Safire Rehabilitation of Southtowns, LLC
March 29, 2017 Certification/complaint Survey

Standard Health Citations

E3BP 402.6(a):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. (a) The provider shall ensure the submission of a request for a criminal history record check for each prospective employee. If a permanent record does not exist for the prospective employee, the Department shall be authorized to request and receive criminal history information from the Division concerning the prospective employee in accordance with the provisions of section 845-b of the Executive Law. Access to and the use of such information shall be governed by the provisions of such section of the Executive Law. The Division is authorized to submit fingerprints to the FBI for a national criminal history record check.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

Based on interview and record review during a Standard Survey completed on 3/29/17, the facility did not request criminal history information through the Criminal History Record Check (CHRC) program for an employee in a timely manner. This affected one (Employee #6) of eight employee files reviewed for compliance with CHRC regulations. The finding is: 1. Review of the personnel file for Employee #6 on 3/23/17, revealed Employee #6 was initially hired by the facility in (MONTH) (YEAR) as a Certified Nurse Aide (CNA) and was submitted for CHRC review at that time. Further review revealed a Non-Ident Letter was issued for Employee #6 on 2/10/16 (Non-Ident Letters - indicate the individual has no criminal history background). Continued review revealed Charge Notification After Hire letters were later issued for Employee #6 on 9/19/16 and 10/28/16. Interview with the Human Resource Generalist (Authorized Person) on 3/27/17 at approximately 2:15 PM revealed the last day Employee #6 worked in the facility was 9/16/16 and at that time, a DOH 105 Termination Form was submitted to CHRC for Employee #6. Interview with the Staffing Coordinator on 3/27/17 at approximately 3:25 PM revealed Employee #6 was re-hired on 12/8/16 as an Agency CNA. Interview with the Human Resources Generalist (Authorized Person) on 3/27/17 at approximately 2:15 PM revealed she submitted a new CHRC 102 Form for Employee #6 on 1/31/17, when she first became aware that Employee #6 was re-hired. Review of an automated time card printout revealed Employee #6 worked 36 shifts, each between 2:00PM and 9:00AM, from 12/8/16 through 1/31/17, without being submiited for review by the CHRC program. 402.6(a)

Plan of Correction: ApprovedApril 22, 2017

F 702

The corrective action for employee #6 was that this employee was submitted to CHRC for review on 1/31/17 when the Human Resources Generalist came to knowledge of rehire.

The identification and corrective action for all other employees having the potential to be affected by the same deficient practice.
All employee files will be audited to ensure paper CHRC 102 Form submitted within appropriate time frame from hire date, including all agency staff.
This will be the responsibility of the Human Resource Generalist.

The systemic changes to ensure that this deficient practice does not recur.
To ensure the deficient practice does not recur, the facility will use an audit tool on all new hires on all new hires, which will include employee name, date of hire, CHRC 102 Form, submission 103 form date, CHRC Submission response date, and CHRC 105 termination form date, if applicable.
The Staffing Coordinator will generate and send a new employee list to the Human Resource Generalist weekly on Fridays. This list will include all agency staff working in the building. The HRG will ensure all employees have been submitted to CHRC for review and submit findings to the Administrator. This will be completed weekly for 60 days.
A monthly audit on 15 new employee files with be completed monthly for 12 months. Results will be submitted to the Administrator.

All results of these audits will be presented to the QAA committee monthly for review and further recommendations.

Responsible Party: Administrator

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

Based on interview and record review during the Standard survey completed on 3/29/17, the facility did not immediately remove an employee from direct resident care or supervision upon receipt of a negative determination letter from the Criminal History Record Check Legal Review Unit. This affected one (Employee #6) of eight employees reviewed for compliance with Criminal History Record Check (CHRC) regulations. The finding is: 1. Review of the Personnel File for Employee #6 (Agency Certified Nurse Aide) revealed that the facility was notified that Employee #6 received a Pending Denial letter dated 2/1/17 from the New York State Department of Health Criminal History Record Check Legal Review Unit. Review of an automated timecard printout revealed Employee #6 worked after receiving the Pending Denial notification from 2:00 PM on Wednesday 2/1/17 until 6:00 AM on Thursday 2/2/17, 2:00 PM until 10:00 PM on Thursday 2/2/17, 2:00 PM on Friday 2/3/17 until 6:00 AM on Saturday 2/4/17, and 2:00 PM on Saturday 2/4/17 until 6:00 AM on Sunday 2/5/17. Interview with the Human Resource Generalist (Authorized Person) on 3/28/17 at 12:40 PM revealed her computer was not operational from Wednesday 2/1/17 until Friday 2/3/17. Continued interview revealed in that time period, she was unable to check CHRC results on her own computer and did not attempt to access the CHRC program from another computer. Additionally, the Human Resource Generalist stated as soon as she discovered the negative determination letter on Monday 2/6/17, she instructed the facility to remove Employee #6 from service. 402.7(a)(2)(i)

Plan of Correction: ApprovedApril 22, 2017

R 808
The corrective action for those affected by the deficient practice was that Employee #6 was removed from service.
Identification and corrective action for all other employees having the potential to be affected by this deficient practice.
All current employees and agency staff files will be audited to ensure that any and all appropriate actions have been taken in accordance with CHRC.
This was corrected on 2/6/17 by the Human Resource Generalist.

The systemic changes to ensure that the deficient practice does not recur:
The Human Resource Generalist will log the date and time when she rechecks CHRC results to ensure they are checked daily and will take any and all appropriate actions immediately.
In the event she does not have an operational computer, she is to notify the Administrator to provide a functional computer same day.
Log of CHRC review frequency will be submitted to the Administrator weekly for 60 days, then monthly for 12 months.

All results of these audits will be presented to the QAA committee monthly for review and further recommendations.

Responsible Party: Administrator

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/29/17, the facility did not ensure that the resident environment remains as free from accident hazards as is possible. Specifically, two (Residents #8 and 189) of four residents reviewed for accidents had issues with a loose side rail and a bathroom floor door threshold was in disrepair. The findings are: 1. Resident #8 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated 1/31/17 revealed the resident is cognitively intact, is understood and understands. During an observation on 3/23/17 at 9:39 AM, the left 1/2 side rail on the bed was loose and moved approximately two inches side to side. During an observation on 3/27/17 at 9:58 AM, the left 1/2 side rail on the bed was loose and moved approximately two inches side to side. During an interview on 3/27/17 at 9:58 AM at the time of the observation, the resident stated the side rail has been loose for a while and that she uses the side rail every day to help pull herself up. Review of a Physician's Order Sheet dated 2/22/17 revealed an order for [REDACTED]. Review of the Comprehensive Care Plan dated 2/6/17 revealed the resident required extensive assist of one staff member for bed mobility with an intervention to utilize 1 1/2 side rail for T & P. Review of an Interdisciplinary Restraint assessment dated [DATE] revealed the following recommendations: Resident educated and can benefit from 1/2 side rail for T & P. Review of an Occupational Therapy Progress Summary and Goal Tracking Report dated 2/22/17 revealed nursing recommendations to include 1/2 side rail for T & P. During an interview on 3/27/17 at 1:56 PM, the Registered Nurse (RN#1), Unit Manager (UM)stated she would call maintenance to come and fix the side rail right away. During an observation on 3/28/17 at 8:39 AM, the left side rail on bed was very loose. At the time of the observation the resident stated, nobody came in yesterday to look at it or fix the rail. During an interview at 3/28/17 at 8:40 AM RN #1 UM, looked at the side rail and stated that the side rail is too loose and needed to be fixed. The RN stated that she called maintenance yesterday and does not know why it was not fixed. She was going to call them again and write it in the Maintenance Work Request book. The RN further stated that they would need to swap the bed out because the rail is attached to the bed and cannot be removed or tightened. During an interview on 3/28/17 at 8:41 AM, the maintenance worker stated, that type of rail is always loose and there is no way to tighten it. The maintenance worker further stated that he just spoke to RN #1 and he will exchange the bed with a different one as that rail is attached directly to the bed directly and cannot be removed. Review of the Maintenance Work Request log dated 3/28/17 revealed an entry for a new bed. Review of the policy entitled Bed Safety dated 11/9/16 revealed the facility shall try to prevent deaths/ injuries from the beds and related equipment (including side rails). The facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems. c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications. d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit. 2. Resident #189 has [DIAGNOSES REDACTED]. The resident is independent with a rolling walker for ambulation. During an observation on 3/22/17 at approximately 10:57 AM revealed that there were approximately 40 one inch square tiles missing at the threshold of the bathroom door. Leaving a gap in the floor approximately six inches wide and between five to ten inches long. Additional observation on 3/27/17 at approximately 1:47 PM revealed the threshold of the bathroom floor remained in disrepair. During an interview on 3/28/17 at approximately 1:50 PM, revealed the resident can walk to the bathroom using her walker. The resident stated it's a miracle I haven't tripped over that yet, I try to walk around that area so I don't trip. During an interview on 3/28/17 at approximately 10:30 AM, RN #1 UM looked at the threshold and stated the missing tiles could be a possible accident hazard if the resident wasn't paying attention or disoriented. She also stated that she would get maintenance to fix the floor right away. During an interview on 3/28/17 at approximately 10:35 AM, the Maintenance Supervisor stated that the area could be a trip hazard and that it would get fixed as soon as possible. The Maintenance Supervisor also stated he did not know how long the floor was like that, and added that the floor looked like someone attempted to fix it and only part of it was completed. During an additional observation on 3/28/17 at approximately 12:00 PM revealed that the area of missing tiles was repaired with cement. Review of the facility policy Preventative Maintenance dated 2/1/17 revealed that routine inspections promote safety throughout the facility and aid in keeping equipment in good working order. 415.12(h)(1)(2)

Plan of Correction: ApprovedApril 28, 2017

F323 483.25 (d)(1)(2)(n)(1)(3)
Free of Accident Hazards/Supervision/Devices

Resident #8 was provided a new bed by the Maintenance Department on 3/28/17. The new bed has 1/2 side rails directly attached to the bed frame which prevents them from loosening. Resident #8 continues to use 1/2 side rails for turning and positioning. There has been no further issues and resident remains at the facility in stable health.
Resident #189 no longer resides at the facility. The resident was discharged Home in stable condition on 3/30/17.
The Facility will ensure that the resident environment remains as free from accident hazards as possible. The facility will ensure all residents' side rails are tight and floor door threshold are in good condition to prevent resident trip hazards and falls.
All residents who currently reside at Safire Rehabilitation of Southtowns have the potential to be affected by the same deficient practice. The Unit Managers, Therapy and Maintenance
Department will conduct a 100% audit/walk through and inspect those residents who have side rails to ensure there are no loose parts and side rails are safe per manufactures' specifications and are in good working condition.

All deficient practice will be noted in the Maintenance Log by Nursing/Therapy Staff for the Maintenance Department to address. All urgent problems will also be immediately reported to the Maintenance Department, Administrator and the DON to ensure immediate actions and follow up occurs.
The residents are assessed by the IDT for the need of side rails on admission/readmission, quarterly, annually and as needed to ensure the side rail is appropriate for the resident.
The IDT will review and revise those Resident care plans when indicated (i.e.)provided different positioning/safety device, 1/2 side rails vs Full rails or there is a discontinuation of side rails, etc.
The Director of Nursing will analyze and trend all IDT Care Plan issues pertaining to side rails.
All findings will be reported to the CQI/QA committee at the next scheduled meeting.
The Director of Maintenance will conduct an audit on Side rail Repair issues and documentation of loose/broken side rails in need of repair noted in the Maintenance log book.
All findings will be analyzed and trended and reported to the CQI/QA committee at the next scheduled meeting.

The corrective action completed for the threshold for Bathroom in Room 210 that was affected by the missing floor tiles was the repair/replacement of the missing tiles adhering them with hydrylic cement. Other areas will be identified as having the potential to affect residents in a similar fashion through Daily Rounds by the Administrator, Director of Maintenance and the Director of Housekeeping, and Weekly Rounds by the Administrator and Unit Managers and Monthly Rounds by the Administrator, Director of Maintenance, Director of Housekeeping and the Unit Managers to identify any areas of concern, documenting it in the Maintenance Log on each of the Resident Care Units.
The systemic changes made to ensure the deficient practice does not reoccur is the addition of Weekly environmental rounds by the Administrator and the Unit Managers.
The Corrective action will be monitored by the Director of Maintenance reporting monthly to the QA Committee through the Administrator.
The Corrective action was completed on 3/28/17 by the Director of Maintenance who will be responsible for monitoring ongoing and reporting directly to the Administrator any issues.

The RN Unit Manager who failed to document in the Maintenance Log book re the Resident #8's loose side rail and failed to follow the facility Policy & Procedure entitled Bed Safety dated 11/9/16 will be counseled by the DON and re-in serviced on documentation requirements for defective equipment and Resident trip hazards/Safety Concerns and Policy & Procedures for Bed Safety.
The Director of Maintenance who failed to follow the facility Policy & Procedure for Preventive maintenance and conducting routine inspections throughout the facility will be counseled by the Administrator will be re-in serviced on Policy & Procedure entitled Preventive Maintenance dated 2/1/17.
All Facility Staff/New hires will be re-in serviced on the facility Policy and Procedure for Bed Safety dated 11/9/16 and Protocol for maintenance notification based on the Preventive Maintenance policy dated 2/1/17. The Director of Therapy and the Director of Nursing will conduct the Bed Safety trainings.
The Director of Maintenance and the Administrator will conduct the Preventive Maintenance trainings.
The Director of Maintenance will conduct random Side rail audits per unit, weekly times 4 weeks then monthly thereafter to ensure side rails are secure and the area of concern was placed in the unit maintenance log and safety concerns will be immediately addressed and reported to the Administrator and the DON.
All findings will be analyzed and trends will be reported to the CQI/QA Committee monthly. This will be ongoing.
The Director of Maintenance will be responsible for compliance.

FF10 483.80(d)(1)(2):INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 3/29/17, the facility did not develop policies and procedures that ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has been immunized with the vaccine. Two (Residents #8, 175) of five residents reviewed for influenza and pneumococcal vaccination had issues with the lack of administration of the influenza vaccination (Resident #175), and lack of screening the status for influenza and pneumococcal vaccination (Resident #8). The findings are: 1. Resident #175, admitted on [DATE] has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/29/17 revealed that the resident has no cognitive impairment, understands and is understood. Review of the Influenza Immunization Form dated 1/19/17 revealed the resident signed a consent to receive the influenza immunization; however, review of the resident's medical record on 3/23/17 revealed the resident had not received the influenza vaccination. During an interview on 3/23/17 at approximately 7:45 AM, the Registered Nurse (RN) Unit Manager (UM) stated that the resident had not received the vaccine and should have had it administered In January. Review of the facility's policy entitled Immunization: Influenza and (Flu) Prevention and Disease Transmission revealed that current and newly admitted residents will be offered the influenza vaccine during the current annual influenza season. Vaccines will be ordered by the physician and administered when the vaccine is available. 2. Resident #8, admitted on [DATE] has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has no cognitive impairment, understands and is understood. Review of the resident's medical record on 3/23/17 revealed that it did not contain any information regarding the resident's status for influenza and pneumococcal vaccinations. During an interview on 3/23/17 at approximately 7:45 AM, the RN UM stated that the resident should have been screened upon admission and she would screen the resident's immunization status immediately. Review of the facility's policy entitled Immunization: Influenza and (Flu) Prevention and Disease Transmission dated 10/25/16 revealed that current and newly admitted residents will be offered the influenza vaccine during the current annual influenza season. Vaccines will be ordered by the physician and administered when the vaccine is available. Review of the facility's policy entitled Immunization: Pneumococcal Vaccination (PPV) of Residents dated 2/1/17 revealed that all residents over age 65 should receive the pneumococcal vaccine and each resident's pneumococcal immunization status will be determined upon admission and documented in the resident's medical record. 415.19(a)(1)

Plan of Correction: ApprovedApril 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 334 483.80 (d)(1)(2)
Influenza and Pneumonia Immunizations

Resident #175's Primary Care Physician was notified on 3/24/17 once deficient practice identified. An order was given to administer her Influenza Immunization per signed consent dated 1/19/17. The RN Unit Manager reviewed the Influenza consent, signed & dated 1/19/17 with Resident #175. The resident was educated on Risk and benefits and possible side effects that could occur from vaccine. Resident requested vaccine which was administered on 3/24/17. Resident #175's comprehensive care plan was reviewed and revised on same day. Resident remains at the facility in stable condition.
Resident #8's medical record was reviewed on same day deficient practice identified. The RN Unit Manager reviewed the consents and educated the resident on Influenza & Pneumococcal vaccine risks and benefits including possible side effects that could occur from receiving vaccines on 3/24/17. Resident #8 Declined the vaccines, the PCP was notified day of resident's refusal. Resident #8's Comprehensive care plan was reviewed and revised on same day. Resident remains at the facility in stable condition.

All residents who reside at Safire Rehabilitation of Southtowns have the potential to be affected by this same deficient practice. The facility will ensure each resident is offered Influenza & Pneumococcal vaccinations unless contraindicated. Residents will be educated on the risks, benefits and possible side effects of vaccination prior to administration. The residents representative will also receive vaccine information stated above whenever resident is cognitively impaired and unable to consent.
The facility will ensure the consent forms and evidence of above mentioned information and vaccine administration is documented in the resident's medical record as ordered by the physician and per the facility influenza and pneumococcal policies and procedure.
The licensed nursing staff (Unit Managers/Nursing Supervisors) will conduct a 100% medical chart audit to ensure compliance with Department of Health guideline and facility policy with influenza and pneumococcal immunizations.
Each resident who has been identified as not receiving education regarding benefits/risks and potential side effect of the influenza ([DATE]-March 31)and pneumococcal vaccination and or has not been offered these immunizations (unless the immunization is medically contraindicated or resident has already been immunized). Resident will be educated and vaccinated per CDC/NYSDOH guidelines and Facility's revised policy and procedure. All education to the resident or legal representative will be documented in the admission nursing assessment, immunization record, or medical record that the resident was offered the vaccinations, refused or had the vaccination in the past.
The Corporate RN will review the influenza and pneumococcal vaccination policy and procedures to ensure that each resident and legal representative received education of benefits and potential of side effects and is offered both vaccinations unless medically contraindicated or the resident has been immunized. No revision was indicated.
The Director of Nursing (DON) will re-in service the MDS Coordinator, licensed nursing staff, medical staff, social work and clerical staff on the policy and procedure which includes copies of the immunization letters that are sent out to the residents legal representative are maintained in the medical file. The facility current policy and procedure includes that the Director of Nursing is notified is notified within 5 days of admission whenever there are any vaccination refusals. The MDS Coordinator will continue to notify the Director of Nursing in writing and prior to completion of the MDS of any residents who have not be vaccinated or if there is documented evidence of vaccinations. Nursing will continue to ensure every attempt is made to re educate and re-in service the resident and legal representative of benefits of receiving the vaccination whenever it is not contraindicated.
The DON who was responsible for implementing the Resident vaccination Policy & Procedure and oversight during (MONTH) (YEAR) through (MONTH) (YEAR) is no longer employed by the facility.
The RN Unit Manager who did not ensure the Policy & Procedures for Influenza and Pneumococcal vaccinations were followed and Residents #175, #8 did not receive either education pertaining to risk, benefits and possible side effects of vaccinations and required paperwork was completed and vaccinations were administered per MD orders has been issued a Final warning. The warning and re-in service of above mentioned policies/procedures were given on 3/21/17 by the ADON.
The Director of Nursing/designee will conduct weekly audits on new admissions/current residents to ensure appropriate documentation, administration and education was indicated in the medical file and compliance with facility policy and procedures for influenza and pneumococcal vaccinations. The audit will be ongoing throughout the calendar year. All data/findings will be analyzed and trended. Reeducation and staff counseling will occur when indicated. Findings will be reported to the CQI/QA committee monthly. This will be ongoing.

The Director of Nursing will be responsible for compliance.

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed 3/9/17, the facility did not ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Specifically, two (Residents #131,184) of four residents reviewed for nutrition had issues involving a delay in implementation of planned nutritional supplements, the lack of timely nutritional interventions for significant weight loss and the lack of care plan revisions to address the significant weight loss. The findings are: 1. Resident #131 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated 12/17/16 revealed the resident is cognitively intact, is understood and understands. Review of the Weight Record revealed the following weights: 12/07/16 - 207.4 pounds (lbs.) (Admission weight) 12/13/16 - 199.75 lbs (showing a 7.65 lbs / 3.7 % (percent) decrease in six days) 12/20/16 - 194.4 lbs (showing a 13 lbs / 6.3 % decrease in 13 days) 12/27/16 - 192 lbs (showing a 15.4 lbs / 7.4 % decrease in 20 days) Review of Nutritional assessment dated [DATE] revealed weight variance stable, [MEDICATION NAME] level (a blood protein) 3.5 (reference range 3.6-5.1). The documented plan included to provide the resident with 8 ounces of fortified milk at breakfast. Review of the Meal Acceptance Sheet for the week of 12/12/16 to 12/18/16 revealed no documentation that resident was receiving the eight ounces of fortified milk at breakfast. The fortified milk was not listed on the sheet. Review of the Meal Acceptance Sheet for Week of 12/19/16 to 12/25/2016 revealed the fortified milk was listed on the sheet and the resident was accepting less than 50 %. Review of a Dietary Progress Note dated 12/23/16 documented lab results from 12/21/16, [MEDICATION NAME] level down to 3.3. PO (by mouth) intakes 25-100% meals. Refuses - 50% fortified milk. Resident on weekly weights. Review of the entire medical chart revealed no other dietary documentation. Review of physician progress notes [REDACTED]. Physical exam weight documented as NA (not applicable). Review of the Comprehensive Care Plan dated 12/12/16 revealed under Nutritional Status a goal that resident will maintain stable weight without significant weight change throughout next review. Interventions include to provide eight ounces of fortified milk. 2. Resident #184 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, is understood and understands. Review of the Weight Record revealed the following weights: 2/10/17 - 205 lbs (Admission weight) 2/14/17 - 193.6 lbs (showing a 11.4 lbs / 5.6 % decrease in 4 days) 2/21/17 - 193.3 lbs (showing a 11.7 lbs / 5.7% decrease in 11 days) 2/28/17 - 191.4 lbs (showing a 13.6 lbs / 6.6% decrease in 18 days) Review of a Nutritional assessment dated [DATE] revealed weight variance stable, [MEDICATION NAME] level (a blood protein) 2.6 (reference range 3.6-5.1). The documented plan included, D/T (due to) low [MEDICATION NAME] will receive will receive fortified milk at all meals. Review of the entire medical chart revealed no other dietary documentation. Review of Adult Nurse Practitioner Note dated 2/28/17 revealed no documented evidence addressing the weight loss. Review of the Meal Acceptance Sheet for Week of 2/14/17 through 2/19/17 revealed no documentation that resident was receiving the eight ounces of fortified milk at all meals. The fortified milk was not listed on the sheet. Review of the Meal Acceptance Sheet for Week of 2/20/17 to 2/26/2017 revealed the fortified milk was listed on the sheet and the resident was accepting an average of approximately 75 - 100 %. Review of the Comprehensive Care Plan dated 2/15/17 revealed under Nutritional Status a goal that resident will maintain stable weight without significant weight change throughout next review. Interventions include to provide fortified milk. During an interview on 3/28/17 at 9:31 AM the Diet Technician stated I monitor weekly weights by recording them on the weight grid sheets that are in the charts every week. If we need a reweight I ask the nurse and the nurse will ask the aides to do it. The reason why the fortified milk was not on the intake sheets is because I only print the sheets (meal acceptance) up weekly. Every time there would be a nourishment change, I would have to print up new sheets. During an interview on 3/28/17 at 9:38 AM, the Registered Dietitian stated We document weights monthly. We should be documenting the weekly weights and looking closer at them. We should have addressed the weight loss, but we didn't. I question how accurate admission weights are and that is why I didn't document anything about the weight losses. We should have also addressed the weight loss on the care plans and with the physician. The fortified milk should have been added to the intake sheets right away when we initiated it and not wait till they get printed the next week. We will need to go and hand write them on the sheets. Review of policy entitled Nutrition (Impaired) Unplanned Weight Loss- Clinical Protocol dated 2/1/17 revealed the following the threshold for significant unplanned and undesired weight loss will be based on the following criteria: One month- 5% weight loss is significant; greater than 5% is severe. Three months- 7.5% weight loss is significant; greater than 7.5 % is severe. Six months- 10% weight loss is significant; greater than 10% is severe. In addition, the Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/ or impaired nutrition. Review of the policy entitled Nutritional Assessment dated 2/1/17 revealed an individualized care plans shall address, to the extent possible: a. The identified causes of impaired nutrition. b. The resident's personal preferences. c. Goals and benchmarks for improvement. d. Timeframes and parameters for monitoring and reassessment. e. Resident behavior i.e. weight refusal. Additionally, The IDT (Interdisciplinary Team) will discuss resident status (i.e. weight gain or loss) at the am meeting and weekly weight meeting. 415.12(i)(1)

Plan of Correction: ApprovedApril 28, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F325 415.12(h)(1)(2) 483.25(g)(1)(3)
Maintain Nutrition Status Unless Unavoidable

Resident #131 was discharged [DATE] to the hospital and no longer resides in he facility. The RD will pull and review resident # 131 chart.
Resident #184 was discharged [DATE] to Home in stable condition and no longer resides at the facility. The RD will pull and review resident #184 chart.

The Facility will ensure that each resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the residents clinical condition demonstrates that this is not possible. We will ensure there is no delay in implementation of planned nutritional supplements, the lack of timely nutritional interventions for significant weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels and lack of care plan revisions to address the significant weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels.
All residents who currently reside at Safire Rehabilitation of Southtowns have the potential to be affected by the deficient practice. The Dietary Technician will conduct a 100% medical record review for all residents currently residing in the facility with a 90 day look back to ensure resident weight has been obtained as required and no weight loss has occurred . The Diet Technician will notify the Dietician and the DON whenever deficient practice has been identified. The Dietician/DON will notify the resident's physician to ensure appropriate action occurs. The Dietician/Dietary Technician will analyze and trend data collection and report all findings to the QA Committee at the next scheduled meeting. This audit will be conducted by 5/19/17.
The Dietician will conduct a 100% medical record review including meal acceptance sheets and resident weight records, Labs, MD progress notes, nurses notes, care plan review, etc. for all residents who currently reside at the facility with a 90 day look back to ensure all resident dietary interventions and assessment of protein needs and weight loss/gain are within normal levels.
All Comprehensive Care Plans will be updated under Nutritional Status by the RD and goals & interventions will reflect the current Health Status of the resident.
All deficient practice identified will be reported to the resident's physician, DON and Facility Administrator to ensure appropriate follow action immediately occurs. The Dietician will analyze and trend all data collection and forward all findings to the CQI/QA Committee at the next scheduled meeting.
The current policy and procedure for obtaining resident weights dated 9/24/2010 will be revised by the Corporate DON. The Corporate DON will in-service the Diet Technician, Registered Dietician, Regional Nurse Educator, Regional QA Nurse and the DON/ADON on the policy and procedure revision. The DON will in-service the nursing staff on the revised policy and procedure.
The Corporate DON will re-in service the DON, ADON, Unit Managers, RD, Diet Technician, and the Corporate RN Educator on the 2/1/17 policy & procedure titled Nutrition (Impaired) Unplanned Weight Loss Clinical Protocols.
The DON/ADON will re-in service the Licensed nurses including Agency nurses, who currently work at the facility and New hires will be in serviced by the Regional Nurse Educator.
The Corporate DON and a consulting Registered Dietician (who is not employed by Safire Rehabilitation of Southtowns) will review and revised Policy & Procedures for Nutritional assessments weekly Interdisciplinary Team (IDT)weight meeting, weight assessment, interventions, and resident calorie counts.
The Corporate DON will in-service the DON, ADON, RD, Dietary Technician, and Nurse Managers, Regional QA Nurse, and Regional Nurse Educator on policy & procedures. The DON will in-service the Licensed Staff and CNAs as applicable. The Regional Nurse Educator will in-service all New Hires (Nurses, CNAs and Diet Technicians).
The Corporate DON will review and revise the existing protocol for obtaining orders for Nutritional Supplements and weekly weights. Documentation of resident's P.O. Intake and physician and IDT notification of unintended weight loss and impaired nutrition i.e. low [MEDICATION NAME] levels.
The Corporate DON will revise the Nutritional meal consumption sheets. CNAs will no longer document MD ordered supplements. This will be documented by the licensed nurses on the MAR, which will include the amount of supplement consumed each time administered.
The Corporate DON will in-service the Regional In-Service RN, DON, ADON, Unit Managers, RD, Diet Technician on Policy & Procedure Revisions. The DON will in-service the licensed nurses & CNAs as applicable on the policy & procedure Revisions. The Corporate In-Service Educator will in-service Licensed nurses, RD, Diet Technician, CNAs as applicable.
The Registered Dietician will be required to complete a Weight Variance Report sheet and sent to the DON for distribution to the IDT members (Nursing/Dietary staff prior to the meeting and participate by phone or in person at the weekly weight meetings.
The DON will ensure weights are obtained within 24 hours of a resident admission then weekly times 4 weeks and monthly or as ordered by the physician for existing resident weights.
The CNA and Licensed Nursing Staff will receive disciplinary action and re-education for each episode of non compliance by the DON/ADON. This will be ongoing.
The Facility will no longer use Fortified Milk as a nutritional supplement. Prepared supplements such as Ensure, Boost, Glycerna, etc. will be implemented as recommended by the RD whenever the resident needs nutritional supplements to prevent weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels. The physician will order medications to increase appetite as recommended by the IDT and RD.
The Registered Dietitian will be counseled by the Administrator and Corporate DON for not providing adequate nutritional oversight to the residents residing at the facility.
The Facility will replace the current RD. The Administrator will advertise for this position and the Administrator and DON will together interview potential candidates.
The Registered Dietitian will be required to review all New admissions within 72 hours of the admission and conduct record reviews of all current residents exhibiting weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels with the IDT by phone or in person immediately when weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels is identified.
The Diet Technician will conduct a 100% weight review weekly for residents who require weekly weights, monthly for those residents requiring monthly weights and within 24 hours for those residents requiring admission/readmission weights. All deficient practice identified will be immediately reported to the DON/RD to ensure weights are obtained on the same day. All findings will be reported to the CQI/QA Committee monthly. These audits are ongoing.
The RD will conduct a 100% record review monthly on all residents exhibiting weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels to ensure Dietary interventions are implemented for residents and that they are receiving the recommended supplements, Dietary progress notes are current, care plan interventions and goals are in place and the physician is aware of the resident weight loss & impaired nutrition i.e. low [MEDICATION NAME] levels and plan of care.
All data collection will be analyzed and trended and reported to the DON and Administrator whenever deficient practice is identified. The RD will report all findings to the CQI/QA Committee monthly. This will be on going.

The Registered Dietitian will be responsible for compliance.

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a Standard survey completed on 3/29/17 it was determined that the facility did not ensure that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, one (Resident #53) of 27 residents reviewed for quality of care related to physician's orders had issues involving stool specimens that were not obtained as order by the Physician. 1. Resident #53 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 1/16/17 revealed that the resident is cognitively intact, understood and understands. Additionally, the resident required extensive assist from two staff members for transfers and ambulation. Review of laboratory (lab) results dated 3/13/17 revealed the resident's red blood cell count (RBC) was 2.55 (normal 3.8 to 5.10), hemoglobin was 7.1 (normal 11.7 - 15.5), and hematocrit was 21.4 (normal 35-45). Review of a Physician's Order Sheet dated 3/20/17 revealed an order to obtain three occult blood (OB) stool samples (lab test used to check stool for hidden (occult) blood). Review of the Daily Unit Report (24 - hour report) dated 3/20/17 revealed a notation that stool OB x 3 needed for Resident #53. Continued review of the Daily Unit Reports through 3/28/17 revealed additional notations on 3/27/17 and 3/28/17 that stool for OB needed for Resident #53. Review of a BM Record (bowel movement record) revealed the resident had 10 bowel movements between 3/20/17 and 3/27/17. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 3/21, 3/24, 3/25 the 11:00 PM to 7:00 AM shift documented unsuccessful attempts. During an interview on 3/28/17 at approximately 9:21 AM, Licensed Practical Nurse (LPN #1) stated that she should have written that a stool sample was needed on the white board (dry erase board used for notifications) for the certified nurse aides (CNA's) to see. but she did not. LPN #1 stated that she also writes it on the 24-hour report. If the sample is not obtained, it should be carried over to the next 24-hour report. LPN #1 then stated that the nurses should be reviewing the BM record. LPN #1 also stated that the nurses should be telling the CNA's about needing a stool sample. She stated that the resident is uses a bed pan for toileting needs. The LPN further stated that if they are not able to obtain a sample after a few days she would expect her staff to call the physician. During an interview on 3/28/17 at approximately 9:13 AM, CNA #2 the CNA stated that he was not aware that the resident needed a stool sample and that no one told him. During an interview on 3/28/17 at approximately 9:17 AM, LPN #2 stated that she would normally tell her CNA's that a stool sample was needed from the resident. LPN #2 could not recall if or whom she told. During interview on 3/28/17 at approximately 9:19 AM, CNA #1 stated that she didn't know the resident needed a stool sample. During an interview on 3/28/17 at approximately 1:03 PM, the Nurse Practitioner (NP) stated that it's a reasonable expectation to obtain a stool sample within a few days if the resident is regularly having bowel movements. During an interview on 3/29/17 at approximately 10:29 AM, the Director of Nursing (DON) revealed that the she expects the staff to obtain the stool samples within a few days if the resident is regular and if they could not obtain it to get a discontinue order from the physician. Review of the facility policy entitled Laboratory Orders and Transcription dated 6/16/15 revealed that the facilities will provide and obtain laboratory services when ordered by the physician or nurse practitioner and will ensure efficient and effective expediting of results with appropriate follow up. 415.12

Plan of Correction: ApprovedApril 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F309 483.24, 483.25 (k)(1)
Provide Care/Service for Highest Well-Being.
Resident # 53's Primary Care Physician was notified once.
Deficient practice was identified on 3/28/17. The MD discontinued the orders for stool specimen for occult blood times 3, due to recent laboratory values WNR and no S&S of bleeding noted. The Resident's Comprehensive Care Plan was revised on same day MD order given. The resident remained at the facility in stable condition.
All residents have the potential to be affected by the same deficient practice. All residents who currently reside at Safire Rehabilitation of Southtowns will receive the necessary care and services to attain or maintain the highest practical, physical, mental and psychosocial well-being in accordance with the comprehensive assessment and care plan specially to obtaining Laboratory Specimens timely with out delay as ordered by the physician.
All residents who have had laboratory specimens/bloodwork ordered by the physician over the past 30 days will have a 100% chart review audit conducted to ensure labs/specimens have been obtained as ordered. This chart review audit will be conducted by the unit managers/ADON. Any deficient practice identified will be immediately reported to DON to ensure that physician immediately notified and action is taken. Once audit is completed, all findings will be reported to the DON who will analyze and trend data and report findings to the CQI/QA committee at the next scheduled meetings.
The current laboratory collection log on each unit will be updated by the DON to track the date the physician ordered the lab work/specimens, the resident that the lab work was ordered for, tests ordered, date drawn/collect date results received, and date results reviewed by physician. The Corporate DON will review and revise the current policy and procedure for current lab ordering, specimen collecting and tracking. The revised policy and procedure will ensure that the unit clerks conduct a 7 day look back to ensure all laboratory reports have been received and that lab draws have been scheduled as ordered.
The DON will receive copies of the daily laboratory tracking log M-F to ensure laboratory's specimens and Blood draws have been obtained as ordered. The DON will analyze and trend data and report findings to the CQI/QA committee monthly, this will be ongoing.
The Corporate DON will in-service the DON on Policy & Procedure revision. The DON/ADON will in-service Nursing Staff & Unit Clerks/Medical Records Staff of Revised Policies
Procedures and Forms.
The DON will revise the current Daily Nursing Shift assignment form for all units/all shifts to ensure shift communication/follow through occurs. This form will include Specific Issues that are pending/needed, such as stool specimen, urine specimen collections, weights, NPO status, etc.
The DON will in-service all nursing staff on form revision. This form will be in place by 5/19/17.
LPN #1 who did not verbally communicate and did not write on Dry Erase board for the Nursing/CNA Staff to be advised that Resident #53 needed a Stool Specimen obtain on 3/29/17 will be in-serviced, re-educated and counseled by the DON on current procedures for Staff Notifications Policy & Procedure titled Laboratory Orders and Transcription dated 6/16/15/and Change in Status/Physician Notification policy & procedure to ensure MD is notified timely without delay whenever a specimen is unable to be collected.
The ADON who is responsible for conducting a daily resident status review/audit for any change in condition, and ensuring are outstanding laboratory orders/physician orders [REDACTED].#53.
The Corporate DON will in-service the Newly Hired DON on above audit requirements.
The ADON will continue to be responsible for conducting daily resident change in status review audit entries documented on the 24 hour report and supervisor shift to shift report. This will focus on pertinent information such as documentation in the nurse's notes and that there was evidence that the MD was notified timely. The ADON will review data collection records i.e. - VS, SpO2 sats, neurological check forms, MD orders, lab, diagnostic tests and A/I reports etc, when applicable.
The audit will occur daily M-F with a weekend look back on Monday to ensure MD notification and the follow up occurred. The DON will analyze and trend all data collected and report all findings to the CQI/QA committee at the next scheduled meeting. All residents comprehensive care plans will be reviewed and revised whenever deficient practice is identified. This will be ongoing.
The Unit Clerks will conduct weekly laboratory audits for all residents to ensure all laboratory orders prescribed by the physician have been obtained timely without delay. All negative findings will be immediately reported to the DON
to ensure the MD is notified timely and follow up action occurs, the DON will analyze and trend data collection and report findings to the CQI/QA committee monthly. This will be ongoing.

The Director of Nursing will be responsible for compliance.

E3BP 402.9(b)(2):RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF

REGULATION: Section 402.9 Responsibilities of Providers; Required Notifications. ...... (b) Notifications. A provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when: ...... (2) any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provider.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

Based on interview and record review during the Standard survey completed on 3/29/17, the 105 Termination Form was not submitted to the New York State Department of Health Criminal History Record Check (CHRC) program within thirty days of an employee being reassigned from the direct care of residents or terminated from employment. This affected one (Employee #4) of eight employees reviewed for compliance with CHRC regulations. The finding is: 1. Review of the personnel file for Employee #4 revealed that Employee #4 last worked in the facility on 1/26/17. Interview with the Staffing Coordinator on 3/27/17 at approximately 3:25 PM revealed Employee #4 was a no call/no show on 1/30/17, 2/4/17, and 2/10/17. Further interview with the Staffing Coordinator revealed Employee #4 was terminated from the facility on 2/11/17. Interview with the Human Resource Generalist (Authorized Person) on 3/28/17 at approximately 10:30 AM revealed she was not aware that Employee #4 was terminated by the facility. Further interview revealed she knows the CHRC 105 Termination Form must be submitted within thirty days of termination, but in this case, she was not informed of the employee's termination. Per 10 NYCRR Part 402; CRIMINAL HISTORY RECORD CHECK, a provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when: (1) any prospective employee who is subject to a criminal history record check in accordance with this Part withdraws an application for employment or is no longer being considered as a prospective employee as defined in this Part; or (2) any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provide 402.9(b)(2)

Plan of Correction: ApprovedApril 22, 2017

R1022
Corrective action for deficient practice:
CHRC 105 termination form was submitted by Human Resource Generalist when she was made aware of employee # 4 termination.
Identification and corrective action for all other employee files having the potential to be affected by this deficient practice:
Current employee list to be generated and audited against all employee list.

Systemic changes to ensure that the deficient practice does not occur:
Staffing coordinator to submit weekly list of terminations to Human Resource Generalist for 105 Submission.
A monthly audit will be conducted to ensure all terminated employees have a CHRC 105 termination form within 30 days of termination.
Results will be submitted to the Administrator for 6 months, then bi-annually.
All results of these audits will be presented to the QAA Committee monthly for review and further recommendations.

Responsible Party: Administrator

E3BP 402.9(a)(1):RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF

REGULATION: Section 402.9 Responsibilities of Providers; Required Notifications. (a) Recordkeeping. (1) Each provider shall establish, maintain, and keep current, a record of: (i) a roster of current employees who were reviewed pursuant to this Part and a list of their staffing assignments; such roster shall be submitted by April 1 of each year or upon written request of the Department in a form and format specified by the Commissioner. (ii) the names of each person for whom a request for a criminal history information was submitted to the Department; (iii) for each such name recorded pursuant to subparagraph (ii) hereof, a copy of the signed informed consent form required pursuant to section 402.5 of this Part, (iv) and the results of the criminal history record check and determination of the Department with regard to the employment; and (v) for certified home health care agencies, licensed home care services agencies or long term home health care programs licensed or certified under Article 36 of the Public Health Law, the onsite supervision and alternate week contacts made for assessment of temporary employees as set forth in Section 402.4(b)(2)(ii) of this Title.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Standard survey completed on 3/29/17, the provider did not establish, maintain, and keep current, a record of Criminal History Record Check (CHRC) records for one (Employee #7) of eight employees for whom a request for criminal history information was submitted. The finding is: 1. A telephone interview with the Human Resource Generalist (Authorized Person) on 3/27/17 at approximately 2:30 PM revealed she could not locate any personnel documentation on Employee #7. Further interview revealed she attempted to obtain further information on this individual from the facility's department heads, but none were obtained, and she confirmed with the payroll department that this individual never received a paycheck from this facility. Additionally, the Human Resource Generalist stated after a thorough search, she was unable to locate any documentation on this individual including the job title they were applying for, the employee's CHRC 102 Consent Form, the CHRC 103 Submission Form, the CHRC determination letter, and the CHRC 105 Termination Form. Another telephone interview with the Human Resource Generalist on 3/28/17 at approximately 12:40 PM revealed she contacted CHRC directly and they confirmed that the facility submitted a CHRC 102 Consent Form for Employee #7 on 9/19/16 and CHRC responded with a Hold in Abeyance Letter to the facility on [DATE], and the facility submitted a CHRC 105 Termination Form on the same day. Further interview with the Human Resource Generalist revealed she retains all CHRC documents for all applicants, but she cannot locate anything on this particular one. Review of an email correspondence between CHRC and the Human Resource Generalist dated 3/28/17 revealed the CHRC 105 Termination Form was submitted by this facility for Employee #7 on 9/21/16. 402.9(a)(1)(ii) 402.9(a)(1)(iii) 402.9(a)(1)(iv) 402.9(c)

Plan of Correction: ApprovedApril 22, 2017

R1004
The corrective action for the employee affected by the deficient practice.
The Human Resource Generalist contacted CHRC to obtain a CHRC 102 Consent form and a CHRC 105 termination form that the employee was removed from service the same day as the Hold in Abeyance Letter was received.
The completion date was completed by the Human Resource Generalist on 9/21/16.
Identification and corrective action for employees having the potential to be affected by the same deficient practice:
All current employees and agency employee files will be audited for presence of employment application, CHRC 102 consent form, CHRC 103 submission form, CHRC determination letter.

Systemic changes to ensure that the deficient practice does not recur:
The facility will use an audit tool to ensure the presence of completed employment application, CHRC 102 consent form, CHRC 103 submission form, CHRC determination letter and CHRC 105 termination form (if applicable) for all new hires.
The results of this audit will be submitted to the Administrator monthly for 6 months, then bi-annually.
This will be the responsibility of the Human Resource Generalist.
All results of these audits will be presented to the QAA committee monthly for review and further recommendations.

Responsible Party: Administrator

FF10 483.10(g)(10)(i)(11):RIGHT TO SURVEY RESULTS - READILY ACCESSIBLE

REGULATION: (g)(10) The resident has the right to- (i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (g)(11) The facility must-- (i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

Based on observation and interview conducted during the Standard survey completed on 3/29/17, the facility did not make the results of the most recent Standard survey of the facility, conducted by Federal or State surveyors and any Plan of Correction in effect with respect to the facility, available for examination and readily accessible to residents. The finding is: 1. Observations of the Reception Area and the main bulletin board of the facility from 3/23/17 to 3/24/17 and on 3/27/17, between the hours of 7:00 AM and 3:00 PM, revealed a binder entitled Survey Results. The binder contained Abbreviated surveys from (YEAR). However, the binder did not contain the 5/17/16 Standard Survey results. During an interview on 3/23/17 at approximately 2:00 PM, the Resident Council President stated I don't know where the state inspection is posted. During an interview on 3/24/17 at approximately 9:06 AM, the Receptionist stated that she places the documents in the Survey Results binder, which are provided to her by the Administrator. During an interview on 3/28/17 at approximately 9:14 AM, the Administrator stated that he thought the 5/17/16 Standard Survey results were posted in the Survey Results binder and did not know why they were not in the binder. 415.3(c)(1)(v)

Plan of Correction: ApprovedApril 26, 2017

F167
Safire Rehabilitation of Southtowns, LLC shall make the Results of the most recent Standard Survey conducted by the State and/or Federal surveyors, and any Plan of Correction in effect with regards to this facility, available for examination and readily accessible to residents and family members.
This corrective action was accomplished by the immediate insertion of a copy of the Standard Survey of the 5/17/16 Stand Survey Results with the approved Plan of Correction.
This was corrected on 3/28/17.
The Facility has identified that all Residents and Responsible Parties/Family members who wish to review the results of the most recent Standard Survey results/Plan of Correction has the potential to be affected by the same deficient practice and the corrective action taken with the immediate insertion in the Survey Binder of the 5/17/16 Standard Survey Results with the approved Plan of Correction.
The Survey Results Binder for Safire Rehabilitation of Southtowns is accessible to all residents/family members and is located as you enter the facility near the reception desk.

The systemic changes implemented to ensure the deficient practice doe not reoccur will be the Daily Inspection of the Survey Binder to ensure all required documents, especially the most recent Standard Survey results/Plan of Correction are available. This will be the responsibility of the Day Shift Receptionist and any missing documents are to be reported to the Administrator and replaced immediately.
As mentioned above, this corrective action will be monitored Daily by the Receptionist to ensure that the deficient practice does not reoccur, and the results or any irregularities immediately report to the Administrator for correction.
The Administrator will report monthly to the QA committee the results of the monitoring.

Person responsible for ensuring this corrective action is implemented:
The Administrator

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Standard survey completed on 3/29/17, night lights installed in resident rooms were not maintained and operable. This affected two (First and Second Floors) of two resident use floors. The findings are: 1. Observations on 3/27/17 from approximately 12:00 PM to 2:00 PM revealed each resident room on the First and Second Floor was equipped with a wall-mounted recessed night light fixture. Further observation during this time revealed 19 (3, 5, 8, 11, 12, 17, 19, 21, 23, 27, 31, 33, 35, 36, 38, 40, 42, 44, 50) of 19 resident room night lights on the First Floor and seven (204, 209, 211, 215, 221, 222 225) of seven resident room night lights on the Second Floor did not work. Observation in Resident room [ROOM NUMBER] on 3/27/17 at approximately 12:10 PM revealed the Maintenance Assistant removed the night light cover and found the light bulb had blown out. The Maintenance Assistant replaced the light bulb at this time, and the night light still did not work. At this same time, the Chief Engineer turned on an unlabeled switch at the Nurses' Station and the night light in Resident room [ROOM NUMBER] illuminated with the new bulb installed. Interview with the Chief Engineer at the time of the observation revealed he was not aware that one switch at the Nurses' Station controlled the night lights. Interview with the Maintenance Supervisor on 3/27/17 at 12:10 PM revealed he has worked at this facility for approximately [AGE] years and during this time, the night lights have not been checked for operation and the light bulbs had not been changed. Per the New York State Standards for Nursing Home Construction 713-2, resident rooms shall have general lighting and night lighting, and a reading light shall be provided for each resident. 713-2.22(d)

Plan of Correction: ApprovedApril 22, 2017

I570
The facility shall ensure that night lights are installed in all resident rooms will be properly maintained and operable, per the New York State Standards for Nursing Home construction 713-2.
The corrective actions accomplished for those for those residents affected by this deficient practice is the Maintenance Department replaced all light bulbs in every resident night light and monitored for proper functioning.
We have identified that all resident rooms have been affected by the same practice and new light bulbs and staff in-services/education has been completed to correct this issue.
The systemic changes implemented to ensure this deficient practice does not recur is the inclusion of Night light inspection on a monthly /weekly environmental rounds as well as staff in-service/education on the proper functioning of the night lights.

The corrective action will be monitored to ensure the practice will not recur is to include night light inspection on a monthly environmental maintenance rounds which will be documented and reported by the Director of Maintenance monthly to the QA committee.

This will be corrected by the Director of Maintenance by 4/22/17, and will be the responsibility by the Director of Maintenance to report any issues to the Administrator and the QAA committee to review compliance and possible adjustments.

Responsible Party: Administrator

FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

REGULATION: (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual?s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 3/29/17, the facility did not ensure that a resident having pressure ulcers receives the necessary treatment and services to promote healing and prevent new ulcers from developing. One (Resident #133) of three residents reviewed for pressure ulcers had issues involving the lack of implementing treatment orders for the prevention of skin breakdown to the peri-wound of a healing Stage IV sacral (area above the tail bone to right and left buttocks) pressure ulcer. The finding is: 1. Resident #133, admitted on [DATE] and re-admitted on [DATE], has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/9/17 revealed the resident has no cognitive impairment, understands and is understood. The resident requires total staff assistance for bed mobility, and toilet use, has a urinary catheter (tube inserted into the bladder to drain urine) and is always incontinent of bowel. Review of the Physician Admission History & Physical dated 11/18/16 revealed the resident re-entered the facility on 11/1/16 with a Stage IV sacral pressure ulcer measuring 5 centimeter (cm) Length ( L) x 3 cm Width (W) x 2 cm Depth (D) with a pink base and tunneling (passage way of tissue destruction under the surface) at the two o'clock position. Review of a physician's orders [REDACTED]. Apply Skin Prep (topical application that toughens skin and enhances adherence of dressing) to the peri-wound before applying dressing and [MEDICATION NAME] (antifungal) powder to buttocks and thighs every shift for fungal rash. Review of the hospital-based Wound Clinic/Consult Physician Orders by the hospital Nurse Practitioner (NP) dated 3/20/17 revealed the resident has a skin ulcer measuring 3.1 cm L x 3.1 cm W x 1.5 cm D with plans to apply Zinc based barrier cream to buttocks and peri-wound two times daily, cleanse the ulcer with normal saline, use Alginate as the primary dressing, use Allevyn Foam (absorbent dressing) as secondary dressing, three times a week. The order for the Zinc Barrier cream dated 3/20/17 was not transcribed during the medical record review dated 3/24/17. Observation on 3/24/17 at 11:44 AM revealed the Licensed Practical Nurse (LPN) #5 cleansed the resident's wound with normal saline using gloved hands and fingers to navigate the 4 x 4 dressing to cleanse the wound bed, packed the wound with Alginate dressing using her gloved hands and fingers to pack the wound and undermining (destruction of tissue under the wound edges) visible, and covered the wound with an Allevyn. During the observation, the resident's buttocks and upper thighs were bright red, with multiple excoriations and two noticeable open areas on the right and left buttock; the left buttock open area was weeping a moderate amount or serous fluid visible. LPN #5 applied [MEDICATION NAME] powder on the reddened areas; however, no barrier cream was applied to the buttocks or thighs. During an interview on 3/24/17 at 3:56 PM, LPN #4 Unit Manager (UM) stated that she received the end of shift report from the LPN Treatment Nurse who did not report any abnormal findings. LPN #4 UM stated that the Treatment Nurses and Certified Nurse Aides (CNA's) are responsible to inform her of any new open skin issues. During the interview LPN #4 UM reviewed the end of shift report and stated there was nothing regarding the resident on the report for the 7:00 AM - 3:00 PM shift. Further resident observation with the Registered Nurse (RN) #2 acting Director of Nursing (DON) on 3/24/17 at 4:08 PM, RN #2 DON stated that the resident had an extremely reddened buttocks and upper thighs with two new open skin issues not present during the previous skin evaluation. RN #2 DON stated that he would obtain new skin treatment orders for the resident. During an interview on 3/24/17 at 4:18 PM, LPN #5 stated that when she applied the [MEDICATION NAME] powder on the resident's reddened buttocks and upper thighs she did not notice any open skin wounds. Review of the RN Weekly Wound documentation dated 3/24/17 by RN #2 DON revealed the resident had two new excoriations one on the right buttock measuring 4 cm L x 0.5 cm W with 100% (percent) epithelized (formation of surface area of skin) tissue and one on the left buttock measuring 0.4 cm L x 0.4 cm W with 100% epithelized tissue. During an interview on 3/27/17 at 9:39 AM, the facility's NP stated that the resident goes to the hospital-based Wound Clinic every two weeks and the facility follows their treatment recommendations. The NP stated when the resident returns from the clinic the nurses transcribe the orders and the treatment sheets get placed in the provider's order for signature. The NP stated although she signed the 3/20/17 consult, she assumed the nurses had already transcribed the order for the Zinc barrier cream. The NP inspected the resident's skin during the interview and stated that the right buttock was not healed. 415.12(c)(2)

Plan of Correction: ApprovedApril 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F314 483.25 (b)(1)
Treatment/Svcs to Prevent/Heal Pressure Sores.
Resident # 133 Primary Care Physician was immediately notified once deficient practice was identified on 2/24/17. The PCP gave verbal orders to discontinue to the current peri-wound treatment and for [MEDICATION NAME] powder and gave order to start zinc barrier cream to buttocks and peri-wound area two times daily after cleaning site with normal saline. On 3/25/17, the weekly Dermal Wound documentation written by the RN performing weekly assessment measured .4cm excoriated area to Left buttocks was healed. The RN assessment indicated that the .5cm excoriated area identified on 3/25/17 on the Right buttocks was healed. The resident continued with the same treatments after excoriation sites healed. The Sacral ulcer measurement obtained on 3/27/17 indicated a Healing Stage 4, 3.0cm, 3.0cm, 1.5cm, undermining 2.5cm @ 1 o'clock with 20% slough. No drainage noted on 4/3/17.
The resident returned to the Wound Care Clinic. Sacral wound was measured, 3cm x 3.5cm x 1.5cm Stage 4 Pressure Ulcer. No other impaired skin identified and to continue current treatment. Follow up return visit scheduled for 4/17/17.
On 4/7/17 Resident #133 was transferred to the hospital for c/o sore throat and chest congestion and abdominal discomfort.
Resident returned to facility on 4/12/17. [DIAGNOSES REDACTED].
Resident #133 returned to the wound care clinic on 4/17/17. Wound Clinic recommends continue current treatment.
The resident's comprehensive care plan was revised on 3/24/17, 3/25/17, 3/27/17, 4/3/17, 4/7/17, 4/12/17 and 4/17/17 to include wound measuring, staging wound bed description, updated treatment and medication orders and update plan of care/Dx upon return from the hospital on [DATE].
Resident currently resides at the facility in stable condition.
The facility will ensure that each resident having Pressure ulcers receives the necessary treatment and services to promote wound healing and prevent new ulcers from developing and ensure Physicians treatment orders are implemented for the prevention of skin breakdown.

All residents who currently reside at Safire Rehabilitation of Southtowns who have existing pressure sore ulcer, have the potential to be affected by the same deficient practice.
These identified residents will have their plan of care and comprehensive care plan reviewed and revised to ensure they receive necessary treatment and services to promote wound healing, prevent infection and pressure ulcers from developing. These residents who have been identified, will have a 100% medical record review to ensure that their physician's orders [REDACTED]. The IDT team will compare the physician's orders [REDACTED]. All deficient practice will be reported to the MD when applicable.
The DON will analyze and trend all data collection and report findings at the next CQI/QA Committee meeting.
The DON will conduct mandatory trainings for all Nurses/CNAs working at the facility. This will include agency staff and facility employees. These trainings will focus on observe and report resident findings to the licensed nurse whenever impaired skin integrity is identified, or a wound care dressing is soiled/wet due to incontinence or is dislodged from wound. The training will also focus on pressure ulcer prevention interventions such as, turning & positioning, incontinence care, keeping the resident hydrated and following the residents pocket care plan for positioning devices and pressure relief.
The ADON will be responsible for in-servicing all new nurses and CNAs on hire. This will be ongoing.
All Licensed Nurses currently working at the facility including Agency nurses and New Hires will be rein-serviced by the DON/ADON on the existing Policy and Procedure for Medical Appointment Scheduling and Tracking System to ensure resident's consultations are reviewed upon the return visit and the Physician is immediately notified of recommendations and medication/treatment order are implemented on same day.
LPN #5 who did not identify, document, or report to the Unit Manager or RN that Resident #133 had 2 new weeping open areas/excoriation to her buttocks when applying the ordered treatment, will be counseled and re-in serviced by the DON on current Wound Care Policies & Procedures Specific to data collection and reporting and documenting new areas of impaired skin integrity.
The Licensed Nurse who was working the shift on 3/20/17 and did not notify the RN Supervisor or Physician of Wound Care Clinic Recommendations and obtain treatment orders, will be counseled and in-serviced by the DON on following the facility Policy & Procedure for MD notification and medical appointment scheduling Policy which is inclusive of returning from Clinic visits and notification of MD.
The DON will continue to complete the weekly QA Wound Assessment Audit tool and IPRO monthly pressure ulcer tracking tool to ensure pressure ulcer assessment and care plan interventions have been initiated and there is evidence that physician' orders have been carried out for the residents who have pressure ulcers. The data collection review will include wound staging, measuring, wound description, improvement status, and treatment order intervention, documentation that wound cleansing and treatment occurred, pain management and pressure relief interventions are in place and available and the care plan has been completed. The DON will forward this audit to the Regional QA nurse weekly for review.
The IPRO monthly pressure ulcer tracking tool will be completed by the DON monthly. This audit tool will track resident location, admitted , pressure ulcer onset date, in house hospital acquired healing status, current treatment, care plan interventions, etc. This report will be forwarded to the Corporate DON and Regional Quality Assurance RN for review. All findings will be analyzed and trended and reported to the CQI/QA committee monthly. This will be ongoing.
The ADON will be responsible for conducting daily resident change in status entries documented on the 24 hours' report and Supervisor shift to shift report and has been documented in the nurses notes and there was evidence that the MD was notified timely. Record review with include new pressure ulcers/impaired skin integrity, review data collection records, i.e.-VS, SpO2 sats, neurological check forms, MD orders, lab diagnostics tests and A/I reports, impaired skin integrity report have been completed as required, etc.
This audit tool will be completed daily M-F with a weekend look back on Monday to ensure MD notification and the follow up occurred. The DON will analyze and trend all the data collected and report all findings to the CQI/QA committee at the next scheduled meeting. All residents comprehensive care plans will be reviewed and revised when ever a deficient practice is identified. This will be ongoing.

The Director of Nursing will be responsible for compliance.

Standard Life Safety Code Citations

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: March 29, 2017
Corrected date: May 26, 2017

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 3/29/17, the facility did not develop a program for the maintenance of electrical equipment per manufacturer's recommendations and did not maintain a written record of maintenance and testing of all patient care-related electrical equipment. This affected equipment (mechanical lifts and electric beds) used on two (First and Second Floors) of two resident use floors. The findings are: 1. Interview with the Maintenance Supervisor on 3/27/17 at approximately 10:25 AM revealed facility Maintenance staff members conduct weekly preventative maintenance checks on each of their six patient lifts. Further interview revealed the weekly checks included a visual inspection, battery check, and tightening of each lift's bar and boom, however he has no written documentation of these weekly preventative maintenance checks. Review of the lift manufacturer's Maintenance Safety Inspection Checklist revealed the manufacturer recommended monthly inspection of various components for wear, deterioration, and secure joints, and lubrication was to be performed every six months. 2. Interview with the Maintenance Supervisor on 3/27/17 at approximately 10:45 AM revealed facility Maintenance staff members conduct a preventative maintenance check on each electric bed between users. Further interview revealed the checks include proper operation and cord safety, however he has no written documentation of these preventative maintenance checks. Further interview revealed there is no regularly scheduled preventative maintenance check on electric beds where the same resident uses the bed long-term, but Housekeeping Aides do regularly clean all beds, and he expected Housekeeping staff or Nursing staff to report anything out of the ordinary to a Maintenance staff member. Review of the electric bed manufacturer's Maintenance and Safety Checks revealed the manufacturer recommends electric controls, frame welds, and bolts to be checked and moving parts to be lubricated between users. Review of a facility policy titled Preventative Maintenance, issued 2/1/17, revealed Hoyer lifts and beds will have preventative maintenance completed on a regular basis in accordance with the manufacturer's guidelines and a separate file or log will be maintained. The 2012 edition of NFPA 99, Health Care Facilities Code states a record shall be maintained of the tests required and associated repairs or modifications. At a minimum, the record shall contain all of the following: (1) Date (2) Unique identification of the equipment tested (3) Indication of which items have met or have failed to meet performance requirements 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.5.2, 10.5.2.1, 10.5.2.1.1, 10.5.3, 10.5.3.1.2, 10.5.6, 10.5.6.2, 10.5.6.2.1, 10.5.6.2.2

Plan of Correction: ApprovedApril 26, 2017

K921 Electrical Equipment - Testing and Maintenance
The corrective action taken to correct the deficient practice was to have the Director of Maintenance develop and maintain a Maintenance Log to document the weekly preventative maintenance checks on the six (6) Patient Lifts and the various electric beds, utilizing the Manufacture's Specifications to ensure that all audits are consistent with the Manufacture's Requirements.
The facility has identified that all mechanical Lifts and electric beds in the facility have the potential to be affected and implement the Weekly Preventive Maintenance (PM) log, which a copy will be turned in to the Administrator from the Director of Maintenance. The audits will include all electrical equipment in the facility and Maintenance will utilize the Manufactures specifications for care/maintenance including resident's personal equipment.
The systemic changes that the Director of Maintenance will implement to ensure corrective compliance is the establishment of a PM Log Book that will document compliance and submit to the Administrator monthly, which will include all electrical equipment both Facility property as well as resident personal electrical belongings.
This corrective action will be monitored by the Administrator on a monthly basis through review of the submitted PM Log, and then to report results to the QA Committee on a monthly basis.
This correction will be the responsibility of the Director of Maintenance and the Administrator.
Person responsible for compliance:
Administrator

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 29, 2017
Corrected date: May 26, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 3/29/17, the facility's emergency generator was not connected to a remote alarm annunciator. This affected one of one emergency generator, that provided emergency backup power to three (Basement, First, Second) of three floors. The finding is: 1. An interview with the Chief Engineer on 3/23/17 at approximately 11:30 AM revealed the facility's emergency generator was located in the Basement and the facility did not have a generator annunciator panel connected to it. Observation on 3/23/17 at approximately 1:40 PM revealed the facility's emergency generator was located in the Generator room, of the Basement, which was not a regular work station that was readily observed by facility personnel. Per the 2012 edition of NFPA (National Fire Protection Association) 99, Health Care Facilities; A remote annunciator, that is storage battery powered , shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.4.1.1.17, 6.4.1.1.17.5

Plan of Correction: ApprovedApril 22, 2017

K916 - Electrical Systems
How the corrective will be accomplished for any resident affected by deficient practice.
A remote annunciator will be purchased and hard wired to indicate alarm conditions.

How we identified other resident/areas that could be potential affected. All residents are at risk for this deficient practice.
Measures to ensure were/will be put into place to assist this area of concern. All maintenance staff will be educated on the requirement for a remote annunciator to be hard wired to the generator. Generator audits will conducted monthly to ensure that the generator remains in compliance. Any negative findings will be immediately addressed and the staff involved will be re-educated.

How the concern will be monitored and title of person responsible for monitoring. The results of monthly generator audits will be reported to the Administrator and the Quality Assurance committee no less than bi-monthly for review and action as needed.
Person responsible for compliance:
Administrator