Central Park Rehabilitation and Nursing Center
April 10, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure all residents were free from unnecessary drugs for 1 of 3 residents (Resident #22) reviewed for use of [MEDICAL CONDITION] medication. Specifically, Resident #22 was administered an antipsychotic medication without an adequate indication for use. Findings include: Resident #22 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. He required limited assistance with hygiene and no assistance with bathing. The comprehensive care plan (CCP) updated 4/10/2017 documented the issue of noncompliance with showers since admission. The CCP described interventions attempted since 2014 included encouragement and re-approach, consider mood, and explanation that a nurse will do a skin check for issues. The resident had continued to repeat that he will let staff know if he had skin issues, he did not need a shower, and his clothes were not dirty after minimal wearings. The CCP documented the issue of behaviors, with at least monthly updates since (YEAR). Behaviors included disruptive behavior and verbal aggression, with the resident yelling unfounded accusations toward staff. Interventions for behaviors included encouragement, reapproach, education, redirection with firm but [MEDICATION NAME] approach, social work visits, and group and individual activities. The progress note written by nurse practitioner (NP) #11 dated 9/30/2016 documented the resident was alert, oriented to himself, and pleasantly confused. He had no behavioral issues. His hygiene was poor, he had a noticeable odor, and he was strongly encouraged to take a shower. There was no documentation the resident took antipsychotic medication or ever had in the past. The progress note written by NP #11 dated 10/28/2016 documented the resident was seen for evaluation, as he continued to refuse his morning care. The resident was pleasant, alert, oriented to himself, and confused to place. When morning care was discussed, the resident stated, I will go ahead and do it when you put a shower in my room. The NP documented the resident's current medications included [MEDICATION NAME] (antipsychotic, can be used for depression/anxiety) 25 milligrams (mg) at bedtime. The plan for the refusal of hygiene care was to try a small dose of [MEDICATION NAME] (antidepressant) 25 mg at bedtime to see if it would help with his behaviors, brighten his mood, and allow him to be more participatory in his own care. Review of the medical record did not document the use of [MEDICATION NAME] prior to the NP note on 10/28/2016. The physician order [REDACTED].#11) documented the resident to start [MEDICATION NAME] 25 mg daily at bedtime. There was no order for [MEDICATION NAME] as planned in the NP's progress note. The nursing progress noted dated 10/28/2016 at 3:00 PM documented the resident was seen by medical for his shower refusals and was ordered [MEDICATION NAME] 25 mg daily. The 24-hour nursing report (shift-to-shift communication) dated 10/28/2016 documented the resident had a new order for [MEDICATION NAME]. The attending physician progress notes [REDACTED]. The resident was doing well overall, had no ongoing or unresolved issues, and was not having behaviors that were not redirectable. The assessment and plan was depression. There was no documentation regarding the new order for [MEDICATION NAME]. The nursing progress note dated 11/8/2016 at 5:04 PM documented the resident was sent to the hospital with right flank pain. The nursing progress note dated 11/11/2016 at 5:04 PM documented the resident returned from the hospital. The NP was called and approved all medications. The physician's re-admission orders [REDACTED]. The attending physician progress notes [REDACTED]. The resident was seen by an NP on 11/14, 11/16, 11/18, 11/25, and 11/28/2016 with no documentation regarding the use or effectiveness of the [MEDICATION NAME] that was started on 10/28/2016. The resident was seen by 3 different NPs on the 5 visits. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The order was discontinued on 11/8/2016 when the resident went to the hospital and resumed on 11/11/2016. The progress notes written by NP #11 dated 12/2/2016 and 12/9/2016 documented the resident was doing well. He was fairly compliant in maintaining his ADLs, although he did need assistance at times and encouragement for showers on occasion. His current medication list included [MEDICATION NAME] at bedtime. The notes did not document medical justification for the continued use of an antipsychotic medication. The (MONTH) (YEAR) MAR indicated [REDACTED]. The attending physician progress notes [REDACTED]. He had anxiety and the [MEDICATION NAME] seemed to be helping. He had no behaviors that were not redirectable. He was calm and comfortable even though he had some dementia. The progress note written by NP #12 dated 2/1/2017 documented the resident was on [MEDICATION NAME], and [MEDICATION NAME] for dementia with behavioral disturbance. The risks and benefits were reviewed and medications were continued. The plan was to discuss a gradual dose reduction (GDR) with the physician and psychiatrist as soon as possible. (The medical record did not document any psychiatry or psychology consults.) The progress note written by NP #12 dated 3/16/2017 documented the resident was on [MEDICATION NAME], and [MEDICATION NAME] for dementia with behavioral disturbance, and the medications would be continued. During an interview on 4/7/2017 at 2:50 PM, certified nurse aide (CNA) #10 stated the resident was often resistive to care and could be verbally abusive. She stated she had worked at the facility for 6 months and had not noticed any changes in his behavior. She stated he was verbally abusive when asked to shower, and often refused. During an interview on 4/7/2017 at 3:05 PM, licensed practical nurse (LPN) Unit Manager #9 stated the resident was on [MEDICATION NAME] for dementia with behavioral disturbance. She stated it was not a new medication, he had been on it for some time, and he could be very verbally abusive. When she reviewed the resident's record, she stated it was ordered 10/28/2016 and the NP had entered the order into the system. She was unaware the NP's progress note documented he was going to start the resident on [MEDICATION NAME]. During a telephone interview on 4/10/2017 at 1:15 PM, the resident's attending physician stated he tried to minimize the use of antipsychotic medications. He stated he used antipsychotics for [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], and anxiety only if indicated. He stated he did not use antipsychotics on residents refusing care. He stated he could not recall why the resident was on [MEDICATION NAME] and would have to review the record. During a telephone interview on 4/10/2017 at 2:10 PM, NP #11 stated he rarely used antipsychotics and could not recall starting any in the past year. He stated he only ordered antipsychotics when clinically indicated. He stated if he documented the resident was on [MEDICATION NAME], then he read it from the computer and it was not a new order. The surveyor read the progress note from 10/28/2016 to the NP. He stated if he wrote he planned to use [MEDICATION NAME], then he must have forgotten to order it and it was his mistake. He stated he would not have ordered the [MEDICATION NAME] and the resident must have already been on it. 10NYCRR 415.12(l)(1)(2)(i)(b)

Plan of Correction: ApprovedMay 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F329 Drug Regimen Is Free From Unnecessary Drugs

Immediate Corrective Actions:
Resident #22 medications were reviewed by medical and pharmacy consultant and resident?s [MEDICATION NAME] was eventually discontinued.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents on anti-psychotic medications as having the potential to be affected. The facility reviewed all residents currently receiving antipsychotic medications to ensure all had the appropriate indication for use. No identified issues. Facility will monitor all residents currently on antipsychotic medications during the facility?s monthly gradual dose reduction meetings.

Systematic Changes:
Facility Medical Director in-serviced medical staff regarding the appropriate indications for the use of anti-psychotic medications such as [MEDICATION NAME]. All residents on anti-psychotic medications will continue to be reviewed in the facility?s monthly gradual dose reduction meeting to ensure there are adequate indications for the medication as well as monitoring whether the medication should be continued or reduced.

QA Monitoring:
The facility will develop an audit tool to monitor and ensure all residents receiving anti-psychotic medications have the adequate [DIAGNOSES REDACTED]. This audit will be conducted weekly for four weeks with a target threshold of 90%. Once this is met, the audit will be conducted monthly for 6 months thereafter. The results will be reported to the monthly Quality Assurance and Performance Improvement Committee for review. The Assistant Director of Nursing (ADON)will be responsible for oversight of the audits and corrective measures. If a problem is identified, the Director of Nursing will be notified immediately for proper follow up.

Responsible Person: Assistant Director of Nursing (ADON)
Completion Date: (MONTH) 25, (YEAR) and ongoing

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 1 staff member (certified nurse aide (CNA) #3) observed for mask use, the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection. Specifically, CNA #3 was observed wearing her influenza (flu) mask incorrectly in resident areas and when in direct contact with residents. Findings include: The flu immunization consent form dated 12/19/2016 documented CNA #3 refused to receive the flu vaccine. The Declination of Influenza Vaccination form dated 12/19/2016 documented CNA #3 understood the risks of not receiving the vaccine, and she would be required to wear a surgical mask in resident areas during flu season. The employee flu refusal roster updated 4/3/2017 documented CNA #3 did not receive the flu vaccine. On 4/5/2017, CNA #3 was observed: - At 3:50 PM, in the unit dining room with her mask under her chin and not covering her nose and mouth while talking directly to 2 residents. - From 3:55 PM until 4:10 PM, she walked into the kitchenette and dining room with her flu mask below her nose, passed drinks to residents, and at times pulled her mask below her mouth while talking to residents. - At 4:12 PM, she was in the dining room with her nose uncovered, talking 2 feet away from a male resident. - At 4:20 PM, she was in the kitchenette with her nose and mouth uncovered and her mask down around her chin area. - At 4:25 PM, she exited the kitchenette, approached a resident in the dining room and began talking to him with her mask around her chin area and her nose and mouth uncovered. When interviewed on 4/5/2017 at 5:05 PM, CNA #3 had her mask on below her nose and kept pulling on the mask. She stated she was sick, and the mask was bothering her. During the interview, the CNA sniffled continuously. She stated if an employee did not receive the flu vaccine, they were identified by an orange sticker on their identification badge, and had to wear the mask with their mouth and nose covered while in resident areas during flu season. When interviewed on 4/10/2017 at 1:35 PM, the Director of Nursing (DON) stated employees that did not receive the annual flu vaccine were required to sign a declination, were educated on the proper wear of the mask, and had to wear the mask with their nose and mouth covered while in resident areas during flu season. She stated Supervisors checked every shift to ensure non-vaccinated employees were wearing the mask properly. 10NYCRR 415.19(b)(2)

Plan of Correction: ApprovedMay 1, 2017

F441 Infection Control, Prevent Spread, Linens

Immediate Corrective Actions:
CNA #3 received the influenza vaccine and no longer is required to wear an influenza mask.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. All staff who did not receive the influenza vaccine will be educated regarding properly wearing the influenza mask when in resident areas.

Systematic Changes:
All staff will be educated on the facility?s influenza vaccination policy which includes properly wearing the influenza mask so that the mask fully covers the nose and mouth. Those staff that refuse the influenza vaccine will be required to demonstrate competency related to properly wearing the influenza mask.

QA Monitoring:
The facility will develop an audit tool to monitor and ensure staff that do not receive the influenza vaccine will properly wear the influenza mask in resident areas. Randomized audits will be conducted by the Infection Control Nurse as well as nurse supervisors and be completed weekly for four weeks and then monthly thereafter. The results will be reported to the monthly Quality Assurance and Performance Improvement Committee for review. The Infection Control Nurse will be responsible for oversight of the audits and corrective measures. If a problem is identified, the Director of Nursing will be notified immediately for proper follow up.

Responsible Person: Infection Control Nurse
Completion Date: (MONTH) 25, (YEAR) and ongoing

FF10 483.10(e)(1), 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms. (a) The facility must- (1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident?s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification and abbreviated surveys (NY 736), it was determined the facility did not ensure 1 of 3 residents (Resident #6) reviewed for restraints was free from physical restraints not required to treat medical symptoms. Specifically, Resident #6 had a seatbelt that was not released as ordered. Findings include: Resident #6 was admitted to the facility 5/6/2011, re-admitted [DATE], and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She did not ambulate, and required extensive assistance of 2 for toileting and transferring. The resident had a trunk restraint (for main body, such as vest/waist or belt), and had 2 falls with no injuries during the assessment period. The physician order [REDACTED]. The fall risk assessment dated [DATE] documented the resident was at high risk for falls. The restraint assessment dated [DATE] documented the resident had a seatbelt restraint due to multiple falls related to unassisted transfers. The resident was unable to remove the seatbelt and did not have the cognitive ability to release it on her own. The comprehensive care plan (CCP) updated 3/27/2017 documented the resident had a history of [REDACTED]. On 4/5/2017 at 1:15 PM, the resident was observed sitting at the dining room table with food in front of her. Her seat belt restraint was attached. The 4/5/2017 restraint release form documented at 12:01 PM and 1:27 PM that the restraint was not released, and there was no documentation it was released during that time. The form documented the restraint was released at 9:53 AM and then again at 4:43 PM. On 4/6/2017 at 9:40 AM and 1:05 PM, the resident was observed to be sitting in her wheelchair at the dining room table with her seat belt attached. She had her meal in front of her and was eating. The 4/6/2017 restraint release form documented the restraint was released at 7:59 AM (late entry), 9:59 AM (late entry), 11:41 AM, 1:38 PM, and 7:38 PM. When interviewed on 4/10/2017 at 11:00 AM, certified nurse aide (CNA) #1 stated the resident had a seat belt restraint that was to be released every 2 hours and for toileting, care, and meals. She stated care instructions and signing for restraint release were in the Kiosk (electronic chart). When interviewed on 4/10/2017 at 10:45 AM, the registered nurse (RN) Manager #2 stated restraint use and release were on the care instructions, and she expected staff to release it as ordered every 2 hours and for meals, toileting, and care. She was not aware the restraint had not been released at meals. 10NYCRR 415.4(a)(2-7)

Plan of Correction: ApprovedMay 22, 2017

F221 Right To Be Free From Physical Restraints

Immediate Corrective Actions:
Resident #6 was evaluated by nursing staff to make sure there were no ill effects of not having the seatbelt released per the order with none noted. Resident #6 seatbelt restraint is being released every two hours per order. Resident #6 is currently on therapy program working to possibly discontinue the seatbelt restraint.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents with restraints as having the potential to be affected. All residents with physical restraints were reviewed to make sure their restraints were being released every two hours per the order and for meals, hygiene, toileting and other care. No issues noted.

Systematic Changes:
All residents with restraints will be audited by licensed nursing staff to ensure physical restraints are being released every two hours, especially during meal times. All nursing staff to be in-serviced on the facility?s policy for restraints, specifically releasing the restraint every two hours per the order and documenting this in the residents plan of care. Therapy will continue to work with residents with physical restraints to ensure the facility is using the least restrictive restraint and evaluate the need for the restraint on an ongoing basis.

QA Monitoring:
The facility will develop an audit tool to monitor and ensure all residents with physical restraints are released every two hours. This audit will be conducted weekly for four weeks with a target threshold of 90%. Once this is met, the audit will be conducted monthly for 6 months thereafter. Audits will be completed by licensed nursing staff for each resident with a physical restraint. The results will be reported to the monthly Quality Assurance and Performance Improvement Committee for review. The Assistant Director of Nursing (ADON) will be responsible for oversight of the audits and corrective measures. If a problem is identified, the Director of Nursing will be notified immediately for proper follow up.

Responsible Person: Assistant Director of Nursing (ADON)
Completion Date: (MONTH) 25, (YEAR) and ongoing

Standard Life Safety Code Citations

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the locks for 4 of 5 security locking egress doors was in accordance with National Fire Protection Association (NFPA 101) 7.2.1.5. Specifically, all four exit gates on the State Street security fence had key locks on the outside of the fence. Findings include: On 4/5/2017 at 3:23 PM, a surveyor followed an exterior smoker's area exit to the State Street security fence gate. The gate had a broken key lock on the outside of the exit passageway, and was secured shut with zip ties. During an interview on 4/5/2017 at 3:30 PM, the Director of Maintenance stated all the exit gates along the State Street security fence had a key lock on the outside of the exit passageway. Also, he stated the smoker's area exit passageway security gate had been broken for at least two years, since he was hired. On 4/5/2017 at 7:15 PM, a surveyor observed the gate next to the zip-tied State Street security fence gate had a key lock installed on the outside of the gate. During observation and concurrent interview on 4/5/2017 at 7:15 PM, the Director of Maintenance stated the gate exit secured with zip ties could be cut open if the door needed to be used in an emergency situation. He stated during the night shift, two staff had keys - the maintenance person and the security guard. He also stated that to unlock the three working gate key locks, staff would reach through the fence with a key and unlock the gate. He stated all four of these exit gates could be quickly opened in case of an emergency. On 4/10/2017 at 8:45 AM, the Administrator told a surveyor the four exit gate locks, on the State Street security fence, were now installed on the inside of the fence within the path of egress. 2012 NFPA 101: 19.2.2.2., 7.2.1.5 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 1, 2017

K222 NFPA 101 Egress Doors

Immediate Corrective Actions:
All locks on the security fence gates were moved and installed to the inside of the fence within the path of egress. The zip tie on the security fence was removed and a key lock was installed.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. All outside security egress exits were inspected to make sure the locking mechanisms were on the inside of the fence within the path of egress. No other issues were identified.

Systematic Changes:
Maintenance Director or designated maintenance worker will inspect all security egress doors on a weekly basis to ensure the locking mechanisms are working properly and installed within the path of egress.

QA Monitoring:
The Director of Maintenance will monitor and audit that all security egress doors are working properly. The Maintenance Director will report monthly at the Quality Assurance (QA) Committee meeting any identified issues with the egress doors.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 25, (YEAR) and ongoing

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not develop maintenance policies and provide records of all testing and repairs of all patient-care electrical equipment in accordance with National Fire Protection Agency (NFPA) 99 for resident-owned equipment (hair dryers). Specifically, the facility did not have maintenance policies for hair dryers, and maintenance/safety inspections were not documented. Finding include: On 4/5/2017 at 10:40 AM, a surveyor in room [ROOM NUMBER] observed a resident-owned hair dryer under a pile of clothes. The hair dryer was plugged in at the time. When interviewed on 4/7/2017 at 2:09 PM, the Director of Maintenance stated he was not aware that resident equipment needed to be continuously maintained, and the current maintenance of resident equipment was not being documented. When interviewed on 4/7/2017 at 4:06 PM, the Administrator stated he was under the impression the maintenance staff inspected the resident equipment and documented the equipment so it could be tracked. Review on 4/10/2017 of the Daily Maintenance Procedure, last revised 7/2015, revealed a section titled Outside Equipment. This section stated Maintenance will keep an ongoing list of equipment inspected for reference. Although the facility had a policy for resident equipment, as stated by the Administrator, the policy did not include specific equipment testing intervals as required in NFPA 99. On 4/10/2017 at 9:30 AM, a surveyor in room [ROOM NUMBER] observed a resident-owned hair dryer on the floor under a chair. The hair dryer was plugged in at the time. When interviewed on 4/10/2017 at 10:54 AM, the Director of Maintenance stated he was not aware of the Outside Equipment section within the Daily Maintenance Procedure policy, and was not aware of the hair dryer located in room [ROOM NUMBER]. 2012 NFPA 99: 10.5.2.1, 10.5.6 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedMay 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K921 NFPA 101 Electrical Equipment ? Testing and Maintenance

Immediate Corrective Actions:
Resident?s hair dryer in room [ROOM NUMBER] was inspected, tagged and documented in the ?Electrical Equipment? log by the Maintenance Director. The Maintenance Director was in-serviced regarding the facility?s policy for inspecting and logging resident electrical equipment.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. The maintenance department has inspected resident electrical equipment and documented this information in the facility?s ?Electrical Equipment? log.

Systematic Changes:
The facility has reviewed and revised its policy for resident electrical equipment testing. Resident electrical equipment will be inspected and documented in the facility?s ?Electrical Equipment? log. This equipment will be monitored on at least a quarterly basis unless otherwise noted in the manufacturer recommendations.

QA Monitoring:
The Director of Maintenance will conduct weekly environmental rounds on the units to spot check and ensure resident electrical equipment is documented in the facility?s ?Electrical Equipment? log. The Director of Maintenance will audit this log to ensure quarterly monitoring is being completed on the equipment. Audits will be completed weekly by the Director of Maintenance for 4 weeks then monthly thereafter. The Director of Maintenance will report the findings at the monthly Quality Assurance (QA) Committee meeting for review and follow up.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 25, (YEAR) and ongoing

K307 NFPA 101:FIRE DRILLS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure that fire drills were held at unexpected times and under varying conditions on 1 of 3 shifts (second shift) in (YEAR) and (YEAR), as required. Specifically, the second shift fire drills for all four quarters of (YEAR), and first quarter of (YEAR), were not conducted at varying times. Findings include: Review on 4/5/2017 at 4:00 PM of fire drill reports revealed that second shift fire drills were conducted on the following dates and times: - 2/23/2016 at 3:53 PM; - 4/26/2016 at 3:35 PM; - 9/22/2016 at 3:40 PM; - 11/23/2016 at 3:56 PM; and - 1/17/2017 at 3:36 PM. Review of the fire drill reports did not show documentation that drills were conducted at varying times during each shift. When interviewed on 3/30/2017 at 4:15 PM, the Director of Maintenance stated he was not aware the second shift fire drills were required to be done at varying times. He stated he was aware that fire drills were to be done on different units on different shifts. 2012 NFPA 101: 19.7.1 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedMay 1, 2017

K712 NFPA 101 Fire Drills

Immediate Corrective Actions:
Education completed with Director of Maintenance regarding conducting fire drills at unexpected times on each shift (day, evening and night) at least once per quarter.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected.

Systematic Changes:
A monthly fire drill schedule has been developed to track and ensure that fire drills are conducted at unexpected times on each shift (day, evening and night) at least once per quarter.

QA Monitoring:
To ensure continued compliance, the Director of Maintenance will report the results of the actual and simulated drills at the monthly Quality Assurance (QA) Committee meeting for review and follow up.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 25, (YEAR) and ongoing

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 10, 2017
Corrected date: May 25, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure the building's automatic sprinkler system was tested in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems, for 1 of 1 buildings. Specifically, the (YEAR) fourth quarter sprinkler report was not completed, and the ten year testing/replacement for the walk-in cooler and walk-in freezer dry pendant sprinkler heads was not completed. Findings include: 1) Quarterly Sprinkler Reports During review on 4/5/2017 at 4:45 PM of the quarterly sprinkler inspection reports provided by the facility, a surveyor observed the (YEAR) fourth quarter sprinkler report was missing. The surveyor noted quarterly sprinkler reports were completed on 2/1/2016, 6/10/2016, 8/1/2016, and 1/17/2017. The facility could not provide any documentation during the survey that the (YEAR) fourth quarter sprinkler report was completed. During an interview on 4/5/2017 at 4:45 PM, the Director of Maintenance stated he was not aware the (YEAR) fourth quarter sprinkler report was missing. 2) [AGE] year Dry Pendant Testing/Replacement On 4/5/2017 at 6:05 PM, a surveyor observed: - the dry pendant sprinkler head in the walk-in cooler was date-stamped 2003, and - the dry pendant sprinkler head in the walk-in freezer was date-stamped 1982. During review on 4/5/2017 at 4:45 PM of the quarterly sprinkler inspection reports provided by the facility, a surveyor observed the dry pendant sprinkler heads located in the walk-in cooler and walk-in freezer were not identified. The facility could not provide any documentation the [AGE] year testing/replacement was completed for the above-mentioned sprinkler heads. During an interview on 4/5/2017 at 6:05 PM, the Director of Maintenance stated he was not aware the dry pendant sprinkler heads located in the walk-in cooler and walk-in freezer were required to be tested /replaced every [AGE] years. He did not know the last time these two sprinkler heads were tested /replaced. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 1, 2017

K353 NFPA 101 Sprinkler System ? Maintenance and Testing

Immediate Corrective Actions:
The (YEAR) fourth quarter sprinkler report was completed and documentation was provided to the facility from its vendor. Replacement dry pendant sprinklers were ordered for both the walk-in cooler and walk-in freezer.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. A facility wide inspection of all sprinklers was completed by the maintenance department to ensure testing was complete and documentation present with no issues identified.

Systematic Changes:
Maintenance Director will ensure quarterly tests are completed by an outside vendor on all facility sprinklers and confirm the documentation reports are present.

QA Monitoring:
The Director of Maintenance will monitor the documentation and completion of quarterly sprinkler testing. The Maintenance Director will report monthly at the Quality Assurance (QA) Committee meeting that the facility is up to date and in compliance with sprinkler testing.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 25, (YEAR) and ongoing

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 10, 2017
Corrected date: May 25, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined 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 one isolated area (fourth floor phone room down to second floor phone room). Specifically, the floors in these rooms had unsealed penetrations. Findings include: On 4/5/2017 at 12:50 PM, a surveyor observed the fourth floor phone room floor had an unsealed conduit with three data wires passing through to the third floor phone room below. Further review revealed these data wires also passed through the third floor phone room into the second floor phone room and were not sealed. During an interview on 4/5/2017 at 1:00 PM, the Director of Maintenance stated while he was on vacation last week, new data wires were installed in the phone rooms. He stated he had not checked to ensure the unsealed vertical penetrations were sealed. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMay 1, 2017

K311 NFPA 101 Vertical Openings - Enclosure

Immediate Corrective Actions:
Unsealed vertical openings from the fourth floor phone room down to the third floor phone room and second floor phone room were all sealed with two-hour fire rated caulk.

Identification of Other Residents Potentially Affected:
The facility recognizes all residents as having the potential to be affected. A facility wide inspection was completed by the maintenance department. Any other openings identified were sealed with two-hour fire rated caulk.

Systematic Changes:
Maintenance Director or designated maintenance worker will inspect all construction and work of outside vendors on a daily basis throughout the course of the project to ensure there is no unsealed openings. Any identified unsealed openings will be sealed with two-hour fire rated caulk.

QA Monitoring:
The Director of Maintenance will monitor construction or any other outside vendor work preformed in the facility to ensure there is no unsealed openings. The Maintenance Director will report monthly at the Quality Assurance (QA) Committee meeting any work that was completed by outside vendors or companies and that the work was inspected thoroughly after the vendors were finished working.

Responsible Person: Director of Maintenance
Completion Date: (MONTH) 25, (YEAR) and ongoing