Parkview Care and Rehabilitation Center, Inc.
November 20, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2017
Corrected date: January 2, 2018

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 develop a Comprehensive Care Plan (CCP) with specific goals and interventions for 1 (Resident # 192) of twenty four Stage 2 residents reviewed for CCPs. Specifically, Resident # 192 did not have a CCP developed to include specific goals and interventions related to a [DIAGNOSES REDACTED]. The finding is: Resident #192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental status (BIMS) score of 3 indicating severe cognitive impairment. The MDS documented the resident received an hypnotic medication for 7 of 7 days in the look back period. A Physician order [REDACTED]. There was no documented evidence in the medical record that a CCP was developed to include specific goals and interventions to address the residents [DIAGNOSES REDACTED]. The Director of Nursing Services (DNS) was interviewed on 11/20/17 at 12:45 PM and stated that she reviewed the medical record and a CCP was not developed for the [DIAGNOSES REDACTED]. The Registered Nurse MDS Coordinator was interviewed on 11/20/17 at 1:15 PM and stated she should have initiated a CCP for the [DIAGNOSES REDACTED]. 415.11(c)(1)

Plan of Correction: ApprovedDecember 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F279 Develop Comprehensive Care Plans
Immediate Corrective Action
1.The RNS responsible for development of a care plan for the residents with [MEDICAL CONDITION] was in-serviced on the facility policy on care plan development by the DNS on 12/6/17
2.A comprehensive care plan meeting with the interdisciplinary team was held and a comprehensive care plan was developed on 12/6/17
II. Identification of Others:
1.A list of residents with [MEDICAL CONDITION] with medication management was established by the DNS to ensure that each of the residents have individualized comprehensive care plans developed to address [MEDICAL CONDITION].
III. System Changes
1.The existing policy and procedure on the development of individualized care plans has been reviewed by the DNS and Administrator and found to be complaint
Completion Date: 12/5/17
2.All interdisciplinary care plan members and RN?s will be in-serviced by the Director of Nursing/Designee on the policy and procedure.
Completion Date: 1/2/18
3.A copy of the lesson plan and attendance will be maintained for validation
Completion Date: 1/2/18
IV. QA
1.An Audit of all residents identified with [MEDICAL CONDITION] will be conducted by the DNS to ensure that each resident will have an individualized comprehensive care plan developed to [MEDICAL CONDITION]. The audit will be conducted monthly by the DNS/Designee for 1 yr. Immediate corrective action will be implemented as needed and reported to the Administrator.
2.The outcome of this audit will be quantified and reported to the quality assurance committee by the DNS for one year. After one year the Quality assurance committee will determine an ongoing schedule of audits
V. The date for the correction and title of the person responsible for the correction of the deficiency:
The DNS is responsible for the correction of this deficiency by 1/2/18 and ongoing







FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2017
Corrected date: January 2, 2018

Citation Details

Based on observation and staff interview during the Recertification survey, the facility did not ensure that all kitchen equipment was being maintained in sanitary working order. Specifically, the exterior thermometer of the walk-in refrigerator was in disrepair and in need of replacement, the door handle to a reach-in refrigerator was in disrepair and not staying closed; the piping in a three compartment sink was leaking and in need of repair; three of three (vector) insect glue mechanisms were heavily soiled with debris and dead insects and were in need of thorough cleaning; the fan cages inside of the walk-in refrigerator were heavily soiled with dust and in need of cleaning; debris was underneath the dish machine and was in need of cleaning. The findings are: During the initial tour of the main kitchen on 11/13/2017 at 8:15 AM the following was observed: 1) The exterior thermometer of the walk-in refrigerator was not working and in need of replacement. An interview with the Food Service Director ( FSD) on 11/13/2017 at 8:30 AM revealed that she had not tried to replace the temperature gauge. 2) One of four door handles for the reach-in refrigerator was in disrepair. The door did not stay closed and was in need of repair. 3) The metal piping along the wall behind the three compartment sink was leaking heavily and was in need of repair. The FSD stated on 11/13/17 at 8:30 AM she would have the maintenance department address the leaking pipe. 4) Three of three (vector) insect glue mechanisms hung on the kitchen walls were heavily soiled with debris and dead insects and were in need of thorough cleaning. The FSD stated on 11/13/17 at 8:35 AM that the pest control company usually cleans that equipment. 5) The metal cages protecting the fans inside the walk-in refrigerator were heavily soiled with dust and were in need of cleaning. 6) The floor underneath the dish machine had a build up of debris, including paper wrappers, an empty cup, utensils and was in need of cleaning. An interview with the Director of Maintenance on 11/20/17 at 1:30 PM revealed that the the necessary parts for the repair work will be ordered. 415.14(h)

Plan of Correction: ApprovedDecember 6, 2017

F371- Food Procure, Store/Prepare/Serve-Sanitary
I. Immediate corrective Actions
1.Food Service Director was given an Educational Counseling for not ensuring that the facility stores, prepares, distributes and serves food under sanitary conditions.
Completion Date: 12/4/17
2. A) The exterior thermometer of the walk in refrigerator was replaced.
Completion Date: 12/4/17
B) The handle for the reach in refrigerator was repaired
Completion Date: 12/4/17
C) The metal piping along the wall behind the three compartment sink was repaired
Completion Date: 12/4/17
D) The insect vector glue mechanisms hung on the kitchen wall were cleaned
Completion Date: 12/4/17
E) The metal cages protecting the fan inside the walk in refrigerator were cleaned
Completion Date: 12/4/17
F)The floor beneath the dish machine was cleaned:
Completion date: 12/4/17

II.Identification of Others:
All residents have the potential to be affected by this deficiency.
III. Systemic Changes
1.The Administrator and Food Service Director reviewed and revised The policy on Storing, Preparation, Distribution and Serving of the food.
Completion Date: 12/5/17
2.All Dietary /Kitchen staff will be in-serviced on the policy on storing, preparation, distribution and serving of the food by Administrator/designee. Completion Date: 1/2/18
3.A copy of the lesson plan and attendance will be maintained for validation.
Date of Completion: 1/2/18

IV. QA
1.The Administrator has developed an audit tool to monitor compliance with the facilities policy on Storing, Preparation, Distribution and Serving of the food.
2. The audit will be conducted by the Food Service Director weekly x3months and monthly thereafter and any negative findings will have immediate correction implemented by the FSD and reported to Administrator.
3. The outcome of this audit will be reported to the QA committee quarterly by the FSD for evaluation & follow up as indicated.
V. The date for the correction and title of the person responsible for the correction of the deficiency:
The Administrator is responsible for the correction of this deficiency by 1/2/18 and ongoing

Standard Life Safety Code Citations

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2017
Corrected date: January 2, 2018

Citation Details

2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that fire-rated doors were provided with a legible fire-rated label. This was noted on 1 of 3 units. The findings are: During the Life Safety Code survey on 11/16/17 between 10:00am and 2:00pm, it was noted that the fire rated labels on smoke barrier doors were not legible or missing on the Center Nursing Unit. Examples included the cross-corridor smoke barrier doors on the Center North and Center West wings. In an interview on the same day at approximately 10:20am, the Director of Maintenance stated that the facility would either have the doors relabeled or replaced. 2012 NFPA 101: 19.3.7.8, 8.5.4.4, 7.2.1.15.2 2010 NFPA 105: 4.1.1 2010 NFPA 80: 4.2.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 11, 2017

K374 NFPA 101 Subdivision of Building Spaces-Smoke Barrier
I. Immediate Corrective Action:
1. Director of Maintenance was given an educational counseling for not ensuring that all fire rated doors were provided with a legible fire rated label on 12/11/17
2.Outside Contractor contacted on 12/8/17 to replace the Center Nursing Unit non-legible fire rated labels on the smoke barrier doors
II. Identification of Others:
1.Full house audit completed on all smoke barrier doors to ensure the fire rated labels were legible and in accordance with NFPA guidelines.
Completion Date: 12/11/7
III. Systemic Changes:
1.The Administrator and Director of Maintenance reviewed and revised the policy and procedure on Smoke Barrier Doors.
Completion Date: 12/11/17
2. The maintenance staff will be in-serviced by the Director of Maintenance on the policy and procedure with emphasis on the requirement that fire rated doors must have legible fire rated label and a copy of the lesson plan and attendance will be filed for reference.
Completion Date: 1/2/18
IV QA
1.The Director of Maintenance developed an audit tool to monitor compliance to ensure the fire rated labels on smoke barrier doors are legible
2.The audit will be conducted by the Director of Maintenance/designee on all smoke barrier doors monthly x3 months and quarterly thereafter. Audit findings will be presented to the QA committee for evaluation and follow up as indicated.
V The date for correction and the title of the person responsible for the correction of the deficiency:
1.The Administrator is responsible for the correction of this deficiency by 1/2/18 and ongoing.