Meadow Park Rehabilitation and Health Care Center LLC
October 19, 2016 Certification Survey

Standard Health Citations

FF09 483.75:EFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING

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

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: October 19, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility failed to ensure that the residents' environment remained free of accident hazards. Specifically, the facility failed to protect all of the (135) residents from the potential [MEDICAL CONDITION] scalding related to excessive hot water temperatures from the facility's domestic hot water system. This deficient practice was evident at the resident sinks and common shower rooms on all 3 of 3 resident units. (See F323) This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to Resident Health and Safety. The findings are: During the environmental and unit tours conducted on 10/12/16 between 8:30 AM and 10:50 AM, the following was noted: During the phase 1 tour conducted on 10/12/16 between 8:30- 10:35 AM, the sinks in the following resident rooms: #103, 105, 106, 109, 111, 112, 114, 115, 117, 203, 204, 206, 208, 209, 217, 218, & 219 were observed with extremely hot water. The surveyors tested the hot water by running the water over their hands, after approximately 25-30 seconds the hot water became so hot that the surveyors had to remove their hands. The Sanitarian measured the water temperature using a digital stem- type thermometer. Hot water readings were noted to range from 127 to 137 degrees Fahrenheit (F) at sinks in the residents' bathrooms and common unit shower rooms. Examples of hot water temperatures taken at the hand washing sinks at various locations included but were not limited to the following: 1st floor: Common Unit Shower room [ROOM NUMBER]F Resident room # 103 - 129F Resident room # 114 - 129F 2nd floor: Common Unit Shower room [ROOM NUMBER]F Resident room # 201 - 134F Resident room # 117 - 131F 3rd floor: Common Unit Shower room [ROOM NUMBER]F Resident room # 306 - 134F Resident room # 317 - 136F The maintenance director was advised of the concerns and stated that the system was recently changed over from summer to winter phase on 10/11/16 (the evening before) and that temperature logs were taken daily but were not taken on this day (10/12/16) because the sanitarians were touring the facility with the maintenance staff. He suggested that the increased temperatures may have been the result of the changeover. An inspection of the mixing valve and temperature gauge at the valve was requested and granted. The mixing valve temperature at that time, 10:45 AM was 122F. The temperature gauge was a mechanical gauge situated above the mixing valve. The maintenance director stated that the temperatures are manually adjusted based on temperature reading at the gauge with the expectation of some heat loss in the water system after the valve and gauge areas in the boiler room. The maintenance director further stated that in the summer a small boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. In the winter a large boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. Both systems shared the same mixing valve and temperature gauge. The policy and procedure on Heating System and Water Temperature, dated (MONTH) (YEAR) was reviewed. It documented that it was the policy of the facility to maintain a safe and consistent source of hot water for both heating and domestic use along with maintenance of a temperature log. It documented the presence of one electronically controlled mixing valve that supplies both the kitchen and resident areas with set points at 110F and 120F. It notes that isolation and bypass valves will assure safe temperatures in the event of a mixing valve failure. On 10/12/16 at approximately 11:30 AM, the Director of Building Services was interviewed. He stated that he was in charge of overseeing the day to day maintenance activities. He further stated that the maintenance department is responsible for checking the domestic hot water temperatures on a daily basis to ensure safe hot water temperatures at the resident hand washing sinks. Daily maintenance check logs for the past month were reviewed with the most recent one, dated 10/11/16 documenting a temperature of 120F at 7:00 AM at an undisclosed location in the building. The Director of Building Services stated that no concerns were apparent at that time despite the temperature being at the upper threshold of acceptable limits. He stated that temperatures are typically taken in the morning but were not taken on this day (10/12/16) because the survey had started. He stated that the heating system had just been switched from the summer to winter cycle which involved transitioning hot water production from a small boiler unit to a significantly larger one with the capacity to heat the water and building at the same time. He stated that nursing and other department heads are generally notified of the changeover from summer to winter boiler cycles during the morning report the day after the transition. He added that nursing is immediately notified if the hot water monitoring reveals temperatures above 120F. Temperatures were taken again at 2:00 PM on the 3rd. floor in rooms 306 at 125F and room [ROOM NUMBER] at 122F.The mixing valve gauge reading (boiler room in the basement) was checked again at 2:10 PM with a temperature of 120F shown (5 degrees lower than sink outlet temperature shown 3 floors above in room [ROOM NUMBER] which was 125F) supportive of a concern for defective boiler equipment and inadequate monitoring of water temperatures in the building. The plumber was called by the facility and arrived in the late afternoon. The plumber stated that the temperature gauge was fried and that it would have to be replaced. He stated that the system was being reverted back to the summer setting (smaller boiler) until the repairs could be made the following day. On 10/12/16 at 5 PM the Director of Nursing was interviewed. She stated that she was the Administrator on Duty in the absence of the Administrator due to the Holiday. She stated that she was not aware of the problem stated that she should have been made aware. She stated that she became aware of the problem today when the director of building services brought the matter to her attention. She stated that her role was to ensure that all of the residents are safe. She checks with nurses and supervisors regularly. She states that she is a regular member of the QA team and that a matter like this one would be discussed at the regular QA meetings held quarterly. On 10/12/16 from 1:00 PM - 3:00 PM Certified Nursing Aides from the 1st, 2nd & 3rd floors were interviewed. Certified Nurse Aides # 1-8 denied being notified of any water temperature issue or a transition from summer to winter heating cycle. All the CNAs interviewed stated that they check the water with their hands before exposing their residents to it. CNA #7 stated that she did notice the water temperature to be hotter today than yesterday but did not notify anyone. On 10/12/16 from 1:00 PM - 3:00 PM all licensed nursing staff from all units were interviewed. The Licensed Practical Nurses #1-6 (LPN) and the Registered Nurse #1 all denied being notified of any water temperature issue, or informed of the transition from summer to winter heating cycle. On 10/12/16 an invoice from the plumber was obtained which documented that the domestic hot water temperature was too high at 130F with plans to replace the temperature gauge on the unit. Hot water production was diverted to the smaller heating unit at 115F. Hourly monitoring of temperatures by the facility was conducted beginning at 7:00 PM on 10/12/16 with logs provided to the survey team through 10/17/16 when the immediate jeopardy was removed. Plans to remove the immediacy which included revisions to the policy and procedure on the Heating System and hot water temperature were submitted to the on-site survey team between the hours of 2:00 PM and 8:15 PM on 10/12/16. At 8:15 PM, a final revision to the plan to remove the immediacy was submitted and accepted by the on-site team. The plans included hourly monitoring of water temperatures to resident areas and diversion of the hot water system to the smaller heating unit with a setting of 115F. On 10/13/16 an invoice from the plumber was obtained which documented replacement of 2 defective components of the boiler. A defective temperature gauge and cross tee was replaced. On 10/13/16 at 11:45 AM, the Administrator was interviewed he stated that he is a member of the Quality Assurance Team. He stated that he was not aware of any hot water issue before last night (10/12/16 at 7:45 PM) when he was called and informed by the facility. When asked if he should have been aware of the problem, he responded, no. He stated that his role is to ensure the safety and wellbeing of the residents and that the QA practice is to bring matters of concern from the morning report and 24 hour report to the quality assurance committee when appropriate. The Administrator stated that he was not aware of the hot water issue or of the fact that they were changing over to the winter cycle from the summer cycle on the boiler system. He stated that the following morning the matter would have come to his attention during the morning report. He stated that he knew that a transition was to occur soon but was unaware of exactly when it was scheduled to happen. He added that the department heads would have been notified the next morning during the regular morning report. Monitoring of the facility continued through the weekend with temperatures taken on all floors and staff interviewed to verify provision of in-service by the facility to its staff. The Immediate Jeopardy was removed on 10/17/2016. The team exited the facility on 10/19/2016. Prior to the team's exit the following concerns were addressed to remove the immediate jeopardy status: 1) Repairs were made to the boiler which included replacement of the temperature gauge and cross tee. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas on an hourly basis. Temperatures were monitored daily by the survey team as well and were within acceptable range since the time that immediacy was removed. 3) Evidence of 97% completion of in-service to staff regarding revisions to the policy and procedure on the Heating System. 415.26

Plan of Correction: ApprovedNovember 4, 2016

Immediate Corrective Actions:
1. The Facility Administrator has contracted with consultants from West and Restivo Quality Consulting, LLC to provide the Directed Plan as well as the Directed Inservice for F323 and F490 as per CMS2567.
2. The Facility held a special review Quality Assurance Meeting on 11/2/16 to discuss the deficiencies as cited under F323 and F490. A copy of the agenda and attendance will be filed for reference and validation.
3. The Administrator respectfully reaffirms his commitment to the Facility including the direction of the Facilities Policies, Procedures and most importantly resident safety.
4. F323: The Administrator will oversee all plans of correction and implementation for F323 concerning hot water temperature.
5. The Administrator will attend morning meetings and QA meetings to ensure safe water temperature and consistent compliance.
Identification of Other Residents:
1. F323: The Administrator contracted with the plumber and repairs were made to the boiler which included replacement of the temperature gauge and cross tee pipe.
2. The Administrator monitored the water temperature logs for acceptable water temperatures post boiler repairs to ensure safe water temps.
3. Water temperatures remain in safe temperature zone of 90F to 120F.
Systemic Changes:
1. The Administrator will attend all inservice education programs relative to the P(NAME), including hot water temperatures.
2. The Administrator will receive a One to One Inservice from West & Restivo Quality Consulting, LLC consultant relative to the role of the Administrator and the Directed Plan. The Administrator will sign and retain the Lesson Plan for reference and validation.
3. The Administrator will attend the Morning Meetings, as possible and direct staff accordingly for environmental issues requiring follow up.
4. The Administrator has set up monthly QA meetings to track the implementation of the Plan of Corrections and troubleshoot any quality issues identified. Attendance and Agenda of all QA Meetings will be filed for reference and validation in the P(NAME) Book.
QA Monitoring:
1. The Administrator will review all audit tools completed with negative findings relative to Hot Water temperatures as well as all F tags cited.
2. The Administrator will ensure follow up corrective actions with the appropriate staff as indicated by audit findings.
3. The Administrator will review audit tools, as completed, weekly and discuss outcome with the DNS, Medical Director and Director of Building Services and at quarterly QA Meetings for ongoing compliance.
Responsible Party:
The Administrator will be responsible for attaining and maintaining compliance with this F Tag.

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

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

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: October 19, 2016
Corrected date: November 7, 2016

Citation Details

Based on observation, record review, and staff interviews during the recertification survey, the facility failed to ensure that the residents' environment remained free of accident hazards. Specifically, the facility failed to protect all of the (135) residents from the potential for burns and scalding related to excessive hot water temperatures from the facility's domestic hot water system. This deficient practice was evident at the resident sinks and common shower rooms on all 3 of 3 resident units. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. The findings are: During the environmental and unit tours conducted on 10/12/16 between 8:30 AM and 10:50 AM, the following was noted: During the phase 1 tour conducted on 10/12/16 between 8:30- 10:35 AM, the water from the sinks in the following resident rooms: #103, 105, 106, 109, 111, 112, 114, 115, 117, 203, 204, 206, 208, 209, 217, 218, & 219 were observed by touch to be extremely hot. The surveyors tested the hot water by running the water over their hands, after approximately 25-30 seconds the hot water became so hot that the surveyors had to remove their hands. The Sanitarian measured the water temperature using a digital stem- type thermometer. Hot water readings were noted to range from 127 to 137 degrees Fahrenheit (F) at sinks in the residents' bathrooms and common unit shower rooms. The acceptable water temperature range is between 90F and 120F. Examples of hot water temperatures taken at the hand washing sinks at various locations included but were not limited to the following: 1st floor: Common Unit Shower Room 133F Resident room # 103 - 129F Resident room # 114 - 129F 2nd floor: Common Unit Shower Room 137F Resident room # 201 - 134F Resident room # 117 - 131F 3rd floor: Common Unit Shower Room 127F Resident room # 306 - 134F Resident room # 317 - 136F The Maintenance Director was advised of the concerns and stated that on 10/11/16 (the evening before) the system was recently changed over from the summer to the winter phase. The Maintenance temperature logs were taken daily but were not taken on this day (10/12/16), because the sanitarians were touring the facility with the maintenance staff. He suggested that the increased temperatures may have been the result of the changeover from the summer to winter boiler. An inspection of the mixing valve and temperature gauge at the valve was requested and granted. The mixing valve temperature at that time, 10:45 AM was 122F. The temperature gauge was a mechanical gauge situated above the mixing valve. The maintenance director stated that the temperatures are manually adjusted based on temperature reading at the gauge with the expectation of some heat loss in the water system after the valve and gauge areas in the boiler room. The maintenance director further stated that in the summer a small boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. In the winter a large boiler is used to heat the hot water system leading to the mixing valve, temperature gauge and building. Both systems shared the same mixing valve and temperature gauge. The policy and procedure on Heating System and Water Temperature, dated (MONTH) (YEAR) was reviewed. It documented that it was the policy of the facility to maintain a safe and consistent source of hot water for both heating and domestic use along with maintenance of a temperature log. It documented the presence of one electronically controlled mixing valve that supplies both the kitchen and resident areas with set points at 110F and 120F. It notes that isolation and bypass valves will assure safe temperatures in the event of a mixing valve failure. On 10/12/16 at approximately 11:30 AM, the Director of Building Services was interviewed. He stated that he was in charge of overseeing the day to day maintenance activities. He further stated that the maintenance department is responsible for checking the domestic hot water temperatures on a daily basis to ensure safe hot water temperatures at the resident hand washing sinks. Daily maintenance check logs for the past month were reviewed with the most recent one, dated 10/11/16 documenting a temperature of 120F at 7:00 AM at an undisclosed location in the building. The Director of Building Services stated that no concerns were apparent at that time despite the temperature being at the upper threshold of acceptable limits. He stated that temperatures are typically taken in the morning but were not taken on this day (10/12/16) because the survey had started. He stated that the heating system had just been switched from the summer to winter cycle which involved transitioning hot water production from a small boiler unit to a significantly larger one with the capacity to heat the water and building at the same time. Temperatures were taken again at 2:00 PM on the 3rd. floor in rooms 306 and 305, the temperatures were measured 125F and122F respectively. The mixing valve gauge (boiler room in the basement) reading was checked again at 2:10 PM with a temperature of 120F shown (5 degrees lower than sink outlet temperature shown 3 floors above in room 306 which was 125F). On 10/12/16 from 1:00 PM - 3:00 PM Certified Nursing Aides from the 1st, 2nd & 3rd floors were interviewed. Certified Nurse Aides # 1-8 denied being notified of any water temperature issue or a transition from summer to winter heating cycle. All the CNAs interviewed stated that they check the water with their hands before exposing their residents to it. CNA #7 stated that she did notice the water temperature to be hotter today than yesterday but did not notify anyone. On 10/12/16 from 1:00 PM - 3:00 PM all licensed nursing staff from all units were interviewed. The Licensed Practical Nurses #1-6 (LPN) and the Registered Nurse #1 all denied being notified of any water temperature issue, or informed of the transition from summer to winter heating cycle. The plumber was called by the facility and arrived in the late afternoon. The plumber stated that the temperature gauge was fried and that it would have to be replaced. He stated that the system was being reverted back to the summer setting (smaller boiler) until the repairs could be made the following day. On 10/12/16 at 5 PM the Director of Nursing was interviewed. She stated that she was the Administrator on Duty in the absence of the Administrator due to the Holiday. She stated that she was not aware of the problem, but stated that she should have been made aware. She stated that she became aware of the problem today when the director of building services brought the matter to her attention after the surveyor notified him. She stated that her role was to ensure that all of the residents are safe. She checks with nurses and supervisors regularly. She states that she is a regular member of the QA team and that a matter like this one would be discussed at the regular QA meetings held quarterly. She stated that no issues related to hot water were recently discussed the QA meetings she attended. On 10/12/16 an invoice from the plumber was obtained which documented that the domestic hot water temperature was too high at 130F (at the boiler) with plans to replace the temperature gauge on the unit. Hot water production was diverted to the smaller heating unit at 115F. The policy and procedure on Heating System and Water Temperature, dated (MONTH) (YEAR) was reviewed. It documented that it was the policy of the facility to maintain a safe and consistent source of hot water for both heating and domestic use along with maintenance of a temperature log. It documented the presence of one electronically controlled mixing valve that supplies both the kitchen and resident areas with set points at 110F and 120F. It notes that isolation and bypass valves will assure safe temperatures in the event of a mixing valve failure. Plans to remove the immediacy which included revisions to the policy and procedure on the Heating System and hot water temperature were submitted to the on-site survey team between the hours of 2:00 PM and 8:15 PM on 10/12/16. At 8:15 PM, a final revision to the plan to remove the immediacy was submitted and accepted by the on-site team. The plans included hourly monitoring of water temperatures to resident areas and diversion of the hot water system to the smaller heating unit with a setting of 115F. On 10/13/16 an invoice from the plumber was obtained which documented replacement of 2 defective components of the boiler. A defective temperature gauge and cross tee pipe was replaced. The Administrator stated that he was not aware of the hot water issue or of the fact that they were changing over to the winter cycle from the summer cycle on the boiler system. He stated that the following morning the matter would have come to his attention during the morning report. He stated that the Director of building services would have notified him as well as the Director of Nursing during the morning meeting. He denied any issues during last year's transition from Winter to Summer cycle. Monitoring of the facility continued through the weekend with temperatures taken on all floors and staff interviewed to verify provision of in-service by the facility to its staff. The Immediate Jeopardy was removed on 10/17/2016 following receipt of documentation which included staff sign in sheets to evidence 97% completion of in-service as well monitoring sheets to evidence of hourly temperature monitoring within acceptable ranges. The team exited the facility on 10/19/2016. Prior to the team's exit the following concerns were addressed to remove the immediate jeopardy status: 1) Repairs were made to the boiler which included replacement of the temperature gauge and cross tee pipe. 2) The maintenance staff tested the water temperatures in all resident rooms and common areas on an hourly basis. Temperatures were monitored daily by the survey team as well and were within acceptable range since the time that IJ was removed. 3) Evidence of 97% completion of in-service to staff regarding revisions to the policy and procedure on the Heating System. 4) Hourly monitoring of temperatures by the facility were conducted beginning at 7:00 PM on 10/12/16 with logs provided to the survey team through 10/17/16 when the immediate jeopardy was removed. Examples included: 10/12/16 97.1F-116F 10/13/16 95.4F-115.7F 10/14/16 97.3F-116.1F 10/15/16 100.5F-118F 10/16/16 100.3F-116.9F 10/17/16 98.9F-110.6F 415.12(h)(l)

Plan of Correction: ApprovedNovember 7, 2016

Immediate Corrective Action:
1.The Director of Building Services immediately contacted the facility contracted plumber and repairs were made to the boiler which included replacement of the temperature gauge and cross tee pipe.
2. The Director of Building Services returned the boiler setting to the summer boiler until boiler repairs were completed.
3. The Maintenance staff tested the water temperatures in random resident rooms and common areas on an hourly basis for 6 days after boiler repairs were made.
4. The Director of Building Services set-up a Water Temperature Log. Water temperatures and the locations have been documented on the Log.
5. The Inservice Director provided inservice to all staff on the facility policy regarding hot water temperatures, and to notify the Director of Building Services/Director of Nursing if water is identified to be too hot.
Identification of Other Residents:
1. The Facility respectfully states that all residents were potentially affected; however no residents were harmed.
2. The staff monitored the hot water temperatures hourly for acceptable water temperatures post boiler repairs to ensure safe water temps.
3. Water temperatures remain in safe temperature zone of 90F to 120F.
Systemic Changes:
1. The Facility Administrator has contracted with consultants from West and Restivo Quality Consulting, LLC to provide the Directed Plan as well as the Directed Inservice for F323 and F490 as per CMS2567.
2. The Director of Building Services, in conjunction with the Administrator, revised the facility policy on Monitoring of Hot Water System. Revisions include:
a. The facility?s water heating system will be inspected and tested as per manufacturer?s requirements on a daily basis.
b. Maintenance staff will test water temperatures daily, in a minimum of ten percent of randomly selected sinks/showers in resident areas.
c. Readings shall be entered into the appropriate log. Logs will be kept in the Maintenance Department office. The Director of Building Services is to be notified immediately of any abnormal readings.
d. Thermometers and gauges for measurement shall be calibrated biannually; all portable thermometers shall have temperature verified in ice water.
e. The Director of Building Services will send prior notification of seasonal boiler change to the Administrator, Director of Nursing and other department heads. Testing of water temperatures will increase to hourly for the first 6 hours after seasonal boiler change and then once a shift following the seasonal change over.
f. The Director of Building Services/Designee will investigate the cause of any abnormal readings.
g. The Director of Building Services will supervise any corrections made to the system and/or will call for repairs to the system, as needed.
h. When unacceptable water temperatures are identified, the Director of Building Services/Designee will notify the Administrator, Director of Nursing and/or Nursing Supervisor, as well as any other departments that are involved, to cease the use of water until correction is achieved.
i. The Director of Building Services/Designee will shut off the water to areas in which persons receiving services may have contact with hot water.
j. The Director of Building Services/Designee will also post signage at each nurses? station and at the main entrance notifying all staff, residents and visitors of the issue for awareness and safety.
k. The Director of Building Services will report all disruptions in service to the Safety Committee and to the Quality Assurance Committee.
3. A Lesson Plan has been developed by West and Restivo Quality Consultants, LLC in order to provide education to involved staff as per the Directed Inservice requirements.
a. Inservice Education will be provided to all staff by West & Restivo Quality Consulting, LLC Compliance Consultant on the Hot Water Monitoring revised policy, including but not limited to:
i. Regulatory Reference F323
ii. Scald Burns - Residents at Risk
iii. Definitions of Cutaneous Burns
iv. Corrective Measure
v. Ongoing Monitoring of Water Temperatures
b. A copy of the Lesson plan and attendance will be filed for reference and validation.
QA Monitoring
1. The Director of Building Services has developed an audit tool to monitor the function of the boiler, temperature gauge, and water temps.
2. Audits will be done daily by the Director of Building Services/Designee on a minimum of ten percent of randomly selected locations throughout the facility, including shower rooms, and resident bathrooms.
3. The Director of Building Services/designee will monitor the temperature gauges and on the mixing valve daily to ensure safe temperatures. Temperatures will be recorded on the Water Temperature Log Sheet for validation.
4. Temperatures found to be above the threshold will be reported to the Director of Building Services by the auditor for follow-up and corrective action.
5. Results of the daily audits will be reported to the Quality Assurance Committee quarterly, or via the daily morning report, as indicated for follow-up and corrective action.
Responsible Party:
The Director of Building Services will be responsible for attaining and maintaining compliance with this F Tag.

FF09 483.40(b):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDERS

REGULATION: The physician must review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; write, sign, and date progress notes at each visit; and sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observations during the recertification survey, the facility did not document a recommendation for medication to be initiated for a resident with a new [DIAGNOSES REDACTED]. Specifically, Resident # 174 had a consultation by the Neurologist with a plan that included to add a trial of [MEDICATION NAME] (an Anti-[MEDICAL CONDITION] Medication) to the resident's medication regime. There was no documented evidence in the medical record that the [MEDICATION NAME] had been added to the resident's medication regime as part of the plan as documented by the Neurologist. The finding is: Resident # 174 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident has a Brief Interview for Mental Status (BIMS) Score of 15, indicating that the resident is cognitively intact. The MDS documented that the resident required assistance of staff in all activities of daily living. A Neurology Consultation dated 9/24/16 documented that the resident was displaying Parkinsonian symptoms of examination which included decreased facial expression with rest tremors in the arms and legs. The Neurologist/Medical Doctor (MD) documented the Assessments/Plans to include [MEDICAL CONDITION] and a trial of [MEDICATION NAME] (an [MEDICAL CONDITION] drug). The Consultation documented that the resident's current medications included [MEDICATION NAME] CR 25-100 mg tablet Extended Release three times daily. A CCP dated 9/24/16 for Neurological Diseases/[MEDICAL CONDITION] documented that the resident's drug treatment and dosage adjustments were to be monitored. An update to the CCP documented that the resident was seen by the Neurologist but the recommendation for the [MEDICATION NAME] was not documented. The Registered Nurse (RN)/ Nursing Supervisor was interviewed on 10/17/2016 at 12:27 PM. The RN stated that there was no physician's order for Resident #174 for [MEDICATION NAME]. The RN stated that the Neurologist's Consultation was reviewed by the resident's attending Physician and that all the recommendations were completed except there was no order written for the [MEDICATION NAME]. The Neurologist/MD was interviewed on 10/17/2016 at 12:41 PM. The MD stated that the primary intention was to examine and clear the resident for upcoming surgery. The MD stated that the resident had notable tremors and the trial of [MEDICATION NAME] was documented in the plan to treat the [MEDICAL CONDITION]. The MD stated that if the [MEDICATION NAME] was listed with current medications on the Consultation form it may have been missed as a new recommendation. The Attending Physician/ MD was interviewed on 10/17/2016 at 12:44 PM. The MD stated that the [MEDICATION NAME] would be ordered as indicated for [MEDICAL CONDITION] for Resident # 174. An update to the CCP dated 10/17/16 documented that the order for [MEDICATION NAME] was clarified with the Neurologist and that the medication would be initiated by the Attending MD. 415.15(b)(2)(iii)

Plan of Correction: ApprovedNovember 4, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action:
1. The Attending Physician for Resident #174 reviewed the Neurologist Consultation and [MEDICATION NAME] was ordered on [DATE].
2. Resident #174 continues to receive [MEDICATION NAME] as ordered.
3. The Residents Plan of Care was reviewed and revised to ensure that the Neurologist recommendation for [MEDICATION NAME] was documented.
Identification of Other Residents:
1. The Medical Director, in conjunction with the Nurse Managers reviewed all medical consultations in the past 3 months to ensure that all physician recommendations were followed and/or addressed by the Attending Physician.
2. The List of all Residents in house that were seen by the Consulting Physicians were utilized by the DNS to do a Quality Assurance Chart Review to ensure that all medications listed on their consults are consistent with their current medication orders.
3. No other oversights or physician omissions were noted.
Systemic Changes
1. The Medical Director will inservice all attending physicians via memo, to ensure full review of medical consultations is done and recommendations for treatment are ordered and/or addressed.
2. Memo is maintained on file for reference and validation.
QA Monitoring
1. The Medical Director, in conjunction with Director of Nursing, developed an audit tool to ensure the attending physician addressed medical consultant recommendations.
2. Audits will be conducted by the Medical Director/Designee on all medical consultations completed over the next month, and then random audits will be conducted quarterly for the next year.
3. Audits with negative findings will have immediate corrective action by the Medical Director.
4. The Medical Director will present audit findings to the QA Committee quarterly for evaluation and follow up as needed.
Responsible Party:
The Medical Director will be responsible for attaining and maintaining compliance with this F Tag.

FF09 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not accurately evaluate and/or revise the resident's change in Urinary Continence status. This was evident for one of three residents reviewed for Urinary Incontinence in a total Stage 2 sample of 48 residents reviewed. Specifically, the Comprehensive Care Plan (CCP) for Urinary Continence did not reflect the resident's decline in Urinary Continence and was not updated with new goals and interventions to address the decline. The finding is: Resident # 57 has [DIAGNOSES REDACTED]. The resident's CCP for Elimination-Urinary Continence dated 6/14/16 documented that the resident was always Continent of Bladder. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating that the resident had severely impaired cognition. The MDS documented that the resident required extensive assist of one staff member for Toilet Use and that the resident was always continent of bladder. The Quarterly MDS assessment dated [DATE] documented that the resident was Occasionally Incontinent of Bladder. The CCP for Elimination was updated on 9/27/16. The CCP documented to continue the plan of care and did not reflect the resident decline in continence or revisions in the goals and interventions. The MDS Coordinator/Registered Nurse (RN) was interviewed on 10/17/2016 at 2:18 PM. The RN stated that the CCP's are developed and/or updated by either the unit RNs or the MDS RNs. The RN stated that the CCP should have reflected the decline in the resident's continence. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedNovember 4, 2016

Disclaimer: The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department?s directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This should not be construed as either a waiver of the Facilities right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of any wrong doing or an admission of past or ongoing violations of Federal and State Regulations.

Immediate Corrective Action
1. Resident # 57 was discharged from the facility on 9/26/16.
2. The RN who is responsible for developing and implementing CCP for Urinary Incontinence for Resident # 57 is no longer employed by the Facility.
3. On 11/2/16, the DNS held a CCP educational meeting with the CCP team regarding the importance of assessing residents Plan of Care for significant change including deterioration in Urinary Incontinence.
4. Educational meeting attendance is filed for reference and validation.
Identification of Other Residents
1. The DNS and MDS Coordinator compiled a list of all residents with Urinary Incontinence at all levels.
2. This list was used to do comprehensive medical record reviews to ensure that Bladder Assessments were completed as well as appropriate Progress Notes and Care Plans/CNA plans for any resident with a change in condition related to Urinary Incontinence.
3. Any Resident reviewed found with compliance issues will have corrective actions implemented by the RN Nurse Mangers as directed.
4. The DNS will maintain a list of any medical records that needed correction as identified by the review.
Systemic Changes
1. The DNS reviewed the Policy on Continence Management as well as the Policy for Care Plan Revisions.
2. The Policy has been revised to reflect a change in tracking resident ?s level of incontinence, as follows:
a. The MDS Coordinator will maintain a list of all resident?s level of Urinary Continence/incontinence.
b. The MDS Coordinator will compare level of incontinence coded on subsequent MDS with the Urinary Incontinence list.
c. Any changes in incontinence level identified will have a review conducted by the MDS Coordinator to ensure CCP review and revisions have been completed, as indicated.
3. All licensed Nurses will be educated on the policy and monitoring revision by the Inservice Director. The Lesson Plan will concentrate on the following:
a. Change in condition relative to Urinary Incontinence.
b. Criteria for Care Plan review and interventions for management of Urinary Incontinence.
c. Ongoing Monitoring of Changes in Urinary Incontinence Level.
4. A copy of the Lesson Plan and Attendance Record will be filed for reference and validation.
QA Monitoring
1. The DNS developed an audit tool to track urinary assessment and CCP revisions for residents with a change in Urinary Incontinence.
2. The Nurse Manger will conduct audits on 5 residents per week on each unit over the next month, then monthly thereafter.
3. Audits with negative findings will have onsite corrections by the Nurse Manager and will be reviewed by the DNS for compliance.
4. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up as needed.
Responsible Party:
The Director of Nursing will be responsible for attaining and maintaining compliance with this F Tag.

FF09 483.55(b):ROUTINE/EMERGENCY DENTAL SERVICES IN NFS

REGULATION: The nursing facility must provide or obtain from an outside resource, in accordance with §483.75(h) of this part, routine (to the extent covered under the State plan); and emergency dental services to meet the needs of each resident; must, if necessary, assist the resident in making appointments; and by arranging for transportation to and from the dentist's office; and must promptly refer residents with lost or damaged dentures to a dentist.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: November 7, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record interview, and staff interviews during the recertification survey the facility did not ensure that routine dental services were provided to each resident, for 1 of 3 residents reviewed for dental services, from a total of 48 Stage 2 sampled residents. Specifically, there was no documented evidence that Resident #117 received a dental consult since 8/3/2014. The finding is: Resident #117 had [DIAGNOSES REDACTED]. The resident had a percutaneous endoscopic gastroscopy (PEG) tube (a tube placed into the resident's stomach for medication and nutrition). Resident #117 was observed seated in her room on 10/17/16 at 11:15 AM watching TV. The resident was well groomed and responded with a smile when addressed. The resident was observed to have some natural teeth and some missing teeth. A subsequent observation of Resident #117 was made on 10/19/16 at 11:10 AM. The resident was interviewed and stated that her teeth feel fine and that she brushes them 2 times a day. The resident's mouth was observed to be clean, with some noted build up of plaque type substance along the edge of the tooth/gum line on the lower portion of the resident's mouth. The resident was asked if she recalls being seen by a dentist recently. The resident stated she could not remember. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #117 could usually be understood and usually understands and had a Brief Interview for Mental Status (BIMS) score of 3, indicating that the resident was severely cognitively impaired. The resident required extensive assistance of one staff member for personal hygiene. There were no oral or dental problems identified under Section L: Oral/Dental Status. Additionally, the quarterly MDS, dated [DATE] Section L: Oral/Dental Status documented no dental or oral problems. Review of the Physician order [REDACTED]. The Physician order [REDACTED]. The resident's medical record chart was reviewed and revealed Dental consults dated: 11/23/12, 6/21/13 and 8/3/14. All three reports documented that the residents oral hygiene was poor and included recommendations to brush teeth 2 x day (twice daily). The Comprehensive Care Plan for Dental dated 2/7/16 documented: Own teeth Goal Resident will be free from s/s (signs/symptoms) of oral infection: pain, facial swelling, bleeding gums, change in appetite, chewing difficulty Interventions Dental Consult and F/U (follow up) Observe/Report redness, facial swelling, bleeding gums, change in appetite, chewing difficulty Oral Care 2 x a day and as needed Last updated 9/26/16 Free from oral dental problems An interview was conducted on 10/19/16 at 11:20 AM with the Certified Nursing Assistant (CNA) that was assigned to Resident #117. The CNA stated she was familiar with Resident #117 and that she performs/assists the resident with all Activities of Daily Living, except the resident's teeth. The CNA stated that the resident likes to brush her own teeth and is very determined to perform the task. An interview was conducted with the Registered Nurse (RN) Charge Nurse on 10/19/2016 at 11:35 AM. The RN stated that dental exams should be done annually and as needed (PRN). The RN stated that she had been assigned to the unit for the last month and that Resident #117 had not had an appointment with the dentist since she had been there. The RN checked the Physician order [REDACTED]. The Medical Record staff person was interviewed on 10/19/16 at 11:55 AM and stated if there was not a Physicians' Order for a dental consult, a consult would not have been done. The medical record staff person stated she would check the resident's thinned out files for a recent consult. The Registered Nurse (RN) Director of Nursing (DNS) was interviewed on 10/19/2016 at 12:00 PM and stated that the resident's physician is responsible to order the resident's dental consult. On 10/19/2016 at 12:10 PM an interview with Resident #117's Primary Care Physician (PCP) was conducted. The PCP stated that he is responsible for ordering the dental consults. The physician stated it would be reasonable for the resident to be seen by the dentist annually. 415.17(a-d)

Plan of Correction: ApprovedNovember 4, 2016

Immediate Corrective Action:
1. Resident #117 was evaluated by Dentist on 10/20/16. Resident denies pain or difficulty chewing. Dentist recommended to brush teeth twice a day and to follow up PRN.
2. The Administrator provided educational counseling to the Medical Director for not reviewing and ordering a dental examination on an annual basis as per regulations.
3. Educational counseling is filed for reference and validation
Identification of Other Residents:
1. The Unit Nurse Managers reviewed all residents to ensure Dental Assessments were completed on an annual basis, as per physician orders.
2. Any residents identified to require an annual or follow up Dental Exam will be scheduled and Dentist will be notified.
Systemic Changes:
1. The DNS reviewed the facility policy for annual/physician ordered Dental Exam and revised the policy to include the development and maintenance of a Dental Exam log.
2. The Nurse Manager will inform the attending physician of Resident?s requiring annual dental exams.
3. The Medical staff is responsible for ordering and/or documenting rationale why an annual dental exam may not be ordered on an annual basis.
4. The Inservice Director provided an inservice to all RN staff on the revised policy regarding monitoring the completion of annual/physician ordered dental exam.
5. The Medical Director sent a memo to all attending physicians containing the above referenced lesson plan.
6. A copy of the lesson plan and attendance records will be filed for reference and validation.
QA Monitoring
1. The DNS, in conjunction with the Medical Director, developed an audit tool to monitor the proper completion of Annual/Physician Ordered Dental Exams.
2. The Nurse Managers will conduct the audit weekly for the first month. Random audits will then be completed quarterly over the next year.
3. Audits with negative findings will have immediate corrective action by the auditor and brought to the attention of the Medical Director for follow-up.
4. Audit findings will be presented to the QA Committee on a quarterly basis for evaluation and follow up.
Responsible Party:
The Director of Nursing will be responsible for attaining and maintaining compliance with this F Tag

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: December 16, 2016

Citation Details

1998 NFPA 25: 2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25: 2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100F (38C). 1999 NFPA 13: 5-6.3.4 Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 ft (1.8 m) on center. Based on observation and staff interview, the facility did not ensure that required automatic sprinkler systems were continuously maintained in reliable operating condition in that: 1) sprinklers were spaced less than 6 feet apart in resident rooms; 2) sprinklers in the kitchen were noted to be loaded with dust; and 3) the facility lacked two spare upright type sprinkler heads. This was noted on four of four floors. The findings are: On 10/12/16 between 8:30am- 12:00pm during the recertification survey, the following was noted: 1) Sprinklers were observed to be spaced less than 6 feet apart in resident rooms 115, 215 & 315. 2) Sprinklers in the kitchen were observed to be loaded with dust. 3) Upright sprinklers were observed in the boiler room on the Lobby level. The facility lacked two spare upright sprinklers. In an interview on 10/12/16 at approximately 8:59am, the Director of Building Services stated that he would have one of the sprinkler heads capped. In an interview on 10/12/16 at approximately 10:20am, the Director of Building Services stated that the sprinkler issues would be addressed. 10NYCRR 711.2(a)(1) 1998 NFPA 25: 2-2.1.1, 2-4.1.4 1999 NFPA 13: 5-6.3.4

Plan of Correction: ApprovedJanuary 2, 2017

Immediate Corrective Action:
1. Facility has removed the extra sprinklers in rooms 115, 215 and 315 that were less than six feet apart.
2. Facility has removed dust from all kitchen sprinkler heads.
3. Facility has purchased two spare upright sprinklers that are located in the Boiler room.
Identification of Other Residents:
The facility respectfully states that all residents were potentially affected by this deficient practice.
Systematic changes:
1. Facility has removed the additional sprinkler heads from rooms 115, 215 and 315that are not in compliance with NFPA code.
2. Facility has removed dust and debris from all kitchen sprinkler heads.
3. Facility has added additional spare upright sprinkler heads that are located in the Boiler Room.
Quality Assurance Monitoring:
1. The Director of Building Services will ensure that all sprinkler heads are at least six feet apart in all resident rooms. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and then monthly thereafter. Any negative findings will be brought to the attention of the Administrator immediately.
2. The Director of Building Services will ensure that all sprinklers are to be free of dust and debris. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and then monthly thereafter to ensure that all sprinklers are free of dust and debris. Any negative findings will be brought to the attention of the Administrator immediately.
3. The Director of Building Services will ensure that spare sprinklers are kept at facility at all times. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and then monthly thereafter to ensure that spare sprinklers are kept at facility at all times. Any negative findings will be brought to the attention of the Administrator immediately.
4. All audits will be presented at the Quarterly QA meetings for input and follow up as needed.
Responsible Person:
The Director of Building Services responsible for achieving and maintaining compliance with this Tag.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully-sprinklered buildings, flame spread rating of Class C may be continued in use within rooms separated in accordance with 19.3.6 from the exit access corridors.) 19.3.3.1, 19.3.3.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: December 16, 2016

Citation Details

Based on observation, staff interview and documentation review, the facility did not provide documentation to verify that interior finishes for rooms and spaces not used for corridors or exitways had a flame spread rating of at least Class C. This was noted on three of four floors. The findings are: On 10/12/16 between 8:30am- 10:00am during the recertification survey, interior finishes are required to have a flame spread rating of at least Class C. Interior exposed surfaces, specifically the shelves in storage rooms across from the South Stair on floors 1, 2 & 3, were noted to be made of wood or plywood materials. There was no documentation provided at the time of the survey indicating the flame spread rating of these shelves. In an interview on 10/12/16 at approximately 8:51am, the Director of Building Services stated that he will address the issue. 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJanuary 2, 2017

Disclaimer: The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department?s directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This should not be construed as either a waiver of the Facilities right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of any wrong doing or an admission of past or ongoing violations of Federal and State Regulations.

Immediate Corrective Action:
The shelves made of wood and plywood materials in the storage rooms across from the South Stairs on Floors 1, 2, & 3 were treated with a Class A rated flame spread by the Maintenance Department.
Identification of Other Residents:
The facility respectfully states that all residents were potentially affected by this deficient practice.
Systemic Changes:
The shelves made of wood and plywood materials in the storage rooms across from the South Stairs on Floors 1, 2, & 3 were treated with a Class A rated flame spread by the Maintenance Department. The Maintenance Department also treated all areas of the facility that contain wood or plywood materials with Class A rated flame spread. All appropriate documentation will be available upon request.
Quality Assurance Monitoring:
The Director of Building Services/designee will ensure that all storage closets containing wood and plywood materials have been treated with minimum Class C rated flame spread. An audit tool will be completed weekly for the first month to ensure that all storage closets have been treated with Class C rated flame spread. Any negative findings will be brought to the Administrator immediately. Audits will be presented at the Quarterly QA meetings for input and follow up as needed.
Responsible Person:
The Director of Building Services responsible for achieving and maintaining compliance with this Tag.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: December 16, 2016

Citation Details

Based on observation and staff interview, the facility did not ensure that the exit passageway from the North Stair was maintained with at least a 2 hour enclosure. This was noted on one of four floors. The findings are: On 10/12/16 between 9:00am- 11:00am during the recertification survey, the exit passageway from the North Stair was noted not being maintained with at least a 2 hour enclosure at the Lobby level. Examples are: 1) The self-closing devices on the doors to the cafeteria and the kitchen did not function properly. The doors did not close when tested . 2) The door to central supplies did not positively latch when tested . 3) An approximately 17 inch by 19 inch wired glass window in the corridor wall in the vicinity of the kitchen lacked a fire-rated label. 4) Unsealed pipe penetrations that lacked a rated fire-stopping material were noted above the door to central supplies and above the cross corridor doors. In an interview on 10/12/16 at approximately 10:26am, the Director of Building Services stated that he would seal the penetrations and address the issues. 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJanuary 2, 2017

Immediate Corrective Action:
The Maintenance Department has made the following corrective actions:
1. Installed new door closers on the Cafeteria and Kitchen doors which will now maintain a two hour enclosure.
2. Central Supply door has a positive latch mechanism in place, and latches properly when tested .
3. The wired glass window in the corridor wall in the vicinity of kitchen has been removed and replaced with Firecode Core 5/8 inch 2 hour Rated sheetrock wall.
4. Unsealed pipe penetrations above the door to central supplies and above the cross-corridor doors that lacked a rated fire-stopping material were sealed with rated fire stopping material
Identification of Other Residents:
The facility respectfully states that all residents were potentially affected by this deficient practice.
Systematic Changes:
1. The Maintenance Department of the Facility has installed new self closing door hardware on Cafeteria and Kitchen doors that have been tested and are functioning correctly which will now maintain a two hour enclosure.
2. The Maintenance Department adjusted the Central supply door frame, which included installing a positive latch mechanism, as well as installation of new self closing door hardware.
3. The wired glass window in the corridor wall in the vicinity of kitchen has been removed and replaced with Firecode Core 5/8 inch 2 hour Rated sheetrock wall by the Maintenance Department, and all surrounding openings have been sealed with fire rated stopping material by the Maintenance Department.
4. Unsealed pipe penetrations above the door to central supplies and above the cross-corridor doors. that lacked a rated fire-stopping material were sealed with rated fire stopping material by the Maintenance Department.

Quality Assurance Monitoring:
1. The Director of Building Services will ensure that all self closing doors have proper self closing apparatus attached and is functioning correctly. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and then monthly thereafter to ensure that all self closing doors have proper self closing apparatus attached and is functioning correctly. Any negative findings will be brought to the attention of the Administrator immediately.
2. The Director of Building Services will ensure that all doors have are positive latching. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and then monthly thereafter to ensure that all doors are positive latching. Any negative findings will be brought to the attention of the Administrator immediately.
3. The Director of Building Services will ensure that all glass partitions within wall corridor walls are either fire rated or replaced with Firecode Core 5/8 inch 2 hour Rated sheetrock wall. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and monthly thereafter to ensure that glass partitions within wall corridors are fire rated. Any negative findings will be brought to the attention of the Administrator immediately.
4. The Director of Building Services will ensure that all smoke barrier or unsealed pipe penetrations that lacked a rated fire-stopping material are properly sealed at the locations above Central Supplies and Cross corridor doors. An audit tool will be completed weekly by the Director of Building Services/designee for the first month and then monthly thereafter. Any negative findings will be brought to the attention of the Administrator immediately.
5.All audits will be presented at the Quarterly QA meetings for input and follow up as needed.

Responsible Person:
The Director of Building Services responsible for achieving and maintaining compliance with this Tag.

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

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 19, 2016
Corrected date: December 16, 2016

Citation Details

713-1.9 Mechanical requirements. (i) All handwashing fixtures used by medical and nursing staff and food handlers shall be trimmed with valves that can be operated without the use of hands. Hand operated faucets may be fitted on lavatories in residents' rooms and residents' toilets. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, two of two handwashing sinks in the kitchen lacked trimmed valves that can be operated without the use of hands. The findings are: During the kitchen inspection on 10/12/16 at approximately 10:00am, it was noted that the hand washing sinks in the meat and dairy sections were provided with hand operated valves. In an interview at this time the Director of Building Services stated that he would look into the issue with the valve on the sinks.

Plan of Correction: ApprovedJanuary 2, 2017

Immediate Corrective Action:
The hand washing sinks located in the kitchen on both the meat and dairy sides were replaced by the Maintenance Department with trimmed valves that can be operated without the use of hands.
Identification of Other Residents:
The facility respectfully states that all residents were potentially affected by this deficient practice.
Systematic Changes:
The Maintenance Department has removed the hand operated valves and replaced them with trimmed valves.
Quality Assurance Monitoring:
The Director of Building Services will ensure that Trimmed valves are present on all nursing and food handling fixtures, as is required. An audit tool will be completed by the Director of Building Services/designee weekly for the first month and monthly thereafter, to ensure that Trimmed valves are present on all nursing and food handling fixtures. Negative findings will result in counseling of Maintenance staff and the continuation of monthly reviews until there are no longer negative findings. All audits will be presented at the Quarterly QA meetings for input and follow up as needed.
Responsible Person:
The Director of Building Services responsible for achieving and maintaining compliance with this Tag.