Presbyterian Home for Central New York Inc
December 18, 2017 Certification Survey

Standard Health Citations

FF11 483.10(f)(10)(iii):ACCOUNTING AND RECORDS OF PERSONAL FUNDS

REGULATION: §483.10(f)(10)(iii) Accounting and Records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: December 18, 2017
Corrected date: February 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined during the recertification survey the facility did not provide 2 of 2 residents (Residents #36 and 186), reviewed for personal funds, with their individual financial record through quarterly statements and upon request. Specifically, Residents #36 and 186 were not provided resident personal funds statements at least on a quarterly basis per their preference or on request. Findings include: The 11/1998 Policy and Procedure for Personal Living Accounts documented resident fund statements indicating activity in the account are sent out on a quarterly basis. The policy did not include a plan on who would be receiving the quarterly statements. The copy of the facility's Admission Agreement provided to residents and/or representatives was provided to surveyors on 12/13/17, had no documentation specifying a plan for personal funds statements as agreed upon by the resident and/or representative. 1) Resident #186 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/17/2017 Minimum Data Set (MDS) assessment documented the resident had moderate cognition, and was supervisory to limited assist with activities of daily living (ADLs). The 07/20/2017 nursing admission screening documented the resident was alert, and had intact cognition with short term memory problems. The 07/22/2017 comprehensive care plan (CCP) documented the resident had moderately impaired cognition and decision making skills, and had advanced care directives. Interventions included advocate and assist as needed, and allow and encourage him to express his wishes. The 08/09/2017 social services progress note documented the resident felt he had done well in the long term environment and his placement was considered long term. The resident was offered a bed on a particular unit and had accepted the move. The 09/28/2017 nursing admission screening documented the resident was alert and had intact cognition. When interviewed on 12/12/17 at 10:54 AM, the resident stated the facility did not inform him of how much was in his account. When he has asked, they did not tell him. He asked recently and could not remember when. He had only been in the facility a couple of months and transferred from an assisted living facility. He had not received an account statement from the facility since he was admitted to determine the balance of his account. When interviewed on 12/18/17 at 12:38 PM, Business Office Manager #5 stated personal account statements were sent quarterly unless the resident account was overdrawn and then statements were sent out monthly. The statements were usually sent out to the family or a power of attorney (POA). If the resident was cognizant, the facility still only sent the statements to the family/POA, not to the resident. The resident's statements were sent to family as he recently was admitted from a residential facility. The facility sends the statements to whomever set up the account. 2) Resident #36 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 09/20/17 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and participated in his assessment. During the resident group meeting on 12/13/17 at 10:04 AM, the resident stated he did not receive regular statements documenting his transactions for his personal funds, and he would like to receive them. The 12/17 comprehensive care plan (CCP) documented the resident required reassurance and encouragement to maintain as much independence and control as possible. When interviewed on 12/18/17 at 12:38 PM, Business Office Manager #5 stated personal account statements were sent quarterly unless the resident account was overdrawn and then statements were sent out monthly. She stated the statements were usually sent out to the family or power of attorney (POA). She stated if the resident was cognizant, the facility still only sent the statements to the family/POA. The resident's family member received his statements as he received medicaid assistance, and his family member was POA and set up his account. The resident's account was always overdrawn and his family member received a monthly statement. The resident's 09/13/17-12/18/17 personal funds account statement, documented the resident had an account in place and deposit and withdrawal transactions were made during that time. The resident's account remained in positive balance and was not overdrawn through this time period. 10NYCRR 483.10 (f)(10)(iii)

Plan of Correction: ApprovedJanuary 15, 2018

I. Quarterly Personal Needs Account statements for the period (MONTH) (YEAR) ? (MONTH) (YEAR) have been provided to resident #36 and resident #186 as of (MONTH) 5, (YEAR) and will continue to receive them as they requested.
II. Any resident who wishes to receive the quarterly Personal Needs Account statements could be at risk for this deficient practice. A policy will be developed to address receiving quarterly Personal Needs Account statements. The Resident Council meeting which is Thursday, (MONTH) 11, (YEAR), the attending residents will be informed of their rights to be provided with this document by the Administrator. Social Workers will identify by verbal communication any other potentially affected residents who did not attend the resident council meeting and communicate their right to be provided this document as well. It will be the resident's choice if they would like to receive these statements. This will be completed by (MONTH) 31.2018.
III. The policy for Personal Needs Account statements will include informing all residents upon admission of their right to the statements. Ability to receive statements will be published in the Resident Rights document and an updated document will be provided to all residents. Business office, Social Services, and Admissions will be re-educated on the distribution of quarterly personal needs account statements, including the distribution to residents who request them. If the resident's request the statement, they will not have to continue to request them, it will be provided on a quarterly basis on the 3rd, 6th, 9th and 12th month of the year.
IV. An audit will be performed to validate residents are given a choice to receive their personal needs account statements, have received a copy of the resident rights document, have a designation in their record related to receipt of the statement, and that residents who have requested a statement received one quarterly. The audit will be conducted monthly for all new admissions and quarterly for all others. The audit findings will be presented to the QAPI committee for review and follow up as needed. The audit will continue for at least 1 year.
V. The administrator will be responsible for this correction.

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2017
Corrected date: February 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, the facility did not ensure 1 of 2 residents (Resident #142) reviewed for range of motion (ROM) received the appropriate treatment and services to improve and/or to prevent a decrease in ROM. Specifically, Resident #142 did not have positioning devices in his left hand as planned. Findings include: Resident #142 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/10/2017 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, impairment of one arm and hand, and required extensive assist with most activities of daily living (ADLs) including hygiene, mobility, dressing, and eating. The 11/06/2017 updated comprehensive care plan (CCP) documented the resident had a self-care deficit related to [MEDICAL CONDITION] and dementia, and had left hand contractures. Interventions included palm guard and carrot (foam device used to prevent contractures) in his left hand at all times except for bathing and hygiene, and required the use of a palm guard at all times except during bathing. The undated certified nurse aide (CNA) Kardex (care instructions) documented to turn and reposition every 2 hours with extensive assist of 2, and the resident required the use of a palm guard on at all times except during bathing. When interviewed on 12/12/17 at 11:39 AM, CNA #8 stated the resident was seated in his Geri chair (specialized positioning chair) and was to have hand splints and he had a [DIAGNOSES REDACTED]. His left hand splint was off and in his lap while sitting in the dining room, and staff were bringing residents into the dining room passing by the resident. The resident was observed: - On 12/12/17 at 05:22 PM, the resident was sitting in his Geri chair in the unit dining room, and no palm guard or carrot was noted in his left hand. - On 12/14/17 at 08:27 AM, the resident was seated in his Geri chair in the unit dining room with no left palm roll. He was being fed his meal by staff. - On 12/14/17 at 09:12 AM, the resident was up sitting in his Geri chair in the hallway. There was no palm grip in his left hand. - On 12/14/17 at 01:22 PM, the resident was sitting in his Geri chair in the unit dining room. There was no palm grip in his left hand. On 12/14/17 at 03:17 PM, the resident was laying on his mattress on the floor having spastic movements throughout his body. No palm grip or carrot was noted in his left hand. His left hand remained contracted and he was able to open it slightly when asked. He stated his hand bothered him at times. There was a blue carrot for his left hand in the top drawer of his dresser and no palm grip found in his room. He stated neither the carrot or palm grip bothered him when they were in his hand. On 12/15/17 at 11:39 AM, the resident was in his Geri chair in the unit dining room for an activity. No left hand palm grip was seen. The blue carrot was in top dresser drawer. When interviewed on 12/15/17 at 02:33 PM, CNA #10 stated the Kardex documented resident specific care and what adaptive equipment was needed for a resident, and that CNAs were supposed to follow the Kardex. The resident was to have a palm grip and a carrot for his left hand, she had not seen the carrot in a couple of weeks, and thought therapy put them on the residents daily. Sometimes his palm grips were missing, she would notify the nurse and they would inform therapy. She did not see them in his room at that time. The CNA ADL documentation record did not provide ability for CNAs to sign for adaptive equipment. She thought they were discontinued, was not sure if they were on his Kardex, and did not see the carrot when she checked his dresser drawers that morning. The palm grip and carrot were to prevent pressure sores and worsening of contractures. When interviewed on 12/15/17 at 03:09 PM, registered occupational therapist (OTR) #9 stated she was familiar with the resident. She usually evaluated contractures, measured the range for pre and post therapy, started with a palm guard if they were very contracted and she was concerned about skin integrity and hygiene, and then progressed to using a carrot. For him, she used both on the left hand. He was planned to have both at the same time at all times except hygiene and bathing. She expected staff to follow the care plan. The resident was no longer severely contracted, and if staff do not use the palm guard and carrot his contractures could worsen. She gave him multiple sets of palm guards when she discharged him from therapy a couple of weeks ago, and had his name written on them. The last time she saw him was the end of last month. If worsening of contracture noticed by CNAs, they should speak to nursing and get a occupational therapy (OT) referral. When interviewed on 12/18/17 at 09:38 AM, the Director of Nursing (DON) stated the resident's carrot and palm guard should be used at all times if on the CCP or Kardex. They were not listed on his Kardex, so she did not know how staff would know to use it. OT should have checked to see if they were added to the Kardex, and it was not generated to the Kardex. When re-interviewed on 12/18/17 at 11:54 AM, OTR #9 stated there was not place to check off on the CCP to carry over the carrot and palm guards to the Kardex when she inputted the devices to the CCP. When interviewed on 12/18/17 at 12:21 PM, licensed practical nurse (LPN) #4 stated the registered nurse (RN) Unit Manager completed the CCP, the unit's RN Unit Manager had been out sick for 3 weeks, and other RN Unit Managers had been filling in for her and updating the residents' CCPs. The RN Unit Manager and CCP team ensured CCP and Kardex accuracy. If something was not on the Kardex, it was not in the CCP. The CNAs were supposed to ensure his palm guard and carrot was used, the nurses were supposed to double check, and she checked on them at least once a shift. 10NYCRR 483.25 (c)

Plan of Correction: ApprovedJanuary 15, 2018

Resident #142?s Care plan was updated to reflect contracture information and use of device on 12/18/17. During correction the care plan intervention was set up to transfer over to the kardex for daily care for staff. Cedar staff were immediately educated on 12/17/17. Resident # 142 had no ill effects related to the use of the device. Resident is no longer at the facility. Protection of Others
A current list of residents with contractures and splints within the facility care plans have been reviewed and revised where needed to reflect information to the kardex for daily care for staff. Kardex for each has also been reviewed to confirm information has carried over from the plan of care with task for staff to sign for in relation to the resident daily needs. Contracture list consisted of 22 residents, splint list consisted of 5 residents, all followed by therapy as needed.
Prevention
Contracture list Policy was reviewed and revised to include the following addition:
1. Following PT/OT review of resident identified to have a contracture, screen with interventions will be given to the Nurse Managers to allow their participation in the plan of care and kardex information for staff with task input.
2. Daily skin inspection of contracture area with assistive devices will be placed in the TAR for licensed staff.
3. Q Shift assessment of device will be placed in TARS for sign off by licensed staff.
Mandatory education to all RN an LPN staff, aides, and therapy on the revised policy and procedure by 2/16/18.
Monitor
Nurse Managers will audit TARS for overall compliance of verifying and signing daily.
Initial audit completed by DON, ADON, Nurse Managers.
DON or designee will complete an ongoing audit weekly x 4 weeks, then monthly for 3 months. Audit results will be submitted to QAPI committee monthly for review and follow up as needed. Nurse Manager to observe for use of assistive devices during unit rounds daily.
DON or designee will ensure facility compliance by 2/16/2018.

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2017
Corrected date: February 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey for 1 of 7 residents (Resident #134) observed for infection, the facility did not ensure the facility established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not maintain infection control protocol while providing care for Resident #134 who was on contact precautions. Findings include: The 11/2017 revised [MEDICAL CONDITION] infection control policy documented gloves must be donned prior to entering the room, worn while in the room, and removed before leaving the room. The policy documented hands must be washed before leaving the room. the policy documented gowns were to be worn when entering the room to provide care and removed prior to departing the room. Resident #134 was admitted [DATE], re-admitted [DATE], and had [DIAGNOSES REDACTED]. The 12/09/17 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required limited to extensive assist with activities of daily living (ADLs), was continent of bowel, received an anti-biotic daily, and had [MEDICAL CONDITION] The 10/19/17 hospital report documented the resident was positive for [MEDICAL CONDITION]. The 10/23/17 hospital discharge summary documented the resident was diagnosed in the hospital with [MEDICAL CONDITION], was put on antibiotics, and continued to have loose stools. The 10/23/17 at 10:29 PM nursing progress note documented the resident was readmitted from the hospital, had active [MEDICAL CONDITION], and was placed on contact precautions. The 10/24/17 comprehensive care plan (CCP) documented the resident chose not to self administer medications, had bowel incontinence and [MEDICAL CONDITION]. Interventions included administer medications per physician order; monitor for stool character; provide incontinence care in the morning and bedtime, before and after meals, and as needed; place on contact isolation; and educate resident/family/staff regarding preventative measures to contain the infection. When interviewed on 12/12/17 at 12:13 PM, registered nurse (RN) Unit Manager #3 stated the unit had 3 residents on isolation for [MEDICAL CONDITION]. She stated the surveyor and staff needed to wear/don gown and gloves when entering room, and she expected that they removed gown and gloves and washed hands prior to exiting the room. On 12/12/17 at 12:29 PM, the surveyor was in the resident's room and she was on contact precautions for [MEDICAL CONDITION]. Certified nurse aide (CNA) #6 brought the resident her meal tray without donning a gown and gloves. The CNA was wearing a face mask, he knocked on door, entered room with tray, set the tray down on her overbed tray, the resident refused the meal stating she only wanted soup, the CNA then picked up tray and he exited room. The CNA did not wash his hands prior to leaving the room. On 12/12/17 at 12:33 PM, CNA #6 was observed in room [ROOM NUMBER] setting up the resident's lunch tray, and he washed hands prior to leaving that room. On 12/12/17 at 04:08 PM, licensed practical nurse (LPN) #7 was observed preparing medications at the medication cart in the hallway, he put on gloves and entered the resident's room with medications in a small cup, and did not put on a gown. After administering her medication, he removed his gloves in the room and washed his hands prior to exiting. The 12/13/17 physician order [REDACTED]. When interviewed on 12/14/17 at 04:49 PM, LPN #7 stated the resident was on contact isolation, and personal protective equipment (PPE) depended on what kind of isolation the resident was on. Staff were to always put on gloves, and a gown if possibly coming in contact with objects in the room. If the resident had [MEDICAL CONDITION], he would do nothing different. He would not wear gown if only giving medications, as he was very careful when he went into a room with [MEDICAL CONDITION]. [MEDICAL CONDITION] was very contagious, and there was not always a guarantee I won't bump into something. He went through facility orientation, and did not recall what was taught regarding PPE. CNAs should always wear a gown and gloves when entering the room as they provided hands on care and bump into things while providing care. When interviewed on 12/15/17 at 09:27 AM, CNA #6 stated he had been a CNA for 5 years, and had infection control and PPE education about a year ago. When he brought in the meal tray, he did not put on a gown or gloves. [MEDICAL CONDITION] was very infectious and could be spread if not gowning or putting on gloves. He was taught to gown and glove before entering room, remove gown and gloves in room when done, and wash hands prior to leaving the room. He did not have anywhere to put the tray down prior to entering the room and forgot to put on the gloves and gown. He should have brought the tray cart down the hall to keep the tray on when putting on gown and gloves. When interviewed on 12/18/17 at 09:38 AM, the Director of Nursing (DON) stated for infection control, she expected staff to wear gown and gloves when entering a resident's room when the resident had [MEDICAL CONDITION], and expected proper hand washing with soap and water when leaving the room. She expected them to wear gown and gloves even when passing medications. 10 NYCRR 483.80 (a)

Plan of Correction: ApprovedJanuary 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 134 was not affected by deficient practice. Staff member # 6 and # 7 were immediately disciplined, HR file reviewed, educated with return demonstration for selecting appropriate personal protective equipment (PPE) based on resident specific precautions.
Protection
All other residents were at risk related to the deficient practice, no ill effects have been noted to any resident to date.
Immediate education with return demonstration of PPE were conducted on all units to clinical staff with isolation rooms.
Availability of PPE and appropriate signage is in place for residents with isolation precautions.
Prevention
Contact and [MEDICAL CONDITION] Infection policy and procedure were reviewed. Changes made to contact precautions include:
Patient Care Nurse on duty will have a task in the TAR to include monitoring and stocking PPE, making sure sign is posted on the door QS.
All staff within the facility will be educated by Staff Development and Education to include all types of isolation, selection of appropriate PPE, return demonstration of donning and removing PPE, hand washing.
Monitor
DON or designee will perform an audit on all residents on isolation to include appropriate isolation in place, staff interviews and staff observations during care. Audits will be conducted weekly x 4 weeks, then monthly for 3 months. Audit results will be submitted to QAPI committee monthly for review and follow up as needed.
DON or designee will ensure compliance by 2/16/2018.

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 18, 2017
Corrected date: February 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey the facility did not maintain drugs and biologicals stored and labeled in accordance with currently accepted professional standards, and the expiration date when applicable for 3 of 6 nursing units (Units Birch, Cedar, and Elm) inspected. Specifically, inspection of medication rooms revealed Units Birch and Cedar had multi-dose vials that were expired or outdated beyond the opened expiration date. The Unit Elm nurse administered the [MEDICATION NAME] to Residents #146 and 163, did not label the vial when she opened it, and the vial was not discarded 28 days after opening it. Findings include: The 6/2016 facility Storage and Maintenance of Medication policy documented medication should be checked regularly for expiration dates and deterioration. Expired medications are removed from use and destroyed. The 8/2017 revised facility Medication Administration policy documented all medications with shortened expiration dates when opened should be dated, and staff are responsible for knowing which medication needs to be dated due to shortened expiration. Resident #146 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 11/14/17 Minimum Data Set (MDS) assessment documented the resident had full cognition, and was extensive assist with most activities of daily living (ADLs). The 11/2017 Medication Administration Record [REDACTED]. Resident #163 was admitted on [DATE], re-admitted on [DATE], and [DIAGNOSES REDACTED]. The 10/2/2017 admission MDS assessment documented the resident had full cognition, and was extensive assist with ADLs. The 09/25/17 hospital discharge summary documented the resident had a right lung mass and family did not wasn't a biopsy or treatment. The 11/14/17 MDS assessment documented the resident had full cognition and was limited to extensive assist with ADLs, and used a bilevel positive airway pressure or continuous positive airway pressure ([MEDICAL CONDITION] or [MEDICAL CONDITION], machine used during sleep due to difficulty breathing at night). The 11/2017 Medication Administration Record [REDACTED]. The undated resident immunization record documented the resident was tested for [MEDICAL CONDITION] exposure via a Mantoux test ([MEDICATION NAME] injection under the skin) on 11/08/2017 and 11/21/2017, and both were negative. On 12/13/2017 at 11:15 AM, the surveyor noted a vial of [MEDICATION NAME] labeled as opened on 10/28/2017. The vial was observed in the Cedar unit medication refrigerator. On 12/14/2017 at 02:25 PM, the surveyor observed a vial of [MEDICATION NAME] labeled as opened on 10/24/2017 in the Birch unit medication storage refrigerator. There were needle puncture marks on the rubber [MEDICATION NAME]. When interviewed on 12/18/17 at 11:16 AM, registered nurse (RN) Unit Manager #2 stated she expected whoever opens a multi dose vial to put the date and initials on the label. The [MEDICATION NAME] vial should be thrown out 28 days after opening them. The vials should be checked every day by the day shift nurse. When interviewed on 12/18/17 at 11:44 AM, RN Unit Manager #3 stated the [MEDICATION NAME] vial was to be discarded after 30 days of opening it, and should be dated, timed and initialed by the nurse opening the vial. Multi dose vials were checked weekly by the medication nurse on day shift. There was no specific place to document the vials were checked for expiration, as staff were supposed to check the vials every time prior to administering the medication. On 12/15/17 at 02:11 PM, licensed practical nurse (LPN) #1 opened the Elm medication refrigerator, the [MEDICATION NAME] vial was dated with an expiration of 11/16/2018, it did not have a safety cap on the top of the vial and puncture marks were noted in the rubber [MEDICATION NAME]. LPN #1 stated she opened the vial, never dated the vials when they were opened, and she opened the vial and administered the test to Resident #146 and Resident #163 when they were admitted . She stated she checked the medication expiration dates in the refrigerator on a weekly basis. When interviewed on 12/18/17 at 12:07 PM, LPN #4 stated multi dose vials were to be dated and initialed by whoever opens the vials. The medications nurse checked the multi dose vials every day when they checked the medication fridge and controlled medications. She did not think the facility had a signature sheet for checking the multi dose vials, and did for the narcotics and syringe counts. She opened the [MEDICATION NAME] vial on 10/28/2017, and time and dated it when she opened it. Once the vials were opened, the vials were good for 30 days. The LPN noticed the vial was expired and threw the multi dose [MEDICATION NAME] vial out. She did not notice when the vial had expired until the surveyor asked her just then about the expiration date. She worked full time at the facility on that unit, and checked the vial every day she passed medications on the unit which was not every day. She passed medications last week on the unit, and she did not notice that it had expired. When interviewed on 12/18/17 at 09:38 AM, the Director of Nursing (DON) stated multi dose vials should be dated when opened, and also timed and initialed. She was not sure how often staff were to check on expiration of multi-dose vials and to ensure they were appropriately time, dated and initialed. She would expect staff to throw out the unlabeled bottle and open a new one, or at least research as to when it was opened. 10NYCRR 483.45 (g)(h)

Plan of Correction: ApprovedJanuary 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 146, 163. All mutil dose vials were immediately discarded, new ones were opened and dated, and no ill effect has been noted to either resident.
All other residents had the potential for deficient practice, no ill effects have been noted in any resident to date.
Protection
All multi-dose vials in the facility were checked for date, if no date or were expired, vials were immediately thrown out, new ones opened and dated on [DATE].
Prevention
Policy of Medication Administration was reviewed and revised of the following:
All multi-dose vials are to be dated upon opening with date, time and initials by licensed staff for a discard date per pharmacy regulation.
Reference sheet will be attached to policy from pharmacy for date recommendations.
All multi-dose vials such as [MEDICATION NAME], Influenza, Pneomovax will be stored on Aspen Unit only to avoid multiple open vials within the facility.
Monitor
Aspen Unit Licensed Staff will monitor multi-dose vials for date per pharmacy regulation, time and initial Q shift x 4 weeks, then re-evaluate for compliance and frequency of audit.
All other units, the Nurse Manager or designee will monitor insulin's, fridges, eye drops and medication drawers Q shift x 4 weeks, then monthly for 3 months. Audit results will be submitted to QAPI committee for review and follow up as needed.
All clinical staff will be in serviced on revised policy and procedure.
DON or designee will complete deficient area and facility compliance by [DATE].

FF11 483.10(g)(10)(11):RIGHT TO SURVEY RESULTS/ADVOCATE AGENCY INFO

REGULATION: §483.10(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 (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(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: December 18, 2017
Corrected date: February 16, 2018

Citation Details

Based on observation, record review and interview conducted during the recertification survey it was determined for 4 of 13 anonymous residents in attendance at the Resident Council Meeting, the facility did not ensure results of the most recent Federal/State survey were posted in a place readily accessible to residents. Specifically, survey results were posted in a place that was not frequented by most residents, visitors or other individuals; was not in a location that would allow individuals to examine the survey results without having to ask and to maintain privacy to review the results; and there was no documentation on resident units notifying residents of the location of the survey results. Findings include: During the Resident Council meeting on 12/13/17 at 10:04 AM, 4 anonymous residents stated they were not aware of their resident rights, may have been notified at some point since admission, and needed reminders as to what those rights were. The residents stated they were not aware of the location of the Department of Health Federal/State survey results and would like to know where they were located. A surveyor viewed Units Aspen, Birch, Cedar, Elm, Maple and Willow on 12/18/17 between 10:00 AM and 11:00 AM and did not see survey results posted, or notation documenting the location of survey results. The Survey Results were observed in an office attached to the Administrator office that was just before 3 of the 6 units; and was not in a location frequented by most residents and visitors of the facility. During an interview with the Administrator on 12/18/17 at 11:40 PM, when asked how residents became aware of survey results, the Administrator stated the facility talked about survey results during Resident Council. When asked if all residents attended Council, he stated no. When asked how residents that did not attend council would become aware he stated he would have to check the resident admissions agreement to see if was noted in the agreement. He stated the survey results were located outside his office in the room just off the hallway. In follow up on 12/18/17 at 12:07 PM, the Administrator provided a surveyor with an admission packet that documented residents would have access to the Department of Health survey results of the most recent survey. The Admission Agreement did not document the location of the survey results. 10 NYCRR 483.10(g)(10-11)

Plan of Correction: ApprovedJanuary 15, 2018

I. The four residents were identified as anonymous by the Statement of Deficiencies, so those directly affected could not be addressed. However, at the next Resident Council meeting on (MONTH) 18,2018 the Administrator will present and/or remind all attending residents the location of the previous department of health?s annual survey. Staff assistance will be offered to those residents who feel like they need assistance in understanding the document.
II. Any resident that is interested in examining the results of the most recent Department of Health survey could be affected by this deficient practice.
III. The Resident Rights document that is distributed upon admission and posted on each unit, will contain language designating the location and the right to examine the previous department of health survey results. The actual location of the survey results will be moved so it is more visible to those interested in examining these results. Two locations have been selected to increase visibility. One copy will be in the main hallway leading to Willow, Elm, and Maple units in a three-ring binder attached to the wall outside the Social Service conference room. A second location will be created in the hallway between Aspen and Birch for increased accessibility for residents. The same previous Department of Health survey results will be in a three-ring binder attached to the wall placed outside the Aspen Social Work office. To serve as a reminder to residents, information about the availability of survey results will be discussed quarterly at resident council and included in the resident publication ?Presby Press? monthly. Resident Rights education will be provided to all staff and will be completed by the Director of Social Services and the Administrator. This education will be completed by (MONTH) 28, (YEAR).
IV. An audit will be created, completed 1 a month for 3 months and then 1 every quarter for 2 quarters and then re-evalutaed. it will be presented to the QAPI monthly, to ensure the completion of these following procedures:
1. The posting on each unit of the Resident Rights document.
2. The signed acknowledgments of receipt of the Resident Rights document upon admission.
3. The availability of the most recent Department of Health survey results.
4. The discussion and minutes of Resident Council each quarter about the availability of the Department of Health survey results.
5. That the article is in the facilities newsletter (Presby Press) monthly.
V. Staff responsible for this correction will be the administrator.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2017
Corrected date: February 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined the facility did not properly maintain electrical installations for one isolated room (resident room [ROOM NUMBER]). Specifically, there was an oxygen concentrator that was plugged into an unapproved power tap. Findings include: On 12/19/2017 at 11:05 AM, a surveyor in resident room [ROOM NUMBER] observed an oxygen concentrator that was plugged into an unapproved power tap. A lamp and a respirator was also plugged into this power tap. On 12/20/2017, between 4:00 PM and 4:36 PM, the Operations Manager stated he was not aware the oxygen concentrator located in resident room [ROOM NUMBER] was plugged into an unapproved power tap, and it was hard to regulate this. Staff was trained not to plug any medical equipment into power taps. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 29, 2018

I. Oxygen concentrator was removed from power strip at time of Survey.
II. All residents could be at risk from this deficient practice. Facility Inspection completed though-out facility for any medical devices that are connected to an unapproved power tap.
III. Educate all staff on proper use of extension cords and power strips by 2/16/18. Update existing audit to include the observation for appropriate use of power taps. Any violation will be corrected and reported using a near miss incident report. This information is to be forwarded to the safety committee.Instruction on safety concerns and the use of the near miss' form will be presented during new employee orientation.
IV. Inspection of appropriate use of power taps will be completed weekly for 4 weeks and monthly thereafter. This will be completed by the Director of Education and Safety. Any improper use of extension cords and power strips will be corrected and all audits will be submitted to the safety committee and the monthly QAPI committee for review. This is an ongoing audit and will continue to ensure 100% compliance.
V. Completion and monitoring of this plan is the responsibility of the Director of Education and Safety.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2017
Corrected date: February 2, 2018

Citation Details

Based on record review and staff interview conducted during the recertification survey, the facility's fire alarm system was not tested in accordance with the requirements of NFPA 72. Specifically, the semi-annual maintenance requirements were not completed. Findings include: Record review on 12/20/2017 of the facility's fire alarm system inspection reports indicated that the facility's fire alarm system was tested on an annual basis and was last completed on 10/21/2016. On 12/20/2017, between 4:00 PM and 4:36 PM, the General Manager stated as per the third party vendor the fire alarm system was tested annually. He was not aware of the required NFPA 72 semi-annual maintenance requirements. 2012 NFPA 101: 19.3.4.1, 9.6.1.3 2010 NFPA 72: 14.1 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 29, 2018

I. NFPA 72 and NFPA 101 were reviewed by Director of Building Services and Operations Manager to ensure all criteria for fire panel inspection is met per NFPA inspection, testing and maintenance. This procedure was completed on 12/29/17
II. All residents could be at risk from this deficient practice.
III. A 3rd party vendor conducts annual facility wide inspections of the fire panel. In addition to this a PM, another semi-annual visual inspection, meeting NFPA 72 requirements, will be added to the work order system which will take place every (MONTH) to include (YEAR).
IV. The visual Preventive Maintenance inspection, of the fire monitor system, will be completed by a competent staff member of building services and a record kept in the building service PM files. The PM will be on going to ensure 100% compliance. Staff responsible for this PM will be in-serviced by the Director of building services and a competency letter will be placed with employee records.
V. Completion and monitoring of this semi-annual inspection PM will be the responsibility of the Director of Building Services.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

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

Citation Details

Based on observation and staff interview conducted during the recertification survey, the facility did ensure hazardous areas were maintained for two isolated rooms (Elm Unit pod mechanical room and the main oxygen storage room). Specifically, the Elm Unit pod mechanical room had unsealed wall penetrations, and the main oxygen storage room door had an unsealed hole in it. Findings include: 1) Unsealed Wall Penetrations On 12/19/2017 at 2:15 PM, a surveyor in the Elm Unit pod mechanical room observed the wall shared by the unrated activities/television room had two unsealed 1 inch sprinkler line penetrations and an unsealed 1 inch condensate line penetration. On 12/20/2017, between 4:00 PM and 4:36 PM, the General Manager stated when he checked the Elm pod mechanical room two months ago the room appeared tightly sealed. He did not know why the unsealed penetrations were found during the current life safety code survey. 2) Unsealed Door Penetrations On 12/19/2017 at 3:05 PM, a surveyor observed the main oxygen storage room door had an unsealed ½ inch hole in it. On 12/20/2017, between 4:00 PM and 4:36 PM, the General Manager stated he was not aware the door to the main oxygen storage room had an unsealed hole in it. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 29, 2018

I. The penetrations on the oxygen room door and the Elm mechanical room were repaired with FP 200 fire stop and 3m fire barrier on 12/20/17.
II. All residents could be at risk from this deficient practice. An inspection of all facility doors demonstrated no other penetrations found in the facility.
III. The oxygen room door will be added to the monthly door PM that is in place for the interior of the building. Policy 0006, fire wall penetrations, will be reviewed and updated if necessary by Director of building services. Building service staff will be educated by 1/31/2017 on policy 0006, Fire wall penetrations by Director of building services. 3rd party contractors will be provided a copy of the policy to signify that they have read and agree to follow the guidelines of the policy. Area will be observed by Building Services and the contractor to ensure penetration is sealed. The signed policy by and contractor and Building Services will be approved, and kept on file with Building Services. Building Service Staff will be responsible for the door PMs which will be in-serviced by the Building Service Director.
IV. Completed monthly door PM and other penetration audits will be submitted to QAPI for review. This audit will be ongoing and become part of our regular monthly PM's to ensure 100% compliance
V. Director of Building services and Operations Manager will be responsible for correction of this deficient practice.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

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

Citation Details

Based on observation and staff interview, it was determined the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems for one isolated room (Aspen Unit linen room). Specifically, a sprinkler head located in the Aspen unit linen room had a damaged deflector. The finding was: On 12/19/2017 at 11:50 AM, a surveyor in Aspen Unit linen room observed a sprinkler head with a damaged deflector. Two metal tips of this sprinkler deflector were bent. On 12/20/2017, between 4:00 PM and 4:36 PM, the Operations Manager stated he was not aware of the damaged sprinkler head in the Aspen unit linen room. 2012 NFPA 101: 19.3.5.1 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 29, 2018

I. Work orders were created to assess and repair the deficiencies noted above to the damaged sprinkler head. Sprinkler head repaired 1/2/17.
II. All residents could be at risk from this deficient practice. Facility inspection completed thought-out facility for any damaged sprinkler heads on 1/2/2018.
III. Sprinkler heads are cleaned annually and as needed in the facility by environmental service staff. A visual inspection will be added to the cleaning process of the sprinkler heads. Staff responsible for this inspection be in-serviced by the Director of Maintenance to understand what to look for. This will be managed in the work order system and a PM will be set up to assure that this is completed in addition to the 3rd party vendor quarterly test and inspection. A work order will be generated for any deficiencies found from this visual inspection. All staff completing visual checks have been in serviced on utilizing the work order system.
IV. The Director of Maintenance or the Operations Manager will report any deficiencies noted during the visual inspection to 3rd party vendor for repair or replacement. This is an scheduled ongoing PM to ensure 100% compliance.
V. The Director of Maintenance or Operations Manager will monitor and track completion of this PM.