive care plan (CCP) last reviewed 3/18/21 documented the resident displayed physical and verbal behavioral symptoms. The resident cried easily and expected to have their needs met immediately. The resident was to use coping strategies and demonstrate emotional stability, provide daily 1:1, and supportive tender loving care. The resident would participate in psychiatric and psychology services as recommended by the mental health providers. The 3/18/21 social services progress note documented the resident returned to the facility from a behavioral health hospital. The resident became easily emotional and cried very easily. The resident would participate in monthly psychiatric services. Interventions included coloring, reading magazines, writing, cross-stitch, talking to friends and family on the phone, 1:1 with activities staff, reassurance, emotional support, and comfort. Social services progress notes between 3/30-4/21/21 had no documentation of supportive weekly mental health counseling for the resident as recommended by the PASRR Level II. Nursing progress notes between 3/21/21-4/20/21 documented the resident was emotional, disoriented following admission, felt trapped by staff, received [MEDICATION NAME] (antianxiety medication) for weepiness, displayed aggressive anxious behaviors, was upset with their roommate, and was sobbing. The 4/1/21 psychiatric services note documented they were completing a follow up and medication check. The resident was depressed and anxious and wanted to live elsewhere. The anti-depressant medication was increased. Staff were to monitor mood, behaviors, offer non-pharmacological interventions, and socialization. The plan was to follow up in 4 weeks, or sooner if needed (prn). There was no further documentation of psychiatry services follow up. There was no documentation from the outpatient behavioral health services that weekly counseling was provided to the resident. On 4/19/21 at 11:01 AM, the resident was observed in bed. When addressed, the resident began sobbing and was inconsolable throughout the interview. During an interview with the Director of Social Services on 4/21/21 at 12:16 PM, they stated they did not provide weekly counseling to residents and that would be the responsibility of an outside consult psych service with a licensed social worker/therapist. If a resident was recommended for psych therapy, they would be seen by a local behavioral health agency. If someone had a mental health hospital visit, the outpatient behavioral health service was responsible for setting up the weekly counseling for the resident and calling the resident directly for the appointment. The Director of Social Services did not follow up with the outpatient behavioral health services to ensure the sessions were occurring. The Director of Social Services was familiar with the resident. They had established coping strategies with the resident, and they did not need the session notes. The Director of Social Services stated the CCP was the main plan of care for this resident. When someone had a Level II recommendation it was not specifically addressed on the CCP. The resident's admissions assessments would be updated by both nursing and social services regarding behavioral services. The Director of Social Services had thought the resident's individualized coping strategies were documented on the CCP but was unsure if it was documented on the current CCP. The resident had a prolonged hospitalization and their previous chart with CCP had been broken down, and the Director was unsure if the new CCP had documented individualized interventions for the resident. During an interview with the admissions coordinator on 4/22/21 at 10:20 AM, they stated the screen (PASRR) was collected from the location a resident was being admitted from, such as a hospital. Admissions then provided the screen to social services who was responsible for following up with recommendations. On 4/22/21 at 10:09 AM, the resident was observed in the hallway outside the administrative offices. The resident was yelling, sobbing, and not re-directable by staff. The resident repeatedly stated very loudly they needed to see someone immediately. The Director of Social Services and Administrator met with the resident and the resident was directed back to the unit at 10:35 AM. During an interview on 4/22/21 at 10:26 AM, the resident's representative stated they were concerned for the resident's mental health and emotional needs. They stated they did not think the facility was pushing for the resident's mental health needs. Some of the care was provided but it had been sporadic. During a combined interview with CNAs #13, 15 and 16 on 4/22/21 at 10:38 AM, they stated the resident displayed behavioral symptoms at least once a week and more often on the weekend when social services was not present in the building. They tried coloring books, magazines, puzzles in room, and music on the iPad in the resident's room. 10NYCRR 415.11(e)

Plan of Correction: ApprovedMay 19, 2021

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice: A. Resident 35 was discharged [DATE]. B. Resident 35 Pre Admission Screening and Resident Review (PASARR) Level II reviewed. C. Resident 35 Comprehensive Care Plan (CCP)/chart reviewed by IDT to ensure improvement opportunities as depicted to the Coordination of PASARR and Assessments 483.20(e)(1)(2) have been identified and addressed in this plan of correction. ie: ongoing psychiatric consultations, weekly behavioral health sessions, medication management by psychiatrist/licensed prescriber, clinical counseling, with focus on goals and overcoming barriers to assist with the residents emotional and behavioral needs. II. All residents evaluated by Level II PASARR have the potential to be affected by the same deficient practice. III. The following systemic changes will be put in place to ensure deficient practice does not recur: A. The comprehensive care planning policy and procedure was reviewed and updated to reflect that all Level II recommendations will be specifically addressed on the comprehensive care plan (CCP) with interventions to be individualized to meet the needs of the resident. B. The Social Worker, Admissions Coordinator & MDS Coordinator educated on the updated policy and the Discharge Critical Element Pathway. C. MDS Coordinator educated on their responsibility on identifying residents that were evaluated by Level II PASARR to reflect the Minimum Data Set (MDS) assessments and incorporating the recommendations into the resident assessment and care planning process. IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure deficient practice does not recur A. Comprehensive Care Plans will be reviewed by IDT after admission to ensure PASRR Level II recommendations are carried out, the comprehensive care plan is resident-specific per the recommendations on the PASRR Level II including any transition of care needs the resident may require. B. All Pre Admission Screening and Resident Review (PASRR) Level II determinations will be audited by the Social Worker weekly for 3 months to identify and ensure all recommendations/referrals the resident needs are provided, with results bought forth to the QA Team who will determine the need for further auditing. C. Admissions Coordinator/designee will perform an audit of all residents evaluated by Level II PASARR to assure that it reflects in the MDS documentation. This audit will be performed monthly for three (3) months, to ensure that no other residents are affected by this said practice and that the P(NAME) is followed. Immediate corrective actions will be taken for identified concerns. D. All audits will be presented to the QAA/QA committee for review. VI. Responsible Party: Social Worker

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: April 22, 2021
Corrected date: June 9, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 12 residents (Residents #15 and 35) reviewed. Specifically, Resident #15's care plan did not reflect the resident's medical [DIAGNOSES REDACTED].#35's care plan was not individualized for behavioral interventions. Findings include: The facility policy Comprehensive Care Planning updated 4/30/19 documents an individualized care plan must be initiated by a registered nurse (RN) upon admission for all residents and subacute patients. A care plan will be individualized for each resident using a person-centered approach. Problems will be identified from the Minimum Data Set (MDS) Care Area Triggers and review of the Care Area Assessments, as well as from resident assessment, interview, and direct observation. The care plan must be individualized for each individual. 1) Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. The 2/9/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for most activities of daily living. Care areas triggered and were to be addressed in the care plan included activities of daily living (ADLs) functional/rehab potential, urinary incontinence, psychosocial well-being, falls, nutritional status, dehydration/fluid maintenance, pressure ulcers and [MEDICAL CONDITION] drug use. The undated baseline care plan documented the resident received [MEDICAL TREATMENT] on Monday, Tuesday, and Wednesday. Outside coordination documented [MEDICAL TREATMENT] was received from an outside provider on Monday, Wednesday, and Friday. The resident received [MEDICATION NAME] (rapid-acting) and Basaglar (long-acting) insulins and had blood glucose checks three times a day before meals. The resident had a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) did not include person-specific, measurable objectives and timeframes to evaluate the resident's progress toward their goals for diabetes mellitus, [MEDICAL CONDITION] medications, noncompliance with medical recommendations, and [MEDICAL CONDITION] on [MEDICAL TREATMENT]. The 2/3/21 social services progress note documented the resident had [DIAGNOSES REDACTED]. The 2/3/21 psychosocial CCP documented the resident transferred from another skilled nursing facility. [DIAGNOSES REDACTED]. The CCP did not include documentation the resident received [MEDICAL CONDITION] medications. The 2/4/21 skin breakdown CCP documented the resident had a potential for skin break down related to decreased mobility and recent fall with fracture. The resident had a goal for skin issues to the left knee to be resolved. The interventions documented were pre-populated and did not reflect resident specific interventions for care of the left knee. The 2/9/21 nurse practitioner (NP) progress note documented the resident was being seen for noncompliance and diabetes. The resident was refusing to go to [MEDICAL TREATMENT] and had nausea due to poor dietary choices. The 2/9/21 social service progress note documented the resident had refused [MEDICAL TREATMENT] and three appointments. Compliance was discussed with the resident and possible decline in health if medical needs were not addressed. There was no documented evidence the CCP addressed the resident's noncompliance and refusal to attend [MEDICAL TREATMENT]. The 2/18/21 nutrition CCP documented the resident had a nutritional risk related to diabetes mellitus, MDD (major [MEDICAL CONDITION]), gastro-[MEDICAL CONDITION] reflux disorder (heart burn), and [MEDICAL CONDITION] (high cholesterol). The resident's goal was left blank and nursing was circled as the discipline responsible. Interventions included a regular diet, regular consistency, with thin liquids. There were no other resident specific interventions documented to address the problem areas. The CCP documented 2/18/21 see Nutrition Assessment. Registered dietitian (RD) #11's 2/18/21 Nutrition Assessment documented a [DIAGNOSES REDACTED]. The resident reported they disliked the foods offered at the facility and did not follow a specialized diet for [MEDICAL CONDITION] or diabetes. Their blood sugars had been elevated since admission. Interventions included updating information with [MEDICAL TREATMENT] as needed and to update the resident's preferences. Monitoring and evaluation documented to see the care plan. The 2/19/21 nursing progress note documented the resident's right hand to forearm was red and slightly swollen. The 2/19/21 NP progress note documented the resident had pain in their right hand. The resident had a history of [REDACTED]. The 2/21/21 nursing progress note documented the resident's right hand was red and [MEDICAL CONDITION]; the resident was encouraged to keep their hand elevated on a pillow. The 2/2021 through 4/2021 nursing progress notes continued to document the resident's right had was red and [MEDICAL CONDITION] which improved with elevation. The CCP did not document the resident's right hand redness and swelling or the plan to keep their hand elevated. The 4/9/21 NP progress note documented the resident was noncompliant with their diet and typically ordered out. The resident's insulin had been reduced the week prior due to their concerns of [DIAGNOSES REDACTED]. The resident's recent noncompliance of their diet and decreased insulin had contributed to elevated blood sugar levels. The NP discussed their diet to help control blood sugar levels. The 4/18/21 nutrition progress note by RD #11 documented the RD reviewed the resident's labs with the resident's RD from [MEDICAL TREATMENT]. The residents phosphorus was 7.5 mg/dl (milligram per deciliter; normal 2.5 to 4.5 mg/dl, high), potassium was 6.4 mEq/L (milliequivalents per liter; normal 3.7-5.2 mEq/L, high), and glucose was 485 mg/dl (normal fasting less than 100 mg/dl). The resident's dry weight was obtained. The resident had been consuming 75-100% of meals and insulin was adjusted by the medical staff. On 4/19/21 at 1:14 PM, the resident was observed with their lunch tray. The resident had a grilled ham and cheese sandwich and cottage cheese. The resident had requested the additional cottage cheese on their lunch tray. On 4/20/21 at 12:24 PM, the resident was observed in the hallway. Their right hand was very red in color; the resident was lightly rubbing and scratching their arm. On 4/20/21 at 1:06 PM, the resident was observed with their lunch tray. The resident was consuming an Italian sausage sandwich and cottage cheese, and there were two milks on the resident's tray; the resident was served the meatball sub with tomato sauce but requested the sausage instead. The resident stated they had a history of [REDACTED]. The resident stated they limited food intakes when told their potassium and phosphorus levels were elevated. The resident was aware they had two milks on their tray (high in phosphorus) which they knew they should limit, but they stated they enjoyed milk. During an interview on 4/21/21 at 11:17 AM, occupational therapist #19 stated the resident's arm had been red throughout their admission to the facility which improved with elevation. During an interview on 4/22/21 at 10:42 AM, the Director of Nursing (DON) stated a registered nurse (RN) had to initiate a care plan and a licensed practical nurse (LPN) could update the care plan. One of the RNs from the facility had been out of the country and the other worked part-time. The DON had been responsible for creating the baseline care plans and was not aware of comprehensive care plans. The DON stated residents may have an issue which involved multiple disciplines and should be discussed as a team. The resident's noncompliance was known at the time of the care plan meeting; the resident refused [MEDICAL TREATMENT] or medications and ordered takeout food. None of these issues were reflected on the resident's care plan. The LPN Unit Manager did a lot of the care plan updates, but they were out due to medical reasons and no one had been operating in that position. During an interview on 4/22/21 at 12:48 PM, RD #11 stated she came into the facility about once a week; she documented at least quarterly on the care plan and nutrition assessments, then in between quarterly assessments if nutritional issues such as weight loss or skin issues arose. The CCP documented any nutritional risks based on the MDS assessments. If a resident was noncompliant with their recommended diet, the RD would provide education and would address noncompliance in the care plan if it was chronic. The resident was new to the facility and the RD had not known if the resident had started [MEDICAL TREATMENT] when they were first admitted to the facility. The resident had stated they disliked the food at the facility on admission and the RD addressed preferences with the resident first. The RD had communicated with the [MEDICAL TREATMENT] RD on 4/18/21 and obtained the resident's most recent lab work and dry weight. The resident's phosphorus had been high, and the RD discussed the resident's diet and provided education and did not document it. The resident was able to make their own decisions and the RD respected the residents' right to follow or not follow. The RD had not been contacted from nursing or medical regarding the resident's elevated blood glucose. The RD stated the resident's care plan should have documented more information, especially the resident's dry weight and [MEDICAL TREATMENT]. The RD was unaware that the resident had been requesting additional items at meals and requesting cottage cheese at most meals. 2) Resident #35 had [DIAGNOSES REDACTED]. The 3/24/21 Minimum Data Set (MDS) assessment had no documentation a PASRR Level II was required. The MDS documented the resident was cognitively intact; had disorganized thinking; minimal depression symptoms of moving or speaking slowly or being restless half of the days in the previous two weeks; and required extensive assistance with most ADLs. Hospital records documented the resident was hospitalized between 1/21/21 and 3/18/21 for depression, suicidal thoughts, [MEDICAL CONDITION], and COVID-19. The 3/12/21 Level II PASRR documented the resident had been living in a nursing facility for over a year and recently had a change in mental status, which led to a hospitalization . The resident had a history of [REDACTED]. When first admitted to the hospital, the resident had thoughts of self-harm. The resident met the PASRR inclusion criteria for serious mental illness and needed a hospitalization where day to day life had been impacted by this illness. It was recommended the resident receive ongoing psychiatric consultations and medication management by a psychiatrist tor licensed prescriber; recovery-oriented clinical counseling focused on goal achievement by overcoming barriers due to the individual's mental illness; and therapeutic group interventions. Given current stability, psychiatric appointments were recommended every 10-12 weeks to monitor psychiatric symptoms; would benefit from weekly counseling to treat psychiatric symptoms; counseling to help with depression, develop coping skills, and treat post-traumatic stress disorder ([MEDICAL CONDITION]). the resident would benefit from recreational and therapy groups to have more activities and opportunities to interact with others. The undated baseline care plan documented the resident displayed physical and verbal behavioral symptoms. The resident cried easily and expected to have her needs met immediately. Staff were to use coping strategies and demonstrate motion stability, provide daily 1:1, and supportive tender loving care. The resident would participate in psychiatric and psychology services as recommended by the mental health providers. The 3/18/21 comprehensive care plan (CCP) by the Director of Social Services documented the resident had [DIAGNOSES REDACTED]. The resident was talkative, participated in 1:1 activities, cried easily, and expected to have their needs met immediately. The resident's interventions included: staff would meet the daily needs of the resident and offer choices in ADLs; invite the resident to activities and encourage participation; staff to give daily 1:1, support, tender loving care and reassurance as needed; the physician will monitor and adjust medications; and the resident will actively participate in psychosocial services as recommended by mental health providers. There was no documentation regarding the resident's individualized coping strategies. The 3/18/21 social services progress note documented the resident returned to the facility from a behavioral health hospital. The resident got easily emotional and cried very easily. The resident would participate in monthly psychiatric services. Interventions included coloring, reading magazines, writing, cross-stitch, talks to friends and family on the phone, 1:1 with activities staff, reassurance, emotional support, and comfort. The 3/2020 through 4/2020 nursing progress notes documented the resident exhibited anxious, aggressive, loud yelling, weeping, and sobbing behaviors. The resident was offered 1:1 support or as needed medications when exhibiting behaviors. On 4/19/21 at 11:01 AM, the resident was observed in bed. When addressed, the resident began sobbing and was inconsolable throughout the interview. During an interview on 4/21/21 at 12:16 PM, the Director of Social Services stated she was responsible for updating resident's care plans for psychosocial status and mental health. Level 2 screen recommendations were not documented on the care plan. The resident had a lifelong history of mental illness and had the following coping strategies: music, specifically Christian music; watching Christian shows; coloring pictures; writing lists; calling friends and family; or calling their service providers for information. The resident's CCP should document the resident's individualized coping strategies. The resident had been at the facility last year, had been hospitalized for [REDACTED]. The resident had a new chart created and their new care plan may not have included the resident's prior interventions. On 4/22/19 at 10:09 AM, the resident was observed in the hallway outside the administrative offices. The resident was yelling, sobbing, and not redirectable by staff. The resident stated they needed to see someone immediately. The Director of Social Services and Administrator met with the resident; the resident was able to be directed back to the unit at 10:35 AM. During an interview on 4/22/21 at 10:38 AM, certified nurse aides (CNAs) #13, 15, and 16 stated the resident exhibited behaviors and outbursts at least once a week. The resident enjoyed coloring, magazines, and puzzles in their room. When asked about music, the CNAs stated the resident had a tablet in their room they could utilize. The resident relied on the Director of Social Services when they were exhibiting behaviors. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedMay 20, 2021

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice: A. Resident 35 no longer resides in the facility. A medical chart review will be completed to ensure all improvement opportunities related to the resident's emotional/behavioral needs that were identified in the SOD without individualized coping strategies have been identified and addressed in this plan of correction. B. The following corrective actions were accomplished/will be accomplished for Resident 15: i. Care plan updated to address vascular impairment to right arm including weekly csm and as needed. Direct care staff will be educated as pertains to intervention included in the care plan. ii. NP and RD met with Resident 15 to discuss the resident's preferences including likes and dislikes. The resident [DIAGNOSES REDACTED]. iii. Food Service Director will meet with the Resident to review the resident's selected menu and explore options for lower phosphorus alternatives. iv. Dietary coping strategies added to CCP to include healthier take-out and behavioral referral to address resident's poor dietary choices. v. All direct care staff will be educated on resident 15 Comprehensive Care Plan update(CCP). II. All residents have the potential to be affected by the deficient practice. III. The following systemic changes will be put in place to ensure deficient practice does not recur: A. The Comprehensive Care Planning policy and procedure was reviewed and updated to reflect that all Level II recommendations will be specifically addressed on the comprehensive care plan (CCP) with interventions that will be individualized to meet the needs of the resident. B. The Care Plan Meetings will be scheduled by the MDS Coordinator. Care area triggers and care areas assessments will be used to develop the CCP. The IDT will attend meetings as scheduled and review and or implement individualized care plans consistent with resident conditions, risks, needs, preferences, and behaviors. Consideration will be given to care the resident refuses and not provided allowing residents to exercise their rights. C. The IDT educated on the updated policy and the General Critical Element Pathway & Nutrition Clinical Element Pathway. D. The MDS Coordinator will be educated on their responsibility to identify problem areas noted in the MDS, care area triggers, and care area assessments and present them to the Interdisciplinary Team. IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure deficient practice does not recur. A. All comprehensive care plans (CCP) will be audited by the MDS Coordinator/designee per the Care Plan Meeting Schedule for person-centered interventions with measurable objectives and time frames that meet the residents' needs. B. ADON/designee will perform an audit to ensure that no other residents are affected by this same practice and that the P(NAME) in place is followed. This audit will be performed monthly for three months. Immediate corrective action will be taken for identified concerns. C. All audit findings will be presented to the QA/QAA committee for review. Frequency of ongoing audits will be determined by the Committee based on audit results. V. Responsible party: Director of Nursing

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: April 22, 2021
Corrected date: June 9, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure the resident environment remained free of accident hazards for 1 of 3 residents (Resident #21) reviewed. Specifically, the facility did not re-educate staff to prevent reoccurrence when Resident #21 spilled a hot beverage on themselves. Additionally, the resident was observed unsupervised while consuming a meal. Findings include: Resident #21 had [DIAGNOSES REDACTED]. The 2/24/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with bed mobility and supervision with eating. The 4/2021 certified nurse aide (CNA) instructions documented the resident required supervision with eating. A 4/13/21 at 8:20 AM accident/incident report documented the resident was legally blind and given a cup of hot cocoa. The resident had been at a 45 degree angle but was slouched down in their bed during the drink consumption. The investigation determined abuse, neglect, or mistreatment did not occur as it was an error in judgement but the incident was avoidable. The investigation noted activity aide #10 had provided the resident with the hot cocoa while in bed. The investigation documented that a specialty cup with a straw was added to the resident's care plan. There was no documentation the activity aide was re-educated on providing hot beverages to the resident or the resident's position/location when drinking. Activity aide #10's education record contained no documented evidence education had been provided related to the 4/13/21 incident. A 4/13/21 at 8:35 AM nursing progress note documented the resident had a red area to the right shoulder down to the elbow. The resident was having a morning cocoa with a cup and straw and while trying to tip the cup to reach the straw, they unknowingly spilled cocoa on themself, resulting in a first degree burn (a superficial burn affecting the first layer of skin). On 4/19/21 at 12:49 PM, the resident was observed in the lounge area in a geriatric chair with a side table parallel to the chair. There were no staff members observed in the vicinity. The resident's meal tray was on the table. The resident was slouched down in their chair and tilted to the right. They took a bite of grilled cheese, set it down, and the sandwich slid down the blanket on to the resident's chest on top of the blanket. At 1:01 PM, the grilled cheese was still sitting on the blanket. The surveyor mentioned the grilled cheese to the resident and the resident then felt for the bread and lifted it up. The resident had been reaching over their chest to reach for silverware on the bed side table. During an interview with registered dietitian (RD) #11 on 4/21/21 at 12:31 PM, they stated the resident usually ate in their room and did not know the resident had since been moved to the lounge area for meals. The RD stated the resident was visually impaired and needed staff to tell them where their meal items were. During an interview with activity aide #10 on 4/22/21 at 9:49 AM, they stated on the morning of 4/13/21 they went in to greet the resident and the resident asked for hot cocoa. After pouring a cup of hot cocoa they would leave it on the counter to cool a bit, but it did not seem hot, so they brought it into the resident and set it on the bed side table. The table was parallel to the right side of the resident's bed. The activity aide asked the resident to elevate the bed (electronically) and they thought the resident was centered in bed. The activity aide approached the Assistant Director of Nursing (ADON) and another CNA after the incident, but no one had re-educated them about the hot cocoa or any type of positioning for the resident. The activities aide said the ADON only said, don't do that again. During an interview with the ADON on 4/22/21 at 10:28 AM, they stated they had been notified the resident was in bed, tilted their cup while lying at an angle, and the beverage dumped down their shoulder and upper arm. A referral was made to therapy for a new cup, and the resident now had a cup with a lid. The ADON was not aware of anyone re-educating activity aide #10. The ADON stated on the investigation they documented the incident was avoidable, as the resident had been tilted to the side at a 35 degree angle and attempted to tilt the cup to drink it, leading to a spill. The ADON stated the resident did not have a burn, as noted by the nurse on the unit that day. During an interview with CNA #16 on 4/22/21 at 10:46 AM, they stated the resident recently started having their meals in the lounge area outside of their room. The CNA was not able to fully position the resident upright as the geriatric chair they used hurt the resident's knees when positioning upright. The resident was unable to bend their knees. During meals they put the bed side table to the right of the resident. The resident leaned and shifted to the side a lot in that chair. The resident had a slight visual impairment and now had a specialty cup with a lid related to a hot beverage incident recently. He stated no one had spoken to staff related to the resident's repositioning. 10NYCRR 415.12(h)(1)

Plan of Correction: ApprovedMay 20, 2021

I. The following corrective actions were accomplished for Resident 21 who was found to have been affected by the deficient practice A. Resident was assessed by RN and no burn was noted after spilling hot cocoa on her shoulder and arm. B. Resident's comprehensive care plan was reviewed. OT evaluated. A cup with a lid remains appropriate for hot beverages. All care staff educated on this care plan intervention and monitor the need for additional adaptive equipment. C. Activity aide 10 was educated on proper positioning when providing fluids, when in question seek help from nurse. (4/23/21) D. Resident was also evaluated by OT to address positioning during meals with a recommendation to sit 75-90 degrees during meals while in bed or Geri chair for comfort and safety. The resident is SU for self-feeding and utilizes RUE to self-feed and ensure that food is within reach. Care card and care plan updated. E. All direct care staff and all activity staff will be educated on this update. II. All residents have the potential to be affected by the deficient practice. III. The following systemic changes will be put in place to ensure deficient practice does not recur: A. Following an incident or accident, the cause will be thoroughly investigated by the DON or ADON to ensure the residents' care and environment is free from hazards and resident receives the necessary supervision to prevent accidents. B. ?Ç£Incident and Accident Reporting and Follow Up?Ç¥ Policy and Procedure reviewed and updated. C. All nursing staff re-educated on the ?Ç£Incident and Accident Reporting and Follow Up?Ç¥ Policy and Procedure. VI. The facility compliance will be monitored utilizing the following quality assurance system to ensure deficient practice does not recur. A. All accident and incident reports will be audited by the DON or designee to ensure appropriate interventions have been put into place to prevent potential harm to the resident and to ensure any necessary education needed for avoidable incidents has been completed. B. This audit will be performed weekly for three months to ensure that no other residents are affected by this said practice and that P(NAME) in place is followed. Immediate corrective actions will be taken for identified concerns. All audit findings will be presented to the QA/QAA committee for review. V. Responsible party: Director of Nursing

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: April 22, 2021
Corrected date: June 9, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey, the facility did not ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls for 1 of 1 medication storage rooms (Unit 1) observed. Specifically, the facility did not monitor temperatures in 2 medication refrigerators which contained multiple insulin pens and vaccination and [MEDICATION NAME] testing vials. Findings include: The 5/2018 Health Direct Pharmacy services Medication Storage policy documented that medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of suppliers. All medications are maintained within the temperature ranges noted by the United States Pharmacopeia; refrigerated at a temperature of 36-46 degrees Fahrenheit (F) with a thermometer to allow temperature monitoring. When keeping a log of temperatures remember to report any temperatures that were not within normal range. If vaccines are stored the temperature must be recorded twice a day. The proper storage of medications can have a direct effect on the efficacy of a medication. The 4/8/21 Centers for Disease Control Moderna COVID-19 Vaccine preparation and administration summary documents the Moderna COVID-19 vaccine unpunctured multiple-dose vials can be stored in a refrigerator between 36-46 degrees F for up to 30 days prior to first use. Prescribing information for insulins including Basaglar Kwikpen, [MEDICATION NAME] Flextouch, Seglee Pen, Humalog flex pen, [MEDICATION NAME] flex pen, [MEDICATION NAME] flex pen and Admelog [MEDICATION NAME] documents the insulins should be stored in a refrigerator between 36-46 degrees F if unopened. [MEDICATION NAME] (purified protein derivative), and influenza vaccine prescribing information all documented vials should be stored in a refrigerator between 36-46 degrees F. During an observation of the Unit 1 medication room on 4/20/21 at 11:30 AM with licensed practical nurse (LPN) #20, two small refrigerators were observed being used to store medications. One temperature log dated 03/2021 was completed. The log did not document which refrigerator the recorded temperatures were taken from. There were no temperature logs for 4/2021. Refrigerator #1 had no thermometer located inside and contained the following: -1 unopened multi-dose vial of Moderna COVID-19 vaccine. -29 unopened insulin pens. Refrigerator #2 contained a thermometer and the following biologicals were stored in this refrigerator: -1 unopened multi-dose vial of [MEDICATION NAME] serum (purified protein derivative); -1 opened multi-dose vial of [MEDICATION NAME] serum; -1 unopened multi-dose vial of Moderna COVID-19 vaccine; and -1 unopened multi-dose vial of influenza vaccine. During the observation LPN #20 stated the LPN who worked the nightshift was responsible for keeping track of the refrigerator temperatures. When interviewed on 4/20/21 at 12:01 PM, the Director of Nursing (DON) stated both refrigerators were supposed to have a thermometer and a temperature log. The LPN that worked on the nightshift was to monitor the temperatures of the refrigerators and log them per facility policy. The DON stated they would check with the nightshift LPN, but if there was a log for the 4/2021 temperatures, it should have been hung in front of the 3/2021 log and was not. When interviewed on 4/20/21 at 2:08 PM, pharmacy consultant #5 stated that insulin pens were to be at room temperature for 28 days once opened and refrigerated at 36-46 degrees F if unopened. If there were no temperature logs there was no way to know if the pens were stored colder or warmer than the manufacturer recommendations. The pharmacy consultant stated that vials of vaccines were to be stored at the appropriate temperature range and temperature logs were to be maintained. There was no way to determine if the vaccines and insulin pens had been frozen or if they were still able to be used. On 4/21/21, a copy of one temperature log dated 4/2021 was provided to the surveyor. The log documented that refrigerator temperatures were taken once each day from 4/1-4/16/2021, by LPN #6. There were missing entries on 4/6, 4/7, 4/11, and 4/12, and 4/17-4/21/21. All documented temperatures were within the range of 36-46 degrees F. There was no documentation on the form which refrigerator the log belonged to. When interviewed on 4/21/21 at 3:52 PM, LPN #6 stated she was aware there was only one thermometer for the two refrigerators. She had mentioned this to someone but could not recall who she told. She stated the 4/2021 temperature log was for the refrigerator with the insulin pens in it. She stated typically, the night shift staff checked the thermometers and the missing entries on the 4/2021 log were for those days she was off duty and that she had forgotten to record the temperature the last shift she worked. She stated she believed the temperatures were to be maintained between 38-43 degrees F. 10NYCRR 415.18(d)(e)(1-4)

Plan of Correction: ApprovedMay 15, 2021

I. The following corrective actions were accomplished : A. Refrigerator 1 (1st floor) thermometer placed and new temperature log sheet implemented. B. Refrigerator 2 (2nd floor) temperature log placed. II. All residents have the potential to be affected by the deficient practice. III. The following systemic changes will be put in place to ensure deficient practice does not recur: A. The ?Ç£Medication Storage & Log?Ç¥ policy reviewed and updated. B. The day/night nurse and the day/evening nurse will be responsible for checking and recording the temperatures according to facility policy. C. All licensed nurses will be educated on the updated policy and the Medication Storage and Labeling Critical Element Pathway. D. All licensed nurses will be educated on the Temperature Monitoring Best Practices for Refrigerated Vaccines?ÇôFahrenheit (F) and Storage Best Practices for Refrigerated Vaccines-Fahrenheit (F). VII. The facility compliance will be monitored utilizing the following quality assurance system to ensure deficient practice does not recur. A. The ADON will audit the medication refrigerator temperatures on both floors three times a week x 4 weeks and weekly thereafter to ensure that no other residents are affected by the same practice and that P(NAME) is followed. Immediate corrective actions will be taken for identified concerns. B. Any nurse who fails to check and log the temperature will be re-educated and subjected to discipline. C. Audit results will be taken to the QA Committee for review. Frequency of ongoing audits will be determined by the Committee based on audit results. VI. Responsible party: Director of Nursing

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: June 9, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not notify the Office of the State Long-Term Care Ombudsman of a facility-initiated transfer for 1 of 1 resident (Resident #39) reviewed. Specifically, Resident #39 was transferred to the hospital and the Ombudsman was not notified. Findings Include: The 11/21/17 facility Discharge/Transfer policy documented it is the policy to adhere to all the regulations regarding a resident's transfer and discharge rights. The policy did not document that the Office of the State Long-Term Care Ombudsman was to receive notification of facility-initiated transfers or discharges. Resident #39 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment was not available. The 2/15/21 nursing progress note documented at 5:00 AM the resident was having trouble breathing and was transported to the hospital. There was no documented evidence the Ombudsman was notified of Resident #39's emergency transfer to an acute care facility. When interviewed on 4/21/21 at 3:27 PM, Ombudsman #8 stated long term care facilities were supposed to notify their office of any facility-initiated discharges. The only recent discharge notice she had received from the facility was in 2/2021 and it was not for Resident #39. When interviewed on 4/22/21 at 12:10 PM, the Administrator stated they reported discharges to Ombudsmen #9, and they did not notify the ombudsman of hospitalization s unless they specifically asked. When interviewed on 4/22/21 at 2:29 PM, the Director of Social Services stated they were responsible for notifying the Ombudsman's Office of resident discharges. The Director of Social Services stated they did not notify the Ombudsmen of emergent hospital transfers. The Director of Social Services believed the Administrator was communicating with Ombudsman #9 regarding hospital discharges. The Director of Social Services did not notify the Ombudsmen of Resident # 39's hospital transfer. 10NYCRR 415.3(h)

Plan of Correction: ApprovedMay 19, 2021

I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice: A. Resident 39 did not return from the acute care facility. B. The Ombudsman 9 was notified of the resident 39 discharge. C. The Office of the State Long Term Care Ombudsman was notified of all discharges/transfers for the previous month. II. All residents being discharged /transferred have the potential to be affected by the deficient practice. III. The following systemic changes will be put in place to ensure deficient practice does not recur: A. The facility ?Ç£Transfer and Discharge?Ç¥ policy was reviewed and updated to reflect the need to notify the Office of the State Long Term Care Ombudsman for all transfers and discharges including facility-initiated and/or resident-initiated transfers or discharges. This includes timely reporting, a notice with reason, effective date, location of the transfer/discharge, resident appeal rights, changes to the notice, name, and number of the Ombudsman, and agency responsible for advocacy of those with intellectual and developmental disabilities. B. The Administrator, Social Worker, and Admissions Coordinator educated on the updated policy and the Discharge Critical Element Pathway. IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure deficient practice does not recur: A. All Transfers and Discharges will be reported daily in morning report to ensure notification was timely to the resident and their representative (Ombudsman), has occurred in writing, in a manner they understand, within 30 days for facility-initiated transfers/discharges. All emergent transfers will be reported to the Ombudsman as soon as practicable. B. All transfers and discharges will be audited monthly x 3 months with results brought forth to the QA committee who will determine the need for further auditing. V. Responsible Party: Social Worker

FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 22, 2021
Corrected date: June 9, 2021

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification and abbreviated surveys (NY 227 and NY 733), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported to the New York State Department of Health (NYSDOH) in accordance with State law for 6 of 8 (Residents #5, 6, 14, 31, 37, and 237) reviewed. Specifically, the facility did not report incidents of resident to resident abuse for Residents #5, 14, 31, 37, and 237; a suicide attempt for Resident #31; and misappropriation of property for Resident #6. Findings include: The facility policy Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/27/20 documented the Administrator, DON (Director of Nursing), or designee has the responsibility to report all alleged violations in which there is reasonable cause to believe that abuse, neglect, or mistreatment has occurred, and all substantiated incidents, to the NYSDOH. Staff are to identify, correct and intervene in situations which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes an analysis of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as residents with a history of aggressive behaviors, entering other residents' rooms, (and) self-injurious behaviors. The 11/20/20 facility Abuse Reporting policy documented whenever there is reasonable cause to believe that physical abuse, mistreatment, neglect, or misappropriation of resident property has occurred by staff, or a family member, the suspecting individual must call the NYSDOH. 1) Resident #237 had [DIAGNOSES REDACTED]. The 2/21/20 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; did not exhibit behavioral symptoms affecting self or others; and was independent with locomotion on the unit. The comprehensive care plan (CCP), updated 6/2019, documented the resident had the potential to verbally and physically abuse others, wandered, and had the potential to be a victim of abuse. The following incidents involving Resident #237 were not reported to the NYSDOH as required: -The 7/13/19 at 7:20 AM accident/incident report documented Resident #237 took hold of Resident #37's hair and then hit Resident #37 with a closed fist on the right side of the shoulder, neck and face. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reason there was no abuse. -The 8/7/19 at 3:20 PM accident/incident report documented Resident #237 was whipping another resident with their call bell. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reason staff followed care plan. -The 10/5/19 at 5:24 AM accident/incident report documented Resident #237 went into Resident #14's room and would not leave, Resident #14 then slapped Resident #237. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reason no abuse. -The 1/22/20 at 6:15 AM accident/incident report documented, per a certified nurse aide (CNA), Resident #237 walked into another resident's room. The other resident (name not noted) got up from a chair and slapped Resident #237. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with documented reasons, N/A. -The 3/11/20 at 1:25 PM accident/incident report documented Resident #237 entered Resident #5's room and Resident #5 grabbed and pushed Resident #237. The report documented the interdisciplinary team ruled out abuse, neglect, or mistreatment with noted reason that Resident #237 was unintentionally wandering/entering Resident #5's room. The report documented the event was avoidable. The Director of Nursing (DON) stated in an interview on 4/21/21 at 4:15 PM that they were not familiar with the NYSDOH Nursing Home Incident Reporting Manual and what incidents were to be reported to the NYSDOH. During an interview with the Director of Social Services on 4/22/21 at 2:29 PM, they stated if a resident was physically hurt, then it would be considered abuse. Resident #237 did have physical altercations with other residents. The Director of Social Services considered that inappropriate physical contact, as no one wants to be hit. The Director of Social Services stated when physical contact was made between residents it was reportable to the NYSDOH, but they were not the one responsible for reporting. During an interview with the Administrator on 4/22/21 at 12:10 PM, they stated at the time of the documented incidents the Director of Nursing (DON) was responsible for reporting them to the NYSDOH. At that time the DON did not feel the incidents required reporting. The Administrator stated the incidents involving Resident #237 and other residents with physical contact, should have been reported to the NYSDOH. The reports should also include a clear reason why abuse was ruled out. 2) Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. The 8/7/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required limited or extensive assistance for most activities of daily living, and the resident felt it was very important to take care of their personal belongings or things. The 8/22/19 comprehensive care plan (CCP) documented the resident was alert and oriented; and was friendly and talkative. The 10/21/19 social work progress note documented the resident reported they had loaned $200 to an employee in 8/2019. The employee had signed a statement with a plan to repay the loan in monthly payments starting in 9/2019 and the employee missed the 10/2019 payment. The resident wanted their money back. The social worker and Activities Director interviewed the resident who reported they did not lend the money under duress. The resident was educated to not lend money to employees and employees could not accept any money or gifts from residents. The resident was educated on boundaries with employees and not to talk to them about their personal lives. The resident reported they were not traumatized, they loaned the money of their own free will, and they were not coerced. The resident wanted their $175 back. The 10/31/19 Investigation Summary documented the following: - Activities Aide #1 had borrowed $200 from Resident #6 around 8/20/19 which was discovered on 10/21/19. - Activities Aide #1 was issued a disciplinary notice and reviewed the Facility Policy/Employee Handbook and Corporate Compliance Plan. - Mandatory education was provided to the entire facility staff to prevent similar violations. - Reports and findings were forwarded to legal counsel and reported to the facility Operator. - There was no documentation the misappropriation was reported to the NYSDOH. During an interview on 4/19/21 at 10:03 AM, Resident #6 stated they had loaned the employee money a couple of years ago. The employee did not make a payment and the resident asked to be paid back in full. The facility paid the resident back after the resident reported it. The resident stated they were unaware they could not lend money to the staff. The resident stated they loaned the money because they felt bad for the employee. During an interview on 4/21/21 at 12:16 PM, the Director of Social Services stated Resident #6 had loaned money to Activities Aide #1. The resident had made an agreement with the Activities Aide to be repaid, and when the employee did not pay the resident back as agreed upon, the resident reported it to other staff and requested to be reimbursed in full. The Director of Social Services discussed the situation with the resident, who reported they gave the money of their own free will, was not traumatized, and was not coerced into giving the money. The incident was discussed with the Human Resources Director and the Administrator. The Social Services Director stated they did not reference the Nursing Home Reporting Manual and was not responsible for reporting. During an interview on 4/21/21 at 1:14 PM, the Human Resources Director stated they had been working as the Activities Director at the time of the incident. The Activities Director had been approached by an activities aide who stated that Resident #6 told them that they had loaned money to activities aide #1. The Human Resources Director and the Director of Social Services spoke with the resident. At that time they discovered the resident had loaned money to activities aide #1 a few months before and the activities aide had not paid the resident back. The Administrator was notified, and an investigation was conducted. Activities aide #1 was educated and given a written warning. Activities aide #1 had the remaining balance deducted from their next two paychecks to reimburse the resident. The Human Resources Director stated the Administrator was the facility's corporate compliance officer. During an interview with the Administrator on 4/22/21 at 12:10 PM, they stated the Director of Nursing (DON) was responsible for reporting incidents to the NYSDOH, but their current DON was new to the process. Incidents should be reported based the Incident Reporting Manual criteria. The Administrator stated they did not use the Incident Reporting Manual and did not report the misappropriation of Resident #6's property to the NYSDOH. 3) Resident #31 was admitted to the facility with [DIAGNOSES REDACTED]. The 3/11/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, rejected care and took antipsychotic, antidepressant and antianxiety medications. The resident required extensive assistance or supervision for most activities of daily living (ADLs). The 11/20/20 updated comprehensive care plan (CCP) documented the resident was at risk for sexually, physically, and verbally aggressive behavior. Interventions included to monitor for behavioral status to determine if the resident represented an immediate harm to self or others and required immediate notification to registered nurse (RN) for intervention to prevent harm. The 4/9/21 11:00 PM-7:00 AM shift nursing progress note documented the nurse on the previous shift had sent the resident to the local hospital. The resident was sent out with aggressive behaviors as well as intent to hurt themself. Upon return from the hospital at 12:45 AM, the resident continued with increased agitation. As needed [MEDICATION NAME] (sedative) was given at 12:45 AM with some positive effect. The resident had stated I want to kill myself and I don't want to live anymore. The 4/9/21 at 10:35 AM nursing progress note documented staff reported to the care team that the resident was trying to harm themself overnight by trying to wrap sheets and cords around their neck. The resident had stated they wanted to die. All cords and sheets were removed from the resident's room and the resident was placed on 1:1 supervision. The nurse practitioner (NP) evaluated the resident and the resident was to be sent to a different hospital able to provide psychiatric evaluation and treatment. The 4/9/21 Director of Social Services progress note documented the resident attempted to wrap a cord and sheet around their neck on 4/8/21 and was sent to the hospital. There was no documented evidence an investigation was completed, or the incident was reported to the NYSDOH. When interviewed on 4/21/21 at 4:15 PM, the DON stated there was no investigation done as they just wanted to get the resident treated. The DON did not know who reported facility incidents to the NYSDOH. The DON stated they had reported the incident and had not done any of the DOH reporting since she began working at the facility. The DON stated the Administrator was the only one who knew the reporting process. The DON stated they were not familiar with the NYSDOH Nursing Home Incident Reporting Manual. During an interview with the Administrator on 4/22/21 at 12:10 PM, they stated the incident was not reported to NYSDOH and it should have been. 10NYCRR 415.4 (b)(1)(ii)

Plan of Correction: ApprovedMay 20, 2021

I. The following corrective actions were accomplished for the residents found to have been affected by the deficient practice: A. Residents 5, 6, 14, resident care plans reviewed and updated. B. Resident 37 no longer resides at the facility C. Resident 237 no longer resides at the facility D. The following corrective actions have been accomplished/will be accomplished for Resident 31: a. Resident was seen by Provider following her ER visit due to suicidal ideation. Psychiatric follow-up evaluation completed. Medications were reviewed and reconciled. b. Social worker counseled resident upon return from the Hospital and conducted resident mood interview (PHQ9). Social worker to continue conducting resident mood interview (PHQ9) for Resident # 31 weekly for 3 months to monitor the severity of her depression and response to treatment and present to the QA team for review. Immediate corrective action will be taken for identified concerns. c. Resident care plan reviewed and updated to include psychological therapy once per week and as needed including incorporating activities of her liking. d. All direct care staff will be educated on the updated care plan. II. All residents have the potential to be affected by the deficient practice. A. Administrator and DON with the ADON have reviewed the past 30 days of Accident and Incident reports, specifically to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, were reported to the New York State Department of Health in accordance with State law as applicable. III. The following systemic changes will be put in place to ensure deficient practice does not recur: A. ?Ç£Reporting Resident Abuse, Mistreatment, Neglect or Misappropriation of Property?Ç¥ policy reviewed, updated to include the NYSDOH Nursing Home Incident Reporting Manual & Abuse Critical Element Pathway. B. Administrator, DON, ADON, Social Worker and the rest of the Interdisciplinary team educated on the updated policy, critical element pathway including how to identify an alleged violation involving abuse and injuries of unknown source; immediately reporting incidents to the administrator and NYSDOH; conducting and reporting results of all incidents within five working days to the administrator and NYSDOH officials. C. All nursing staff were educated by the DON on what constitutes a reportable incident. D. Facility A/I Tracker updated to ensure all reportable incidents are completed timely. IV. The facility compliance will be monitored utilizing the following quality assurance system to ensure deficient practice does not recur: A. All reports of alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property will be reviewed by the facility administrator or designee with the IDT at the time of such occurrence and will be reported immediately. B. The accident and incident reports will be audited weekly for three months to ensure that no other residents are affected by this said practice and that P(NAME) in place is followed. Immediate corrective actions will be taken for identified concerns. All audit findings will be presented to the QA/QAA committee for review. V. Responsible party: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 21, 2021
Corrected date: June 7, 2021

Citation Details

Based on observation, record review and interview during the Life Safety Code survey, the facility did not ensure cooking facilities were maintained for 1 of 1 kitchen in accordance with National Fire Protection Association (NFPA) 17A Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Specifically, the kitchen fire suppression system was not inspected monthly. Findings include: During review of a third party email to the facility, dated 4/20/21, the third party vendor stated that the facility was in good condition and did not require any attention until 6/2021. The email documented some agencies may require a monthly visual check on the system where one may date and sign the back of the tags In New York State, you can do a visual check on items like the fire suppression system .and log it into your records as having done such. During an observation on 4/19/21, between 9:30 AM and 9:50 AM, the facility's main kitchen fire suppression system monthly inspection tag documented the last inspection was 12/4/2020. The back of the inspection tag of the monthly visual checks was not completed as required. During an interview on 4/21/21, between 4:30 PM and 5:00 PM, the Maintenance Director stated they were not aware of this ansul system regulation. The Maintenance Director showed the surveyor a third party vendor letter which documented that the facility was in good condition and did not require any attention until 6/2021, the next semi-annual third party inspection. 2012 NFPA 101 19.3.2.5.5, 19.3.5.3, 9.2.3, table 9.7.3.1 2011 NFPA 96 10.2.6 2009 NFPA 17A 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 13, 2021

I. There were no specific residents identified for this deficiency. II. All residents have the potential to be affected by this deficient practice. III. To ensure that deficient practice does not recur, the following systemic changes will be put in place: A. The Facility Administrator educated the Environmental Services Director and Food Service Director regarding the monthly visual check requirement for the main kitchen fire suppression system in accordance with the NFPA 17A. B. We will institute a monthly visual check for the fire suppression system to be logged and dated as having done such. Immediate corrective action will be taken for identified concerns. IV. To ensure that deficient practice does not recur, corrective actions will be monitored by the QA committee. A. Food Service Director/designee will conduct a monthly audit to make sure that the required NFPA 17A monthly visual check requirement is completed as part of preventative maintenance. Findings will be reported to the QA committee. This audit process will be ongoing for the next six months or until the next recertification survey. V. Responsible Party: Environmental Service Director

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 21, 2021
Corrected date: June 15, 2021

Citation Details

Based on observation, interview, and record review during the Life Safety Code Survey, the facility did not ensure that one of one diesel emergency generator (generator #1) was properly maintained. Specifically, generator #1 lacked a remote manual stop station installed outside the generator/boiler room; the annual fuel quality test was not completed for generator #1; the time for the automatic transfer switches to transfer from normal power to emergency power was not documented for generator #1; and the three year four-hour generator run test was not completed. Findings include: 1) Remote Manual Stop Stations During observations on 4/19/21, between 2:50 PM and 4:30 PM, and on 4/21/21 at 9:30 AM there was no remote manual stop station installed outside the generator/boiler room. During an interview on 4/21/21 at 2:30 PM, the Maintenance Director stated that they were not aware that a remote manual stop station was required to be installed outside the generator/boiler room. The Maintenance Director could not find a remote manual stop station within the facility and was unsure if the facility had one. 2) Annual Fuel Quality Tests During an interview on 4/21/21, between 4:30 PM and 5:00 PM, the Maintenance Director stated they were not aware the facility was required to annually test the diesel fuel used for the generator. The Maintenance Director could not find any annual fuel tests for 2020 and 2021. 3) Length of Time During Load Tests During an interview on 4/21/21, between 10:40 AM and 11:45 AM, the Maintenance Director stated the time for the automatic transfer switches to transfer from normal power to emergency power during monthly load tests was less than ten seconds. The time for transfer from normal power to emergency power was never documented during the monthly load tests. During review of the 2020 and 2021 monthly load test sheets, there was no documented transfer times from normal power to emergency power. 4) Three Year Four Hour Run Test During an interview on 4/21/21, between 4:30 PM and 5:00 PM, the Maintenance Director stated they were not aware the facility generator was required to be run for four hours every 3 years. She could not find any documentation this was completed in 2020 or 2021. 2012 NFPA 99: 6.5.3.1 2012 NFPA 101: 9.1.3.1, 19.5.1 2010 NFPA 110: 5.6.5.6, 8.3.8 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 13, 2021

I. There were no specific residents identified for this deficiency. II. All residents have the potential to be affected by this deficient practice. III. To ensure that deficient practice does not recur, the following systemic changes will be put in place: 1. Third Party Penn Power was immediately contacted and requested to come and provide the necessary work. A proposal for work was provided (04/21/2021) in conjunction with information provided in the SOD related deficiency. i. Penn power will install E-stop/remote manual stop station outside of the generator/boiler room in coordination with the Electrical Company. 2. The Facility runs on natural gas and does not have diesel as stated in the SOD. 3. The facility weekly generator test form was updated to include the time for transfer from normal power to emergency power for the monthly load test. i. The report will be brought forth to the QA committee for review. Immediate action will be taken for identified concerns. ii. The Environmental Services Director was in-serviced to this update. 4. The Facility contacted (05/06/2021) third party vendor Pennpowergroup to send us a new pm agreement for the facility generator with provisions to include exercise once every 36 months for four continuous hours in accordance with NFPA 110 IV. To ensure that deficient practice does not re-cur; the corrections/repairs completed will be verified by the Facility Administrator and the Environmental Service Director when completed and report will be brought forth to Quality Assurance Committee for review by the QA committe. V. Responsible party: Administrator

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: April 21, 2021
Corrected date: June 15, 2021

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility's emergency lighting was not tested and maintained for one isolated area (generator/boiler room) as required by code. Specifically, there was no battery-operated emergency light in the generator/boiler room. Findings include: During observations on 4/19/21, between 2:50 PM and 4:30 PM, and on 4/21/21 at 9:30 AM there was no battery operated light within the generator/boiler room. During an interview on 4/21/21, between 9:30 AM and 10:40 AM, the Maintenance Director stated they were not aware of the battery operated light requirement in the generator/boiler room and they could not find any battery operated lights in that room. 2012 NFPA 101: 19.2.9.1, 7.9 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedMay 13, 2021

I. There were no specific residents identified for this deficiency. II. All residents have the potential to be affected by this deficient practice. III. To ensure that the deficient practice does not recur, the following systemic changes will be put in place. A. Third-party vendor (Electric Company) was contacted and visited the Facility on 05/10/2021 and performed a field survey to plan for the installation of battery-operated emergency light in the generator/boiler room. B. The newly installed battery-operated emergency light will be added to the Facility's weekly testing/checking as part of preventative maintenance performed by the Environmental Service Director/designee. IV. To ensure that deficient practice does not re-cur; the corrections/repairs completed will be verified by the Facility Administrator and the Environmental Service Director when completed and the report will be brought forth to Quality Assurance Committee for review by the QA committee. V. Responsible Party: Environmental Service Director

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 21, 2021
Corrected date: June 7, 2021

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure 1 of 2 fire barriers (second floor main smoke barrier) observed was constructed to a 1/2-hour fire resistance rating. Specifically, the second floor smoke barrier had an unsealed penetration. Findings include: During an observation on 4/21/21, between 3:30 PM and 3:45 PM, the second floor main smoke barrier had an unsealed 1-inch circular penetration. There was also unknown debris coming out of the unsealed penetration. During an interview on 4/21/21, between 4:30 PM and 5:00 PM, the Maintenance Director stated the other maintenance staff person had been responsible for checking the integrity of the smoke barriers. The Maintenance Director stated they had never checked the integrity themself. The Maintenance Director was aware the facility smoke barriers were required to be smoke tight. 2012 NFPA 101 19.3.7.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 13, 2021

I. There were no specific residents identified for this deficiency. II. All second-floor residents have the potential to be affected by this deficient practice. III. To ensure that deficient practice does not recur, the following systemic changes will be put in place: A. The identified unknown debris coming out of the unsealed penetration was removed B. The Administrator educated the Environmental Service Director regarding the need to complete environmental rounds to specifically check the integrity of the smoke barriers; this includes monitoring for any unsealed penetration and debris. C. Unsealed penetration identified in the SOD will be sealed with approved fire-rated sealant IV. To ensure that deficient practice does not recur, corrective actions will be monitored by the QA committee. A. The Environmental Services Director will conduct weekly rounds, to check the integrity of fire barriers in compliance with NFPA 101, specifically looking for unsealed penetrations and debris for the first month, and monthly thereafter. Immediate corrective actions will be taken for identified concerns. B. Report will be brought forth to the QA committee for review. This audit process will be ongoing for the next six months or until the next recertification survey. V. Responsible party: Environmental Services Director

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: April 21, 2021
Corrected date: June 7, 2021

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 1 of 2 emergency exit stairwells (east emergency exit stairwell) reviewed. Specifically, the wall over the first floor access door to the east emergency exit stairwell had multiple varied sized unsealed penetrations and holes. Findings include: During an observation on 4/21/21 at 3:15 PM, the wall over the first floor access door to the east emergency exit stairwell had multiple varied sized unsealed penetrations and holes. There were multiple areas on the wall in which the cinder-blocks were cracked or broken apart. There were wires and pipes that passed through these broken cinder-blocks. During an interview on 4/21/21, between 4:30 PM and 5:00 PM, the Maintenance Director stated they had never checked the integrity of the east emergency exit stairwell fire rated walls. They stated they had been the interim Maintenance Director for the last 4 or 5 years while the facility was looking for a permanent Maintenance Director. They thought the previous Maintenance Director had checked the integrity of the emergency stairwells. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 13, 2021

I. There were no specific residents identified for this deficiency. II. All residents have the potential to be affected by this deficient practice. III. To ensure the deficient practice does not recur, the following systemic changes will be put in place. A. The Administrator educated the Environmental Service Director and Housekeeping Supervisor regarding the need to complete environmental rounds to check for the integrity of all emergency exit stairwell walls specifically to monitor for unsealed penetrations and holes in walls B. The Facility Administrator and Environmental Service Director with the Housekeeping Supervisor completed an environmental round to identify holes and unsealed penetrations that needed repair. C. Unsealed penetrations and holes identified in the SOD were sealed with approved fire-rated cement/sealant IV. To ensure deficient practice does not recur, corrective actions will be monitored by the QA committee. A. Housekeeping Supervisor will conduct weekly rounds looking specifically for unsealed penetrations and holes for the next month and monthly thereafter. A written report will be prepared and submitted to the Environmental Service Director. Immediate corrective actions will be taken for identified concerns. B. The Environmental Service Director will conduct an audit based on the report received by the Housekeeping Supervisor. C. Environmental Service Director will conduct weekly rounds for the first month, then monthly thereafter to check the integrity of emergency exits stairwell fire-rated walls. Immediate corrective actions will be taken for identified concerns. D. The audits will be brought forth to the QA meeting for review by the team. The reports and audits will continue for a period of six months or until the next recertification survey. V. Responsible Party: Environmental Service Director