Rosewood Rehabilitation and Nursing Center
January 25, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure that that it developed and implemented a baseline care plan for each resident within 48 hours of the resident's admission, that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for two of 10 residents. Specifically, the facility did not ensure that Baseline Care Plans were developed for Resident #5's pain and Resident #217's respiratory status and oxygen use. This is evidenced by: Resident #5: The resident was admitted to the nursing home on 10/2/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The admission MDS dated [DATE], documented that the resident had a frequent pain level of 8. Physician (MD) Orders dated: 12/6/18 documented [MEDICATION NAME] 2 mg 1 tab every 6 hours for acute pain. 1/11/19 [MEDICATION NAME] 20mg/ml 0.25 milliliter (ml) sublingual every 4 hours. The Baseline Care Plan did not include a care plan for the resident's pain. During an interview on 1/25/19 at 1:34 PM, Registered Nurse (RN) #1 stated that the base line care plans should address the resident's pain. Resident #217: The resident was admitted to the nursing home on 1/14/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. During observations on 1/17/19 at 08:04 AM and 12:43 PM, and on 1/18/19 at 10:15 AM, the resident was noted with oxygen on. The Resident's Baseline Care Plan did not include a care plan for his pneumonia and use of oxygen. During an interview on 1/25/19 at 8:23 AM, RN #3 stated the resident should have had a base line care plan to address his respiratory status and use of oxygen, because he was on oxygen when he was admitted to the nursing home. 10NYCRR 415.11

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #5 no longer a Resident at Rosewood Rehab. and Nursing
Resident #217, the IDCPT reviewed Residents baseline care plan, updated to include pneumonia and oxygen use per MD order. The Resident and responsible party reviewed and received an updated signed copy of the baseline care plan.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected.
Last 30 days of admitted residents were reviewed by the IDCPT to ensure that the baseline care plan was completed to include, all admitting primary diagnosis, any nursing interventions or MD orders needed upon admission were placed on the baseline care plan and a copy was reviewed with each Resident/responsible party and a signed copy was given to the resident and or responsible party.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:

The policy and procedure titled Care planning process was reviewed by the interim DON, with no changes needed.
All RN licensed Nurses were educated on the above policy and procedure as it relates to baseline care plans upon admission, this will ensure the primary diagnosis, the nursing interventions, and MD orders are all placed on the baseline care plan. The baseline care plan will be reviewed and signed off with resident and or responsible party. A copy of the baseline care plan will be completed and given to the resident and or responsible party within 48 hours of admission.
The facility will ensure all baseline care plans are reviewed by the IDCPT in each morning meeting following all new admissions.
How the corrective action will be monitored to ensure the practice will not recur:
The ADON/designee will audit all new admissions weekly x12, monthly x3 to ensure 100% compliance with all new admissions baseline care plan within 48 hours of admission. The baseline care plan will cover primary diagnosis, nursing interventions, and MD orders within 48 hours of admission. Also, will ensure the Resident and or responsible party received a signed copy after review.
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON


FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey and an abbreviated survey (Case #NY 513) the facility did not ensure development of comprehensive care plans for 11 (#'s 5, 8, 18, 32, 33, 40, 51, 52, 63, 64, and 66) of 18 Residents reviewed. Specifically: For Resident #8, the facility did not ensure that a CCP was developed for the resident's discharge; for Resident #33, the facility did not ensure a CCP was developed to address the residents respiratory care status to include continuous oxygen at 2L via nasal cannula; for Resident #32, that a Comprehensive Care Plan (CCP) for anxiety was developed that included non-pharmacological interventions for use prior to the administration of as needed (PRN) antianxiety medication; for Resident #52, that a CCP to address the pressure ulcers was developed; for Resident #66, that a CCP to address the self administration of medication was developed; for Resident #18, the facility did not ensure a care plan for oral care before and after tooth extraction was developed; for Resident #40, the facility did ensure a care plan for oral care of the top dentures was implemented, resulting in dentures not being cleaned regularly; for Resident #63, who was receiving Hyperdermoclysis (fluid infusion) and who was admitted with a Stage 2 and Stage 1 pressure area ) had CCPs developed for hydration pressure ulcers. Additionally, for Resident #5, the facility did not ensure a CCP was developed for the resident's use of oxygen therapy; for Resident #51, that a CCP was developed for anticoagulation therapy and for Resident #64, that a CCP for impaired skin integrity and [MEDICAL CONDITION] were developed. This is evidenced by: Resident #64: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE], documented the resident understands and is understood by others with moderate cognitive impairments. Review of nursing progress notes documented the resident was hosptalized on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Treatment Administration Record dated 1/18/19, documented calcium alginate 4x4 dressing apply to right lower leg one time a day and prn after cleanse with wound cleanser cover with dry protective dressing. The resident's medical record did not include a care plan to address the resident's impaired skin integrity or [MEDICAL CONDITION]. Interview on 1/24/18 at 4:07 PM, Registered Nurse Unit Manager (RNUM) #1 reported the RLE [MEDICAL CONDITION] was present on admission and there should be a care plan to address impaired skin integrity/[MEDICAL CONDITION]. Interview on 1/25/19 at 11:24 AM, the Director of Nursing (DON) said a care plan to address Impaired Skin Integrity/[MEDICAL CONDITION] should have been implemented upon readmission. Resident #5: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Date Set ((MDS) dated [DATE] documented the resident had moderate cognitive impairments, and understands and is understood by others. During observation on 01/17/19 02:37 PM, the resident was in bed wearing a nasal cannula. The oxygen concentrator was set at 3 liters. Physician (MD) Orders documented: 1/4/19 - Pulse oximetry monitoring every shift to maintain oxygen saturation rate above 90%. 1/16/19 - Oxygen 3 Liters via nasal cannula continuous maintain oxygen saturations of 90% and above. The resident's medical record did not include a CCP to address respiratory care to include the use of oxygen. During an interview on 01/25/19 at 10:51 AM, RNUM #1 reported a respiratory care plan should be in placed upon readmission. During an interview on 01/25/19 at 12:20 PM, the Director of Nursing (DON) stated A respiratory care plan should have been implemented upon readmission. Resident #63: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had severely impaired cognition and could usually understand others and could make himself understood. The Comprehensive Care Plan for Risk for Skin Breakdown, last updated 12/22/2018, documented the resident was at risk of skin breakdown related to limited mobility and inadequate intake. No Comprehensive Care Plan did not include a care plan for the resident's IV fluids or Hyperdermoclysis. A Nursing Assessment Form dated 12/21/18, documented a Stage 1 area to coccyx and Stage 2 area to left elbow. A Medication Administration Record [REDACTED]. A Medication Administration Record [REDACTED]@ 50ml per hour via clysis for 3 days, [DIAGNOSES REDACTED]. Physician orders [REDACTED].@ 50ml per hour for 3 days, [DIAGNOSES REDACTED]. During an interview on 01/18/19 at 2:41 PM, the Registered Dietician (RD) stated the hydration care plan is completed by the RN and includes the nursing physical assessment for hydration status. During an interview on 1/23/19 at 9:35 AM, the Assistant Director of Nursing (ADON) stated if a resident was admitted with a stage I and II pressure ulcer, she would expect to see care plan for pressure ulcers. Additionally, she stated if a resident received treatment for [REDACTED]. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedFebruary 15, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #8 the IDCPT held a care plan meeting to discuss discharge options, a comprehensive care plan was developed as it relates to the Resident wishes for discharge to Assisted Living. SW will continue to assist Resident in his wishes to improve enough to discharge to an assisted living center.
Resident #33 the IDCPT held a care plan meeting to discuss the residents Respiratory care status and use of Oxygen nasal cannula per MD order, a comprehensive care plan was developed as it relates to the Residents current Respiratory care status and oxygen use per MD order
Resident #32 the IDCPT held a care plan meeting to discuss the resident?s use of [MEDICATION NAME] and the reason for use per MD documentation. The care plan for Anxiety was discontinued, a comprehensive care plan was developed for use of [MEDICATION NAME] related to muscle spasms. The MD evaluated the use of PRN [MEDICATION NAME] and the comprehensive care plan was updated according to the MD visit, the medication is given for muscle spasms.
Resident #52 no longer a Resident at Rosewood Rehab. and Nursing
Resident #66 Nursing completed an assessment for self-administration of medications, the IDCPT held a care plan meeting to discuss the outcome of the self-administration assessment and a comprehensive care plan was developed for self-administration of medication related to [MEDICATION NAME] inhaler
Resident #18 IDCPT held a care plan meeting to discuss the history of a tooth extraction and a comprehensive care plan was developed for dental services including daily oral care, and oral care prior to and after a tooth extraction
Resident #40 no longer a Resident at Rosewood Rehab. and Nursing
Resident #63 no longer a Resident at Rosewood Rehab. and Nursing
Resident #5 no longer a Resident at Rosewood Rehab. and Nursing
Resident #51 Nursing reviewed current MD orders for [MEDICATION NAME] use. The IDCPT had a meeting to discuss the continuation of an anticoagulation medication, A comprehensive care plan was developed for anticoagulation therapy.
Resident #64 An RN assessment was completed on 02/06/18, the resident will continue on weekly wound rounds. The IDCPT held a meeting to discuss the skin integrity and development of [MEDICAL CONDITION], it was determined that the [MEDICAL CONDITION] was resolved after the Residents admission to the facility. A comprehensive care plan was developed related to impaired skin integrity and history of [MEDICAL CONDITION].
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
A full house audit of all active residents was completed to ensure individualized person-centered comprehensive care plans are in place for all Residents.

The policy and procedure titled Care planning process was reviewed by the interim DON, with no changes needed
Education was provided to the IDCPT and the RN licensed nurses on above policy and procedure as it relates to care planning on each individual resident. All Care Plans will be person centered and individualized for each Resident
The facility IDCPT will follow the weekly care plan meetings for each unit, Wednesday Unit 1, Thursday Unit 2. During each meeting the team will review scheduled Resident?s to ensure a second check is completed on all care plans for each new admission resident and long-term residents.
How the corrective action will be monitored to ensure the practice will not recur:
The ADON/designee will conduct a weekly audit x12 weeks, then monthly x3 on 10% of active residents following the weekly scheduled care plan meetings for each unit
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.21(c)(1)(i)-(ix):DISCHARGE PLANNING PROCESS

REGULATION: §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure development and implementation of an effective discharge process for 1 (Resident #8) of 2 residents reviewed. Specifically, the facility did not implement a discharge process for Resident #8 following the residents completion of rehabilitation. This was evidenced by: Resident #8: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was able to understand others and could make himself understood. The policy & procedure (P&P) titled Discharge Summary and Plan dated 11/2018, documented when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to the new living environment. A Social Worker (SW) progress note dated 8/30/17, documented an Initial Care Conference held on this date. Resident would like to be discharged to a sort of ALF (assisted living facility) after he completes treatment with Speech Therapy. The MDS's dated 2/2/18, and 4/28/18, documented in section Q Participation in Assessment and Goal setting for question Q0100, the resident participated in the assessment and question Q0400 documented that an active discharge planning was already occurring for the resident to return to the community. A nursing progress note dated 6/28/18, with an illegible writer signature, documented resident is scheduled for PEG tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) removal in August. His goal continues to be to discharge to an assisted living facility. The MDS dated [DATE] documented in section Q Participation in Assessment and Goal setting for question Q0100, the resident participated in the assessment and question Q0400 documented the resident did not have an active discharge plan for the resident to return to the community. The Speech Therapy Discharge Summary dated 7/30/18, documented the resident was able to prepare honey thickened liquid independently to continue safe intake by mouth. The Psychological Services Progress note dated 8/23/18, documented the patient reported that everything went well and he successfully had the feeding tube removed. He will not be changed to regular foods until he is about to move to his next placement which will most likely be assisted living. The Psychological Services Progress note dated 8/30/18, documented resident reported that he is now just waiting for some kind of SW person to come on board and start working with him on finding a place to live. The Psychological Services Progress note dated 9/6/18, documented the resident reported that things remain the same and that he simply had to wait things out until a SW type person comes on board at the facility and gets him out of here to a new place to live. The MDS dated [DATE] documented in section Q Participation in Assessment and Goal setting for question Q0100, the resident participated in the assessment and question Q0400 documented that an active discharge plan was not occurring for the resident to return to the community. A review of the comprehensive care plans (CCP) dated 11/24/18, did not include a care plan to address the resident's discharge plan. The CCP dated 11/24/18 titled ADL Functional/ Rehabilitation potential documented the resident is independent with his activities of daily living. During an interview on 01/17/19 at 11:19 AM, Resident #8 stated that he wanted to leave the facility and live elsewhere. He further stated that the change in social worker's (SW) employment at the facility was so frequent that his discharge plan would be dropped after a SW left. He had been asking for months to be transferred to an assisted living facility, and he was waiting for the new social worker to start over and help him to find a place to go. During an interview on 01/18/19 at 09:42 AM, the SW stated she started as the full time SW one month ago. The previous SW had been working at the facility for a few months and gave no hand off information to her when she left. She had not aware of a discharge process for Resident #8 prior to yesterday. There was a care plan meeting yesterday (1/17/19) and the resident told them in the meeting that he does want to go to an assisted living facility. During an interview on 01/18/19 at 10:16 AM, the Rehabilitation Director stated Resident #8 had been cleared for discharge some time ago. Once his G tube had been taken out, all he needed was to be passed off by the Speech therapist to be able to mix his own thickened liquid. During an interview on 01/23/19 at 02:34 PM, the Registered Nurse Manager (RNM) stated she was not sure where Resident #8 stands right now in the discharge process. Nursing does very little for him, he is independent in his care. During care plan meetings a resident's discharge is discussed and the SW documents the meeting. She is not aware of a documented note for Resident #8's discharge. During an interview on 01/24/19 at 09:45 AM, the SW stated she had looked through the files in the SW office and she could not find any documentation of a discharge process in (YEAR) for Resident #8. During an interview on 01/24/19 at 10:00 AM, the Human Resource Director (HRD) stated there have been a few social workers in the last year. A SW from (MONTH) (YEAR) through (MONTH) (YEAR). Another SW from (MONTH) through (MONTH) (YEAR). A SW from (MONTH) through (MONTH) (YEAR). The current SW started working full time in (MONTH) (YEAR). HRD had no knowledge if information sharing took place with the SW leaving and the SW coming in. During an interview on 01/24/19 at 10:15 AM, the Rehabilitation Director stated the discharge process with the current SW is easier and more efficient. There are regular scheduled discharge meetings on Thursdays with the SW, Rehab staff, Billing staff, RNM and MDS coordinator who discuss the residents discharge progress. She did not know why Resident #8 did not have a discharge process implemented. He needed skilled nursing due to his altered fluid consistency and diet back in the summer of (YEAR), once he could do his own thickened liquids he could have been discharged . During an interview on 01/24/19 at 02:33 PM, the Acting Administrator (AA) stated the facility did have crossovers in SW staff. When the AA started working for the facility in the summer of (YEAR) the SW resigned in (MONTH) and did not leave the SW office organized. A SW was brought in on [MEDICATION NAME] status and worked some hours on the weekends to help with the lag between SWs and she helped with new admissions. The next SW came in September, and the Administrator had assigned SW duties to himself and the Director of Nursing to assist. The AA did not know why Resident #8 did not have a discharge plan. 10NYCRR415.11(d)(3)

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #8 the IDCPT held a care plan meeting to discuss the resident?s preferences for discharge process to assisted living facility
The Social Worker sent 3 referrals to 3 assisted living facilities, at this time Resident #8 has been declined by the 3 assisted living facilities.
The Social Worker has sent a referral to the open doors program (section Q referral) A meeting took place with the Resident and they are currently working with Resident to find all community options that would fit his needs at this time
SW developed a comprehensive care plan related to the resident?s preference for his discharge plan to an assisted living facility
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected
A full house audit of all active Residents was conducted by the facility Social Worker, to ensure each Resident has a discharge plan and a comprehensive care plan in place related to the resident?s preference for their discharge process.
Any concerns identified the facility with hold a care plan meeting with the IDCPT, Resident and or responsible party per the weekly care plan schedule. The facility will review the resident?s preference for discharge plan and care plan accordingly.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy titled discharge summary and plan was reviewed by the DON, Social Worker, and Administrator, no changes needed
Education was given to the IDCPT members reviewing above policy as it relates to discharge process for each individual resident, also included in the education was the importance of SW initiating an assessment and comprehensive care plan for the preference of each resident?s discharge plan
The IDCPT will follow the weekly care plan meeting schedule to ensure all Residents have a discharge plan and comprehensive care plan in place to ensure the preference is met for discharge
How the corrective action will be monitored to ensure the practice will not recur:
The Social Worker/designee will audit weekly x12, then monthly x3 10% of all Residents following the weekly care plan schedule for each unit (1 and 2), the SW will choose Residents on each Unit to cover the 10% of Residents following the care plan schedule
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on record review and interview during the recertification survey the facility did not ensure their policy and procedure developed for the monthly drug regimen review (MMR) included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: Review of the policy revealed that it did not include a date when it was implemented, or that an annual review and/or revision was completed. During interview on 1/25/19 at 11:24 AM, the Director of Nursing stated the policy needs to be revised to include the specific time frames for the steps in the process. 10 NYCRR415.18

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
The facility held a meeting with the IDCPT and pharmacist consultant to review and revise the policy titled Drug regimen review for the date of 2/2019. Included in the revision of the policy it now has time frames for the different steps in the process and the steps the pharmacist must take when he/she identifies an irregularity that requires urgent action to protect the resident.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected
A 60 day look back of all pharmacy reviews was completed to ensure appropriate time frames were obtained in the different steps in the review process, and to identify any urgent irregularity?s that require attention to protect all residents within those 60 days.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy and procedure titled Drug regimen review was reviewed and revised 2/2019 by the IDCPT and Pharmacist consultant
Education was provided on the above policy to the IDCPT, Pharmacist consultant, and all RN?s to ensure the knowledge of the time frames involved in the different steps of the process and any urgent irregularities identified by the pharmacist consultant including time frames to address the concerns to protect the resident.
How the corrective action will be monitored to ensure the practice will not recur:
The DON/designee will audit all monthly drug regimen reviews monthly x12 to ensure all time frames and urgent irregularities are identified and handle to protect the resident

All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure kitchen equipment was maintained in safe operating condition. Specifically, the ice machine in the kitchenette was dripping, the garbage disposal in the main kitchen was leaking on the dish room floor, and the dishwasher pressure gauge was not operating correctly. This is evidenced by: During an observation on 1/17/19 at 8:11 AM, the kitchenette ice machine was dripping water. During an observation on 1/17/19 at 10:25 AM, the kitchenette ice machine was dripping water. During an observation on 1/23/19 03:30 PM, pooling water was noted in the area between the dish room and the dining room. During an observation on 1/23/19 at 2:24 PM, the dish machine pressure gauge showed resting water pressure of 50 ppm, and final rinse pressure of 25-30ppm. The facility was unable to produce current work orders for the ice machine, garbage disposal, or dishwasher pressure gauge. During an interview on 1/17/19 9:16 AM, the Food Service Director (FSD) stated the ice machine always goes down on that unit. During an interview on 1/17/19 at 10:06 AM, the Director of Maintenance stated preventative maintenance is completed quarterly on the ice machines. During an interview on 1/23/19 at 2:24 PM, the FSD stated he will put in a work order for the dish machine pressure gauge. He stated he is unsure why the resting pressure of the dish machine is 50ppm. During an interview on 1/23/19 at 3:43 PM, the FSD stated the garbage disposal is broken and leaking water. He stated they are waiting for a part. During an interview on 01/24/19 at 9:40 AM, the FSD stated the company replaced the dish machine pressure gauge and adjusted the pressure. 10NYCRR415.5(e)(1)(2)

Plan of Correction: ApprovedFebruary 21, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
No residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected by this practice.
An outside contractor performed preventive maintenance on the kitchenette ice machine on 1/18/19. Ongoing preventive maintenance will be performed quarterly.
The dishwasher pressure gauge was replaced on 1/24/19.
The garbage disposal is not scheduled to be replaced at this time. The opening in the stainless steel shelf will be sealed to ensure that water and debris do not fall to the floor.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The facility will review its policy and procedure on work order requisition process and revised if necessary to indicate the importance of maintaining the safe operating condition of all kitchen equipment.
The facility will develop a work order log to indicate when work orders were placed, the type of equipment needed to be repaired, and when the repair was completed.
All facility employees particularly kitchen and maintenance staff will be provided education on the revised policy and proper procedures on the facility's work order systems.

How the corrective action will be monitored to ensure the practice will not recur:
Audits will be performed to ensure that the preventive maintenance is performed on the kitchenette ice machine and that the floor under the stainless steel shelf adjacent to the dishwasher remains clean. Additionally, audits will be performed on the dish machine pressure gauge and other kitchen equipments with similar gauges.

The audits for the floor in the dish room and dish machine pressure gauge will be performed weekly X 6 months.
The audits for the preventive maintenance on the kitchenette ice machine will be performed quarterly for one year.
The results of the audits will be reported to the QAPI Committee on a monthly basis. The Committee will determine the ongoing frequency of the audits.

Responsibility: Director of Facilities

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and interviews during the recertification survey, the facility did not ensure food was prepared and distributed in accordance with professional standards of food safety. Specifically, the facility did not ensure hair restraints were worn by dietary staff and that floors and equipment were kept clean. This is evidenced by: The Policy and Procedure (P&P) titled Employee Sanitary Practices dated (YEAR) stated all employees will wear hair restraints to prevent hair from contacting exposed food, and will clean and sanitize equipment and work areas after use. During an observation on 1/17/19 at 7:48 AM, the main kitchen dish room floor and the area behind the pot sink were soiled with food and debris. During an observation on 1/17/19 at 10:10 AM, a staff member was in the main kitchen without a hair net. During an observation on 1/17/19 at 8:45 AM, the Chef was plating food wearing a hairnet that did not cover the hair on her neck. During an observation on 01/17/19 at 8:55 AM, clean utensils were stored in a utensil holder soiled with debris. During an observation on 01/17/19 at 8:56 AM, the back of the stove was soiled with grease. During an observation on 1/17/19 at 12:27 PM, the Assistant Director of Nursing (ADON) was observed in the kitchen wearing a hairnet that exposed her bangs. During an observation on 1/23/19 at 11:25 AM, a Food Service Worker (FSW) was preparing food with no hair restraint over his beard. During an interview on 1/17/19 at 7:48 AM, the Food Service Director (FSD) stated kitchen and floors should be cleaned daily, and the dish room should be cleaned after each meal. During an interview on 1/23/19 at 02:24 PM, the FSD stated the FSW should have been wearing a beard net, which were located in the FSD's office. Additionally, anyone in the kitchen should wear a hairnet. Kitchen staff were in-serviced quarterly on proper hairnet use. The FSW had been disciplined by the FSD in the past about beard net use. 10NYCRR415.14(h)

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
No residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected by this practice.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The cleaning schedule for the kitchen has been adjusted to include the back of the stove and utensil holders.
The kitchen staff were reeducated on the use of hair nets, beard nets, and proper cleaning techniques.
How the corrective action will be monitored to ensure the practice will not recur:
Audits will be performed to ensure cleanliness in the kitchen and that the staff are wearing hair/ beard nets as appropriate.
The audits will be performed weekly times 4 months. The results of the audits will be reported to the QAPI Committee on a monthly basis. The Committee will determine the ongoing frequency of the audits.
Responsibility: Administrator

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey the facility did not ensure as needed (PRN) orders for [MEDICAL CONDITION] drugs were limited to 14 days unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for one (Resident #32) of five residents reviewed for unnecessary medications. Specifically, for Resident #32, the facility did not ensure that an as needed (PRN) antianxiety medication was not ordered for more than 14 days without a physician's rationale. This is evidenced by: Resident #32: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, could understand others and could make herself understood. A physician's orders [REDACTED]. A consultant pharmacist's note to the physician dated 12/27/18, documented [MEDICAL CONDITION] medication ordered on a PRN basis was not recommended. The pharmacist recommended the physician evaluate the PRN [MEDICATION NAME] and if continued, to document the medical necessity of the order. The physician documented in response that he disagreed with the pharmacist's recommendation due to the patient's request for the PRN medication. The medical record did not include a medical justification for continuing the resident on PRN [MEDICATION NAME] for more than 14 days. During an interview on 01/24/19 at 3:55 PM, the physician reviewed his documentation in the resident's medical record. He stated there was not a documented justification to continue PRN [MEDICATION NAME] beyond 14 days and stated there should have been since the PRN order continued for more than 14 days. He also stated he was aware of the regulation regarding PRN orders for [MEDICAL CONDITION] medications and the orders should be time limited and re-evaluated based on the resident's use of the PRN. 10NYCRR 415.12(1)(2)(ii)

Plan of Correction: ApprovedFebruary 15, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #32 was evaluated by the MD for PRN [MEDICATION NAME]. After MD completed a full assessment of the Resident the PRN [MEDICATION NAME] was discontinued and a new order was placed for Routine [MEDICATION NAME].
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected
A report in ChemRX was run for the past 90 days to capture all PRN ordered [MEDICAL CONDITION].
No other concerns identified
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy and procedure titled Antipsychotic medication use was reviewed by the Interim DON, no changes needed.
The IDCPT, all Licensed nurses were educated on the above policy as it relates to PRN antipsychotic ordered medication, the need for a new order every 14 days, if the MD feels the medication should continue PRN documented rational must be clear from the MD in the resident medical record.
Education on the GDR program was provided to the Medical Director, Pharmacist consultant, and the IDCPT
The facility will conduct a monthly GDR meeting utilizing the GDR program with the IDCPT, medical director, and the pharmacist consultant.
How the corrective action will be monitored to ensure the practice will not recur:
The DON/designee will complete a 100% audit of the monthly GDR meeting to ensure all Residents on antipsychotic PRN medications that the MD has a documented rational if exceeds 14 days.
DON/designee will audit monthly the chemRX PRN antipsychotic ordered medications to ensure all Residents on antipsychotic PRN medications have a documented MD note stating the rational when going beyond the 14 days.
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during a recertification survey the facility did not ensure the resident environment remained as free of accident hazards as was possible for 3 of 3 residents (Resident #24, 29, and 36). Specifically, for Resident's #24, 29, and 36, the facility did not ensure disposable razors were stored properly; and for Resident #36, who was receiving anticoagulation therapy, did not ensure he was not using a disposable razor. Additionally, The facility did not ensure that chemicals were stored properly for 1 of 1 kitchenettes. This is evidenced by: Finding #1 A policy and procedure titled Shaving the Resident revised (MONTH) (YEAR) documented if using a safety or disposable razor to dispose of the razor in a designated sharps container. If there was a sharps container designated For Disposable Razors Only and that container was outside the resident's room, the razor must be transported to that destination in a puncture- resistant, closed, and marked container. Resident #24: The resident was admitted to the facility on [DATE] with [MEDICAL CONDITION], Type 2 Diabetes, and Major [MEDICAL CONDITION]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition, could understand others and could make himself understood. The Comprehensive Care Plan (CCP) for Behavioral Symptoms, last updated 11/21/18 documented the resident wanders through the building and has exit seeking behaviors. The Care Card, last updated 11/14/18 documented the resident is an assist with shaving, 1 assist with hygiene, and ambulated independently with wheeled walker on and off the unit. During an observation on 1/17/19 at 9:30 AM, the resident's semi-private bathroom in room [ROOM NUMBER] on Unit #1 had 3 unlabeled, green disposable razors on the bathroom sink. Additionally, there was an unlabeled, unopened disposable razor in an unlabeled wash basin on the night stand. During an observation on 1/17/19 at 12:48 PM, the resident's semi-private bathroom in 128 on Unit #1 had 3 unlabeled, green disposable razors on the bathroom sink. Resident #29 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident usually makes self-understood and usually understands others with a brief interview for mental status (BIMS) at 03. During an observation on 1/17/19 at 9:16 AM, a private room (room [ROOM NUMBER]) on Unit #2 had a disposable razor on the bathroom sink. The Comprehensive Care Plan (CCP) for Average Daily Living (ADL)/Rehabilitation potential started on 11/19/18 documented the resident requires assist with all ADL's secondary to decreased mobility skills and decreased cognition. The CCP dated for Behavioral Symptoms started on 11/14/18 documented goals of resident accepting assistance with personal hygiene. The CCP for Falls dated 11/20/18 documented resident has a history of falling r/t impaired cognition with poor safety awareness and impulsive behavior. Goal is resident will remain free from injury. Resident #36: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had moderately impaired cognition, could understand others and could make himself understood. The MDS documented the resident was independent with personal hygiene. During an observation on 01/17/19 at 9:30 AM, the resident in private room [ROOM NUMBER] on Unit 1 had 6 black disposable razors on the night stand. During an observation on 01/18/19 at 07:24 AM, the resident in private room [ROOM NUMBER] on Unit 1 had 6 black disposable razors on the night stand and 1 black disposable razor on the sink in his bathroom. During an observation on 01/18/19 at 09:30 AM, the resident in private room [ROOM NUMBER] on Unit 1 had one black disposable razor on the sink in the bathroom of his private room. The Comprehensive Care Plan (CCP), last revised 12/19/18, documented the resident had the potential for bleeding/hemorrhage secondary to anticoagulant therapy for cardiac health and the daily use of Aspirin. A physician's orders [REDACTED]. Interviews During an interview on 1/17/19 at 1:31 PM, Certified Nursing Assistant (CNA) #2 stated razors should have been thrown away in the sharps box. She stated Resident #24 was non-compliant, and the razors observed on the bathroom sink are not the facility razors. That razor was brought from his home by family. During an interview on 1/17/19 at 1:50 PM, CNA #1 stated the razors should be put in the sharps container. If she sees a razor, she would normally put it in the sharps container. During an interview on 1/17/19 at 1:54 PM, Licensed Practical Nurse (LPN) #2 stated the razors should have been thrown in the sharps box. During an interview on 1/17/19 at 1:56 PM, LPN #1 stated the razors go in the sharps container and are not supposed to be left out in the resident rooms. During an interview on 1/18/19 at 09:38 AM, CNA #10 stated razors were not kept in resident rooms unless the resident had their own personal razor, either disposable or electric. She stated the razors supplied by the facility were one time use razors. The razors should be brought into the resident's room to be used and thrown away in the red sharps container in the room. She stated the residents who have their own razors should keep them locked in their nightstand. She stated a razor should never be left out on the sink and if she saw a razor on the sink or laying out in a resident room, she would ask the resident to lock it up and make the nurse aware that there was a razor in the room. The CNA stated that Resident #36 had his own disposable razors. She observed the razor on the resident's sink and stated it was not acceptable for the razor to be out on the sink. During an interview on 1/18/19 at 4:41 PM, the Assistant Director of Nursing stated razors were not to be kept in resident rooms. The razors were supposed to be brought into the room and then disposed of in the sharps container in the resident's room. She stated sometimes residents had their families bring razors in from home and families do not tell the staff they brought in razors. She stated she thought the staff were aware of the razor policy and tried to follow it. She stated the expectation was for staff to pick up any razors they saw laying out in a resident's room and to dispose of the razor in the sharps container. During an interview on 01/24/19 at 2:27 PM, the Director of Nursing stated she would have to refer to the razor policy, but razors should not be left laying around or visible. She stated there was a sharps container in every room and in the hallways where the razors should be disposed. She stated any resident on anticogulation therapy should have electric razor due to risk of bleeding. Finding #2 During an observation on 1/17/19 at 8:09 AM, Microkill disinfecting wipes were stored in the unlocked top left cabinets of the kitchenette with a water bottle and disposable cups. Stainless steel cleaner wipes, no rinse spray, and rubbing alcohol were stored in the unlocked top right cabinets of the kitchenette with ginger ale. During an interview on 1/17/19 at 9:16 AM, the Food Service Director (FSD) stated the chemicals should not be stored in the kitchenette cabinets on the unit. During an interview on 1/17/19 at 10:06 AM, the Director of Maintenance stated no chemicals are expected to be stored in the kitchenette cabinets on the unit. 10NYCRR415.12(h)(1)

Plan of Correction: ApprovedMarch 3, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #24 facility completed a sweep of Residents room and bathroom and removed and disposed of all razors.
Resident #29 facility completed a sweep of Residents room and bathroom and removed and disposed of all razors.
Resident #36 is no longer a Resident of Rosewood Rehab. and Nursing
All chemicals were immediately removed from unit 1 and unit 2 kitchenettes cabinets.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected
A full house sweep of Resident rooms, bathrooms, and shower rooms was completed to ensure no disposable razors are laying around.
Any disposable razors found were immediately removed and thrown in the sharp?s container.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy and procedure titled Shaving the Resident was reviewed by the interim DON, no changes needed.
All Nursing staff were educated on the above policy as it relates to the use of disposable razors and the immediate disposing of the razor into a sharps container for resident safety after use.
The policy and procedure titled storage of chemicals was reviewed by the facility Administrator, no changes needed
All facility staff were educated on the above policy as it relates to storage of chemicals, not storing chemicals of any kind on the units in the kitchenettes.
How the corrective action will be monitored to ensure the practice will not recur:
The ADON/designee will complete a random audit (10) rooms weekly x12 weeks, then monthly x3 of Resident rooms, Resident bathrooms, and shower areas to ensure all disposable razors are immediately discarded in a sharp?s container after use.
The director of environmental services/designee will conduct an audit bi-weekly x6, then monthly x3 of unit 1 and unit 2 kitchenettes to ensure chemicals are not being stored in the cabinets.
Responsible Party: DON

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during recertification survey the facility did not ensure written notice which specifies the duration of the bed hold policy was provided to the resident and residents' representative at the time of transfer for one (Resident #5) of two residents reviewed for hospitalization . Specifically, for Resident #5, the facility did not ensure that written notice which specifies the duration of the bed hold policy was provided to the resident and the resident's representative at the time of transfer. This is evidenced by: Resident #5: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Date Set dated 10/9/18, documented the resident had minimal cognitive impairments, she understands and is understood by others. A nursing progress note dated 12/10/18 at 7:30 PM, documented the resident was sent to the hospital and directly admitted to the Intensive Care Unit for possible permanent pace maker placement. The Hospital Transfer Discharge summary dated 12/28/18, documented a new [DIAGNOSES REDACTED]. During an interview on 01/25/19 10:33 AM, Registered Nurse Unit Manger #1 reported that she believed the social work department was responsible to notify the residents representative. During an interview on 01/25/19 11:51 AM Social Worker #7 reported that a written notice of bed hold policy was not provided to the resident or the residents representative at the time of transfer and that it should have been. 10NYCRR415.3(h)(4(i)(a))

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #5 is no longer a Resident at Rosewood Rehab. and Nursing
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected.
Last 30days of discharged Residents were reviewed by the IDCPT to ensure all Residents and families had received in writing a notice for the bed hold policy.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The notice for bed hold policy and procedure were reviewed by the Interim DON and facility Administrator with no changes needed
Education was provided to the IDCPT members on above notice for bed hold policy and procedure
All licensed nurse?s RN and LPN were educated on the above notice for bed hold policy and procedure
How the corrective action will be monitored to ensure the practice will not recur:
The DON/designee will audit all discharged Resident?s weekly x12, monthly x3 to ensure the notice for bed hold policy and procedure was given to Resident and responsible party/family for all discharged Resident?s to the hospital setting
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party: DON


FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during the recertification survey the facility did not ensure that the resident and resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language they understand for one (Resident #5) of two residents reviewed for hospitalization s. Specifically, for Resident #5, the facility did not ensure the resident or residents' representatives were notified in writing of the reason for the transfer/discharge to the hospital in a language they understand. This is evidenced by: Resident #5: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set dated 10/9/18 documented the resident had minimal cognitive impairments; the resident understands and is understood by others. A nursing progress note dated 12/10/18 at 7:30 PM, documented the resident was sent to the hospital and directly admitted to the Intensive Care Unit for possible permanent pace maker placement. The Hospital Transfer Discharge summary dated 12/28/18, documented a new [DIAGNOSES REDACTED]. During an interview on 01/25/19 10:33 AM, the Registered Nurse Unit Manger #1 reported that she believed the Social Work Department was responsible to notify the residents representative. During an interview on 01/25/19 11:51 AM, Social Worker (SW) #7 reported that the Transfer/Discharge Notices was not completed at the time the resident was transferred to the hospital and it should have been. 10NYCRR415.3(h)(1)(iii)(a-c)

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #5 is no longer a Resident at Rosewood Rehab. and Nursing
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:

All Residents have the potential to be affected.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
Last 30days of discharged Residents was reviewed by the IDCPT to ensure all Residents and families had received in writing the Transfer/Discharge notice in a language they could understand. The policy and procedure titled Transfer form were reviewed and revised by the Interim DON and the facility Administrator
The Notice of transfer/discharge form was reviewed by the Interim DON and the facility Administrator
Education was provided to the IDCPT members on above policy and form as it relates to transferring and discharging a Resident from Rosewood Rehab. and Nursing
Education was provided to all Licensed Nurses RN and LPN on the above policy and form as it relates to transferring and discharging a Resident from Rosewood Rehab. and Nursing
How the corrective action will be monitored to ensure the practice will not recur:
The DON/designee will audit all discharged Resident?s weekly x12, monthly x3 to ensure the Transfer/Discharge notice was given to all Resident?s and responsible party/families in a language that is understood
All results of the above audits will be reviewed by the QA committee monthly for any concerns


Responsible party: DON


FF11 483.25(k):PAIN MANAGEMENT

REGULATION: §483.25(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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, the facility did not 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 for two (Resident #'s 5 and 64) of four residents reviewed for pain. Specifically, for Resident #64, the facility did not ensure pain management was consistent with the comprehensive person-centered care plan for the location of pain and monitoring effectiveness, and with professional standards of practice and for Resident #5, that the effectiveness of the medication was monitored after it was administered (post). This is evidenced by: The Policy and Procedure (P&P) titled Controlled Substances dated 11/2018, documented the control sheet record must contain the name of the resident, the name and strength of the drug, the quantity received, the time of administration, the method of administration, and the signature of the nurse administering the medication. Additionally, the Director of Nursing (DON) shall investigate any discrepancies in narcotics reconciliation. Resident #5: The resident was admitted to the nursing home on 10/2/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The Comprehensive Care Plan (CCP) for pain dated 12/31/18, documented to administer medications as scheduled and monitor and record the effectiveness. Physician (MD) Orders documented: 12/6/18 - [MEDICATION NAME] mg: 1 tab every 6 hours for acute pain. 1/11/19 - [MEDICATION NAME] 20mg/ml; 0.25 ml sublingual every 4 hours as needed (PRN). A Medication Administration Record [REDACTED]. Of those 25 occasions 13 occasions did not include a follow-up pain level. A MAR from 1/12/19 at 7:45 AM - 1/6/19 at 10:00 AM, documented that PRN [MEDICATION NAME] was administered on 13 occasions. Of those 13 occasions, 4 occasions did not include a follow-up pain scale. During an interview on 1/25/19 at 1:34 PM, RN #1 stated that the pre and post administration pain levels need to be done each time a PRN medication is given to determine if the medication is effective in managing the pain. During an interview on 1/25/19 at 1:57 PM, the Director of Nursing stated there is aggressive education regarding assessing pre and post pain level assessments. Resident #64: The facility did not ensure pain management was consistent with the comprehensive person-centered care plan for location of pain and monitoring effectiveness, and with professional standards of practice. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderately impaired cognition, could understand others and make herself understood. Additionally, the MDS documented the resident had frequent pain or hurting in the last 5 days with an intensity of 7 out of 10 (Section J). The MDS documented the resident received scheduled pain medication and prn (as needed) pain medication and did not receive non-medication interventions for pain. The Comprehensive Care Plan for Pain, last updated 11/13/2018, documented the resident had complaints of chronic pain related to migraines. Interventions included administer medications, monitor and record effectiveness, assess past effective and ineffective pain relief measures, and use non-medicated pain relief measures: biofeedback, heat/cold, acupuncture, etc. Finding #1: During an observation on 01/17/19 at 10:57 AM, LPN #5 asked the resident about her about pain, and the resident stated she had left hip pain 11 on a scale of 1-10. The resident was observed with increased restlessness, moaning & groaning while discussing her pain with LPN #5, and during an observation on 01/17/19 at 11:10 AM, the resident was overheard from the hallway yelling out while the caregiver was providing AM care. Physician orders [REDACTED]. During an observation on 01/17/19 at 10:53 AM, the resident asked LPN #5 for something for pain, and nurse told the resident she just had something with her morning meds. The Medication Administratiion Record (MAR) dated 1/17/19, documented that [MEDICATION NAME] had been administered at 5:30 AM. The MAR indicated [REDACTED]. Finding #2: The Medication Administration (MAR) dated 12/18/18 - 1/22/19, [MEDICATION NAME] was administered 63 occasions. Of those 63 occasions, 22 of them had no post pain level documented. Interviews During an interview on 01/24/19 at 3:55 PM, the Physician stated when he orders PRN medications, for a limited period, typically 7 days, and will re-evaluate the need for the PRN medication based on the resident's use; if the resident is using the PRN regularly, he will give an order for [REDACTED]. During an interview on 1/25/19 at 10:35 AM LPN #1 stated she would note effectiveness of the pain medication by revisiting resident and asking what their pain level is to determine the effectiveness. She would call the doctor if she noted the pain was not relieved or that the resident was using the PRN medication routinely. During an interview on 1/25/19 at 10:51 AM, RN #1 stated pain medications should be documented on front of the MAR for being given to the resident, and on the back for pain assessment. There is no other specific timeline to review prn medications, if a resident requires PRN on a regular basis, the MDS person will let them know when she does her quarterly review.

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #5 no longer is a resident of Rosewood Rehab. and Nursing
Resident #64 RN Unit Manager re-assessed the residents pain level at this time by utilizing the pain assessment in Matrix Care.
Resident #64 was re-evaluated by the MD for pain management- new orders received reflecting the pain status of Resident #64 at this time.
Resident #64 The IDCPT held a care plan meeting with Resident and or responsible party to discuss pain management plan that will be effective for the Resident.
The comprehensive care plan for pain management was updated to reflect the Residents person centered care for pain medication goals and pharmacological and non-pharmacological interventions to control her pain levels effectively.
The primary LPN?s were re-educated on the importance of documenting the pre-pain scale number and the post pain scale number to evaluate the effectiveness of ordered pain medication. This evaluation is placed on the back of the MAR by the LPN
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected

A full house audit was completed from a ChemRX report to show all active Residents on PRN and Routine ordered pain medications, a review of all MAR?s, care plans, the most recent pain assessment, and MD orders for Residents captured on the ChemRX report was completed.

Any concerns identified an IDCPT meeting was held for individual Residents to ensure a person-centered pain management care plan is put in place with goals and interventions that are non-pharmacological and pharmacological to achieve effectiveness with pain management.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy and procedure titled pain management guideline was reviewed and revised by the Interim DON
All LPN?s and RN?s were educated on the above policy as it relates to documenting the pre and post pain scale numeric value, having a comprehensive care plan that is person centered for pain management to ensure (pharmacological and non-pharmacological interventions are in place for effective pain management.
A daily audit will be completed by the Unit Managers to ensure controlled substances are stored properly, that the ER kits are secured with the red lock provided by pharmacy, and that the controlled substances are signed for when given on both the controlled substance log sheet and the resident MAR?s to include the pre and post pain rating on the back of the MAR, the audit will be reviewed in the facility morning meeting process Monday-Friday daily.
How the corrective action will be monitored to ensure the practice will not recur:
The DON/designee will audit 10% of Residents receiving pain medication both routine and PRN x12 weeks, then x3 months to ensure all Residents receiving pain medication (routine and PRN) is monitored pre-pain med and post pain med on the back of the MAR, to ensure a comprehensive care plan that is person centered is in place for pain management, and to ensure there is an updated pain assessment completed as needed.
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification survey, the facility did not ensure procedures that assured the accurate acquiring, receiving, dispensing, reconciliation, and storage of medications. Specifically, the facility did not ensure that narcotic medications received into the facility were not stored in a desk drawer under a single lock, that they were properly logged as being received, and that drugs signed out on the controlled substance sheets were also signed out in the residents' Medication Administration Record [REDACTED] A facility policy titled, Controlled Substances last dated 11/2018, documented that controlled substances must by counted upon delivery. The nurse Receiving the order along with the person delivering the medication order must count the controlled substances together, and both individuals must sign the designated narcotic record. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsible parties. Finding #1: During an observation on 1/23/19 at 3:08 PM, the Assistant Director of Nursing/ Nurse Manager ADON/NM opened one lock on her desk drawer and removed approximately 10 blister packs of narcotics and handed them to the 2 different nurses on the unit. A Pharmacy shipping manifest of Schedule CII - CV (narcotics given to the pharmacy) dated 1/23/19, documented that the pharmacy delivered the following narcotic medications: [REDACTED] 180 - [MEDICATION NAME] 50 mg tablets (pain medication), 90 - [MEDICATION NAME] 1mg tablets (benzodiazepine antianxiety medication), 30 - [MEDICATION NAME] 0.5 mg tablets, 14 - [MEDICATION NAME] 10 mg tablets (sleeping pill), 90 - [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablets (pain medication), 15 - [MEDICATION NAME] 250 mg tablets (a muscle relaxant), 60 - [MEDICATION NAME] 5 mg tablets (antianxiety/[MEDICAL CONDITION] medication), and 100 [MEDICATION NAME] HCL 5 mg tablets (pain medication), belonging to seven different residents. The sheet was not signed by the persons who delivered or received the medication. A review on 1/25/19, of the House Log Book (a book that contains a list of all the narcotics received by the facility), did not include the narcotics listed on the Pharmacy Shipping Manifest dated as received on 1/23/19. During and interview on 1/23/19 at 3:10 PM, the ADON/NM stated that was is not appropriate to store the narcotics in her desk drawer under a single lock on her desk. She was supposed to log them into the house book but did not have the time. During and interview on 1/24/19 02:46 PM, Licenced Practical Nurse (LPN) #4 stated if we are not available when the narcotics are delivered by pharmacy, the ADON will lock them in her desk. Finding #2: The Controlled Substance Record for resident #5, from 1/11/19 at 10:30 pm - 1/18/19 at 11:40 AM, documented that 25 doses were signed out as administered. There was no documentation of doses were wasted. A MAR for Resident #5, from 1/11/19 - 1/18/19 documented that [MEDICATION NAME] was administered on 17 occasions. The Controlled substance records for Resident #64, dated 12/18/18 - 1/22/19, documented 69 doses of [MEDICATION NAME] were signed out. None of these doses were documented as wasted. The MAR for Resident #64, from 12/18/19 - 1/22/19, documented [MEDICATION NAME] was administered on 63 occassions During an interview on 1/25/19 at 10:35 AM LPN #1 stated the 1/14/18 8:00 AM dose of [MEDICATION NAME] was not signed for on the controlled substance tracking sheet, and it was also not on MAR. During an interview on 1/25/19 at 1:21 PM, the ADON/NM stated that nurses should be signing on the Controlled substance sheet and the MAR indicated [REDACTED]. She is not involved in any audits of the narcotic sheets and if she received that audit would do medication error for the nurse and report it to Bureau of Narcotic Enforcement. During an interview on 1/25/19 at 1:57 PM, the (DON) stated that she was not aware that narcotics signed out the the Controlled Substance Record were not signed out on the MAR indicated [REDACTED]. Finding #3: During a medication storage observation on Unit 1 on 1/23/19 at 1:54 PM, there were two red emergency (ER) boxes of medication had no seal locks (a plastic locking ring that can be broken to access ER medication when needed) on them. During an interview on 1/23/19 at 1:56 PM, Licenced Practical Nurse (LPN) #2 stated she did know the ER boxes were unlocked and she did not remove anything from them. During an interview on 1/23/19 02:02 PM, LPN #4 stated she believed that the ER boxes are seal locked when they receive them from pharmacy but once they are opened the seal locks are not replaced. During an interview on 1/23/19 02:04 PM, the ADON stated the seal locks should be replaced when medications are replaced and the replacement plastic locks are inside the ER box. 10NYCRR 415.18(b)(1)(2)(3)

Plan of Correction: ApprovedFebruary 15, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #5 is no longer a resident of Rosewood Rehab. and Nursing.
Resident #64 a review of the MAR indicated [REDACTED]?s that didn?t sign as given the [MEDICATION NAME] on the MAR.
Resident #64 a dose of [MEDICATION NAME] dated 1/14/19 at 8am was not signed for on the controlled substance sheet and was not signed for on the MAR- the LPN responsible received a discipline and medication error for not signing for the controlled substance.
The DON no longer works at Rosewood Rehab. and Nursing
The ADON received an educational counseling related to improper storage of controlled substance, lack of signing for the controlled substance by ADON and Pharmacy when they were delivered to the facility by pharmacy, and the house log book on 1/25/19 was missing the controlled substances that the ADON had in possession on 1/23/19.
The Unit 1 ER boxes for medications were immediately secured with red locks. LPN #2 and LPN #4 received educational counseling for not having the ER medication kits x2 locked with the red locks provided by pharmacy.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected
An audit was completed on unit 2 to ensure all controlled substances were stored properly.
No concerns identified.
The 2 ER medication kits on unit 2 were checked to ensure the red locks from pharmacy were intact and secure.
No concerns identified.
An audit was completed on unit 2 with all controlled substance sheets and MAR?s to ensure all medications were signed for in both controlled substance book and the MAR?s.
Any concerns identified medication error reports were filled out and given to the LPN?s responsible for not signing.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy titled Controlled substances was reviewed by the Interim DON, no changes needed
The policy titled ER medication kit was reviewed by the Interim DON, no changes needed.
All licensed Nurses were educated on the above policies as they relate to storage of controlled substances, securing the ER medications kits, and the signing of controlled substances on the control substance sheet and the MAR?s when given a Resident a controlled substance as ordered.
A daily audit will be completed by the Unit Managers to ensure controlled substances are stored properly, that the ER kits are secured with the red lock provided by pharmacy, and that the controlled substances are signed for when given on both the controlled substance log sheet and the resident MAR?s to include the pre and post pain rating on the back of the MAR, the audit will be reviewed in the facility morning meeting process Monday-Friday daily.
How the corrective action will be monitored to ensure the practice will not recur:
The ADON/designee will audit Unit 1 and Unit 2 100% monthly x3 for proper storage of controlled substances, secured ER medication kits, and the signing of controlled substances sheets and MAR?s.
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.25:QUALITY OF CARE

REGULATION: § 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record observation, record review, and interview during a recertification survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan, and the residents' choices for one (Resident #26) of two residents reviewed. Specifically, the facility did not ensure that dressing changes were done per the Medical Doctor (MD) orders, that wound measurements were done, that education was provided to the resident for refusal of care regarding the risks to himself and others of not having dressings changed, that the Medical Director was notified of the frequency of refusals for wound care, and that drainage from the resident's wounds was contained in the dressing. This is evidenced by: Resident #26: The resident was admitted to the nursing home on 3/4/15 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Finding #1: The facility did not ensure physician ordered dressing changes were applied. During observations on 1/23/19 at 11:28 AM, a malodorous odor was noted when a surveyor entered the unit and was even stronger at the resident's door. Physician orders [REDACTED]. On 1/23/19 at 10:44 AM, Certified Nursing Assistant (CNA) #3 stated there is a horrendous smell when you open the resident's door. Treatment Administration Records from 10/24/19 - 12/21/19 documented 53 opportunities to change the resident's dressing. Of those 53 opportunities, it documented that the resident refused to have his dressings changed on 40 occasions and on 13 occasions there are no nurse initials to indicate the dressing was done. During an interview on 1/24/19 at 9:10 AM, Licensed Practical Nurse (LPN) #5 stated that the resident refused his dressing change everyday that it was scheduled. She notified the Nurse Manager (NM) and Medical Doctor (MD) when he refused, but did not talk to the residents about the risks of not having it done; she thinks the Registered Nurses (RN) do that. She had seen it dripping and believed there was an order for [REDACTED]. During an interview on 1/24/19 at 9:16 AM, CNA #9 stated she just asks if he needs anything. There is an odor in the room that smells like death. She did not see the dressings but did see his socks and they always look wet, with a brownish yellow staining. She did not report it because that is his norm. During an interview on 1/23/19 at 10:42 AM, Housekeeper #13 stated that the smell in hallway had been going on for months, and smelled like rotten food or meat. Other residents and anyone walking down the hall had complained about the smell. Finding #2: The facility did not ensure that wound measurements were done per standard of practice. Wound Tracking Flow sheets from 8/17/18 - document 20 opportunities for observations for wound measurements by the Wound Care Team. On 8/17/18, the assessment documented that the resident's vascular wound involved his entire RLE from right below the knee 20 cm long around the circumference of his leg and measured 36 cm. The other 19 opportunities documented that the resident refused. During an interview on 1/24/19 at 1:37 PM, the Medical Director stated that the resident's wound measurements absolutely should have been monitored. Finding #3: The facility did not ensure that that education was provided or documented when the resident refused. During an interview on 1/24/19 at 10:57 AM, Social Worker #7 met with the resident to discuss the resident's clothing. Had not spoken to anyone about the dressing not being done. During an interview on 1/24/19 at 10:02 AM, the Medical Director would expect notes from the doctor about refusals. This should have been brought to his attention and a meeting should have been held to discuss options. Does not know if meeting was held with family. Would expect MD to look at the wounds and if the resident was allowed to do his own dressing changes, then that should be documented. During an interview on 1/24/19 at 10:19 AM, the Assistant Director of Nursing (ADON) stated the resident was not seen by wound care, was not able to say that a meeting took place with IDT and the MD. There should have been formal meeting to discuss options. There is always seepage from the resident's dressing. During an interview on 1/24/19 at 2:16 PM, House Keeper #14 had a hard time cleaning his room; he refuses a lot. At times she had seen dirty dressings in the resident's garbage. During an interview on 1/24/19 at 3:48 PM, the Infection Control Nurse (ICN) stated that the resident refused leg dressing. The Director of Nursing had conversations with the Resident but there was no documentation. The resident did not shower or bathe, and washed his upper body at the sink. There has not been any formal meetings about what to do. During an interview on 1/24/19 at 9:25 AM, RN #1 stated that she had reeducated him in the past but did not document it; noone is documenting what they are seeing. Finding #4: The facility did not ensure the Medical Director was made aware of the extent of the resident's wound and of dressing change refusals. The last Medical note dated 10/18/18, documented that the resident was seen for his medicare required visit with a chief complaint of bilateral stasis [MEDICAL CONDITION], chronic [MEDICAL CONDITION] of the left lower extremity, non-compliance, characterized by patient refused to have his leg dressing or changed stating that he would do it himself. Under plan, it documented that the resident does his own dressing most of the time. During an interview on 1/24/19 at 9:25 AM, RN #1 stated that noone is documenting what they are seeing, the resident did not get discussed in morning meeting or IDT. During an interview on 1/24/19 at 10:02 AM, the Medical Director stated that he would expect notes from MD about refusals. Staff should have been brought this up to him and a meeting should have been held to discuss options. Would expect MD to see the wounds and if the resident was allowed to do the dressing changes himself, those dressing changes should have been documented. Additionally, he did not not know if a meeting was held with family or family representative. Finding #5: The facility did not ensure infection control was maintained. During observations on 1/23/19 at 10:42 AM, and 1/23/19 at 11:28 AM, a very malodorous odor like an infectious process, was noted when surveyor entered the unit and even stronger at the resident's door. An LPN in the vicinity stated that the smell was terrible even with the door closed. A Social Work (SW) note dated 8/2/17, documented that providers at the facility felt that the resident's lack of compliance and hygiene are beginning to become a serious problem for other residents a and quite possibly a health risk. A SW note dated 1/18/18, documented that the resident is affecting others in a negative way by risking infectious disease spread due to hygiene. A hand written note by an LPN, in the chart, in front of the MD notes dated 12/2/18, documented the resident had a malodorous odor coming from his right leg, had refused treatments stating that he had feelings of general malaise, fever, and nausea and felt the wound was infected. During an interview on 1/23/19 at 10:42 AM, HK #13 stated that the smell in hallway had been going on for months, and smelled like rotten food or meat. Other residents and anyone walking down the hall had complained about the smell. During an interview on 1/24/19 at 9:25 AM, RN #1 stated that she did not know how they were protecting everyone else in facility. During an interview on 1/24/19 at 3:48 PM, the Infection Control Nurse (ICN) stated that there had not been any formal meetings about what to do, and she had been saying in morning report that the resident should go to the hospital. During an interview on 1/24/19 at 1:37 PM, the Medical Director stated that the resident's wounds absolutely should have been monitored. If they documented concerns about a possible infectious process, then the resident should have put on isolation and placed on the line list. 10NYCRR 415.12

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #26 was assessed and evaluated by the DON, ADON, and the MD (medical director) on 1/24/19
The MD medical director documented a visit note and new orders were obtained for treatment related to resident?s lower extremity ulcers.
Resident #26 is being seen weekly by the interim DON and the wound team as he allows. Documentation and re-approach will continue with any refusals from the resident
The IDCPT held a care plan meeting with Resident #26 to discuss care options related to his lower extremity ulcers and poor hygiene choices. A comprehensive care plan was developed related to impaired skin integrity, and refusal of care.
The IDCPT provided education to Resident #26 explaining the importance of following the plan of care and MD orders for his safety and well being and the safety and well being of others.
The housekeeping staff will continue to complete daily room cleaning according to the schedule, if Resident refuses the housekeeping staff will report immediately to their supervisor/designee
The DON responsible for wound tracking and documentation is no longer working at Rosewood Rehab. and Nursing
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected

A full house audit was completed on all active Resident?s receiving wound care utilizing weekly wound round documentation report from Matrix Care.
100% audit was completed of Resident?s on the wound report from Matrix Care.
The treatment records, MD orders, care plans, and individual weekly documentation in Matrix Care were reviewed for all active wound residents to ensure wound care including measurements and RN assessments, MD orders, and care plans are completed, and no refusals noted.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy and procedure titled Pressure ulcer treatment was reviewed by the Interim DON, no changes needed
All RN licensed Nurses were educated on the above policy as it relates to wound care and what to do when a Resident refuses wound/treatment care.
Environmental services director developed a housekeeping check list and added Resident refusals of room cleaning to the list.
The housekeeping department was educated on the above check list as it relates to resident refusals of room cleaning and the need to report to their supervisor/designee immediately
How the corrective action will be monitored to ensure the practice will not recur:
The ADON/designee will complete a weekly audit x12, then a monthly audit x3 of 100% of wound Resident?s to ensure wound care, treatments, MD orders, care plans are compliant, and to ensure no Resident refusals are occurring without notification to MD/family and provided nursing documentation
The ADON will run a weekly wound report from Matrix Care to complete all audits
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey and abbreviated survey (Case #NY 513) the facility did not ensure complete, accurate and accessible medical records for 10 (Resident #'s 5, 11, 18, 26, 32, 63, 64, 217, 267, and #268) of 18 residents reviewed. Specifically: For Resident #267, the facility was unable to locate and provide the medical record; for Resident #63, an admission weight was not documented per policy, food and fluid intake documents were not completed and accurate, and the resident care card was not updated to reflect a diet change and isolation precautions; for Resident #'s 5, 18, 32, and #268, the facility did not ensure physician documentation was clear and legible; for Resident #'s 11 & 217, the facility did not ensure that the resident's medical records accurately documented their advanced directives in each location it was documented, and that the doctor's handwriting was legible. This was evidenced by: Resident #32: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact, could understand others and could make herself understood. During an interview on [DATE] at 3:22 PM, the Director of Nursing (DON) was asked to read a physician's note dated, [DATE] regarding Resident #32. The DON was unable to read the physician's hand writing and stated she was not sure what had been written in the physician note. She stated she was aware staff had difficulty reading the physician's notes, but that the physician was available by phone for staff to contact if they needed his documentation to be clarified. During an interview on [DATE] at 3:55 PM, the physician stated he was aware his hand writing was difficult for the staff to read and stated everyone told him his writing was hard to read. He stated the staff could call him or could fax him the paperwork if they need to clarify his writing and he would read his notes over the phone to them. Resident #267: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE]. During an interview on [DATE] at 1:44 PM, the Acting Administrator (AA) stated the facility started storing the medical records offsite 3 to 4 months ago. When the DOH requested the medical record for Resident #267, the facility requested the boxes from the medical record storage company. The boxes did not include the medical record for Resident #267. The AA had requested several more boxes to be delivered to the facility. During an interview on [DATE] at 11:50 AM, the AA stated that the facility was unable to find the medical record for Resident #267. Resident #63 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition and could usually understand others and could make himself understood. Finding #1: A Policy and Procedure (P&P) titled Weight Assessment and Intervention dated ,[DATE] documented the nursing staff will measure resident's weights on admission and weekly for four weeks thereafter. An Initial Admission Nursing Assessment form dated [DATE], documented a blank next to the area for weight. A Physician order [REDACTED]. A weight record documented; [DATE] admission weight 104lbs, [DATE] weekly weight 103.5lbs, and [DATE] weekly weight 102lbs. During an interview on [DATE] at 2:41 PM, the Registered Dietitian stated the admission weight should be done by the RN doing the initial assessment and should have been obtained within 24 hours. During an interview on [DATE] at 9:34 AM, the Assistant Director of Nursing (DON) stated weights should be obtained within the first 24 hours of admission, and documented in the weight book and on the nursing admission form. For Resident #63, No admission weight was obtained until [DATE]. Finding #2: A P&P titled Consumption Policy and Procedure dated ,[DATE], documented meal consumption tracking sheets will be completed for every resident, every shift, and every meal. 24 hour totals for fluid will be tallied by the overnight nurse on each floor, and any resident with a food intake less than 50% for 3 consecutive meals and/or fluid intake less than 1500mL in a 24 hour period will be placed on the 24 hour report for closer monitoring. Daily food and fluid consumption sheets dated [DATE] - [DATE] documented food and fluid intake on 20 of 78 meals for the residents room number. Available food and fluid consumption sheets documented the residents name on [DATE] - [DATE], and no name or the incorrect name was documented on available sheets [DATE] - [DATE]. Nine intake sheets were not tallied for fluid intake. Food and fluid consumption sheets were not available for the following dates: [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 10:56 AM, Certified Nursing Assistant (CNA) #2 stated food and fluid consumption are documented in the intake and output book by available nursing staff. They work as a team to document and no one person is assigned. If a resident name is missing or wrong, she would notify the Registered Dietitian (RD) or Food Service Director (FSD). During an interview on [DATE] at 11:01 AM, Registered Nurse (RN) #3 stated the Unit Secretary updates the resident names on the intake sheets. When a resident's room is changed, all staff recieved an email stating there has been a room change. The Nurse Manager and Registered Dietitian review the food and fluid consumption records for accuracy and completion. The DON had recently provided education to staff that the night shift totals the intakes and reports them to the Nurse Manager. During an interview on [DATE] at 11:10 AM, the Registered Dietitian (RD) stated the unit secretary was responsible for updating the resident names on the intake sheets after she received e-mail notifiction. The nursing staff documents intake. The Unit Manager reviews CNA documentation and intakes are totaled by nursing. During an interview on [DATE] at 11:19 AM, Unit Secretary #1stated the receptionist updates the food and fluid intake sheets at the front desk. During an interview on [DATE] on 11:24 AM, Receptionist #13 stated she updates the food and fluid intake sheets. She used to update them every 30 days, and was recently told to update them every day. During an interview on [DATE] at 2:43 PM, the DON stated the overnight nurses are supposed to tally total fluid intakes, and this was not being done. Additionally, the resident name and room number should be documented on the food and fluid intake sheets. Finding #3: A physician order [REDACTED]. A physician order [REDACTED]. A CNA care card last updated [DATE], documented Mechanical Soft diet with chopped and whole milk, and did not document contact precautions. A second CNA care card last updated [DATE], documented Mechanical Soft Diet with chopped and whole milk, and documented contact precautions. During an interview on [DATE] at 2:41 PM, the DON stated CNA care cards are pulled and updated when changes are made to a residents care. The Licensed Practical Nurse (LPN) will communicate changes in resident care to staff for 3 shifts. If CNA care cards are changed and updated there should be a date and initials. The DON stated the second CNA care card was updated to reflect the contact precautions when it was brought to the facilities attention and the date should have been updated. 10NYCRR415.22(A)(,[DATE])

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #5 is no longer a resident at Rosewood Rehab. and Nursing
Resident #11 The facility provided access for the MD to document in Matrix care (electronic medical record). Social Services reviewed the advanced directives for this resident with the MD. The advanced directives were documented in the medical record (Molst form), MD progress note, MD orders, and comprehensive person-centered care plan.
Resident #18 The facility provided access for the MD to document in Matrix Care (electronic medical record)
Resident #26 The facility provided access for the MD to document in Matrix care (electronic medical record)
Resident #32 The facility provided access for the MD to document in Matrix care (electronic medical record)
Resident #63 is no longer a resident at Rosewood Rehab. and Nursing
Resident #64 The facility provided access for the MD to document in Matrix care (electronic medical record)
Resident #217 The facility provided access for the MD to document in Matrix care (electronic medical record). Social Services reviewed the advanced directives for this resident with the MD. The advanced directives were documented in the medical record (Molst form), MD progress note, MD orders, and comprehensive person-centered care plan.
Resident #267 is no longer a resident at Rosewood Rehab. and Nursing
Resident #268 is no longer a resident at Rosewood Rehab. and Nursing
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All Residents have the potential to be affected
A full house audit was conducted for weekly, monthly, and weights x4 after admission to ensure all Resident weights are recorded as ordered and per policy.
Any weights not recorded per MD order/policy those Residents have been evaluated by the Dietician and MD to ensure the resident?s needs are met.
A full house audit was completed on the last 60 days of consumption sheets to ensure that the facility IDCPT can identify the lack of documentation, and the lack of proper consumption records filled out for each resident.
The facility started all new consumption records for each Resident to ensure the sheets are properly filled out and that all meals are recorded per policy.
A full house audit was completed of Resident care cards to ensure accuracy to each resident. Any concerns identified the Resident care card was updated by the IDCPT immediately.
The facility discontinued the care cards in the Resident closets, keeping the care card binders active on each Unit (1&2).
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The policy and procedure titled weight assessment and intervention was reviewed by the Interim DON and dietician, no changes needed.
All nursing staff/IDCPT were educated on the above policy as it relates to ordered weights
The policy and procedure titled Consumption policy and procedure was reviewed by the Interim DON and the Dietician, no changes needed.
All Nursing staff/IDCPT/receptionist/medical records were educated on the above policy as it relates to appropriately filling out the consumption records for each Resident on a monthly bases and record each meal for all Resident?s.
The facility will maintain and audit each Care Card binder, Unit 1 and Unit 2 during morning meeting process Monday-Friday daily with any updates or changes needed to ensure each Resident Care Card is accurate and up to date.
How the corrective action will be monitored to ensure the practice will not recur:
The ADON/designee will audit 100% of monthly weights, weekly weights, and weights x4 on admission x12 weeks, then x3 months to ensure all weights are obtained per MD order/policy.
The Dietician/designee will conduct an audit of 20% consumption records on each unit 1 and unit 2 x12 weeks, then x3 months to ensure the sheets are filled out accurately month to month and to ensure all meals are documented on the consumption records.
The DON/designee will audit 10% of each Unit 1 and 2 Care Card binders x12 weeks, then x3 months to ensure all updates are placed on the care card after review of the comprehensive person-centered care plan.

All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party: DON


FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(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: January 25, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey, the facility did not ensure (i) A resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and (ii) A resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #52) of 3 residents reviewed for pressures ulcers. Specifically, the facility did not ensure Resident #52's clinical condition was evaluated and risk factors for developing pressure ulcers were identified upon re-admission to the facility. Additionally, a comprehensive care plan to address pressure ulcers was not developed to define and implement interventions consistent with resident needs, goals, and professional standards of practice. This is evidenced by: Resident #52: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively impaired, could understand others and could make herself understood. The Minimum Data Set (MDS) documented the resident was at risk for developing pressure ulcers and had one unhealed Stage 2 pressure ulcer. A Policy and Procedure titled Pressure Ulcer Prevention dated 12/2018, documented Braden Assessments (an assessment tool to predict pressure ulcer risk) were completed on admission and recommended, weekly for 4 weeks after admission. An admission Braden assessment dated [DATE], documented the resident had a Braden score of 15, indicating the resident was at low risk of developing a pressure ulcer. A subsequent Braden scale dated 12/17/18, documented the resident had a Braden score of 12, indicating the resident was at high risk of developing a pressure ulcer. The assessment documented the resident had very moist skin, was bedfast, and required maximum assistance for moving and repositioning. A physician's orders [REDACTED]. A nursing progress note dated 12/17/18 at 1:45 PM, documented the resident had a Stage 2 cluster pressure ulcer to her sacrum and bilateral buttocks. Four superficial wounds were noted over an area measuring 3.5 centimeters (cm) x 3.5 cm. The doctor was notified and approved the [MEDICATION NAME] dressing to treat the wound. A Registered Nurse (RN) wound observation dated 12/28/18, documented the wound cluster on the resident's sacrum had improved since identified on 12/17/18 and had decreased to 1 open area measuring 0.3 cm x 0.3 cm. The following RN wound observation dated 1/04/19, documented the sacral ulcer improved, measuring 0 cm x 0 cm, and the wound margins resurfaced (meaning the wound was completely covered with new skin) with fragile tissue. The surrounding tissue was pink and normal. The wound observation entered in the electronic medical record (EMR) on 1/12/19 and dated for 1/10/19 documented the sacral ulcer was closed and surrounding skin was pink and normal. A nursing note dated 1/10/19 at 11:53 PM, documented the resident was readmitted from the hospital after she had an [DEVICE] (used to stabilize bone and soft tissues at a distance from the operative site) removed. The resident was non-weight bearing to the left leg and vital signs were stable. The medical record did not include documentation of an RN assessment when the resident returned from the hospital on [DATE]. In addition, there was no documented evidence a comprehensive care plan (CCP) was developed to address pressure ulcers or deep tissue injuries (DTIs). An RN wound observation entered in the EMR on 1/12/19 and dated for 1/10/19 documented the resident had deep purple discoloration across her bilateral (both) buttocks and sacrum upon readmission. The wound observation documented a 3 cm x 4 cm unstageable deep tissue injury to the left buttock, a 5 cm x 5 cm unstageable deep tissue injury to the sacrum, and a 4 cm x 4 cm unstageable deep tissue injury to her right buttock. An RN wound observation dated 1/18/19, documented a 5 cm x 3 cm Stage 2 to left buttock, a 3.5 cm x 5 cm Stage 2 to sacrum, and a 5 cm x 3 cm Stage 2 to right buttock. The status of the wound was noted to have declined. The wound progressed to be one continuous sDTI (soft deep tissue injury) from the right buttock to the sacrum and to left buttock with each of the 3 open areas measuring 1 cm x 1 cm. A Comprehensive Care Plan initiated on 1/18/19 documented, upon readmission the resident had sDTIs to her bilateral buttocks and sacrum. The care plan interventions included: the use of an air mattress; assess the pressure ulcer and surrounding skin weekly; apply dressings per physician order; and turn and position every 2 hours. An RN wound observation dated 1/19/19 documented the right and left buttock wounds merged with the sacral wound and the wounds would be measured as one area. The RN documented a 10 cm x 20 cm Stage 2 pressure ulcer to the sacrum. The wound status was noted to have declined related to acute illness, poor PO intake, refusal to reposition, and an air mattress was placed. A physician's orders [REDACTED]. A dietary progress note dated 1/22/19 at 11:23 AM, documented the dietician was made aware on that date the resident returned from the hospital with a sDTI. The note documented the resident's needs were re-assessed and a recommendation was made for a multivitamin with minerals, in addition to adding mighty shakes (a high-calorie shake) at lunch and supper to increase the resident's protein intake in small volume. During an interview on 1/23/19 at 2:58 PM, the Assistant Director of Nursing (ADON) stated the resident was at high risk for pressure sores and did not move herself in bed or get out of bed. She stated the resident refused to be turned and positioned and documentation of her refusals should be in the progress notes. The ADON was unable to locate an admission care plan to address the resident's pressure ulcers and was unable to locate documentation that the resident's skin condition was assessed upon readmission from the hospital. She stated the pressure sore was noted on 1/10/19 upon readmission and should have had a care plan in place when it was found. She stated the nurse who readmitted the resident should have documented on the resident's skin condition and the nurses should also be documenting on the wound with each dressing change and report back to her. During an interview on 1/23/19 at 3:43 PM, RN #4 stated she did not re-admit the resident on 1/10/19 and did not look at the resident's buttock when the resident returned to the facility on [DATE]. During an interview on 1/23/19 at 3:48 PM, CNA #5 stated the resident has a sore on her bottom and was repositioned every 2 hours. The CNA stated the resident does not refuse to be turned and positioned. During an interview on 1/24/19 at 9:28 AM, CNA #10 stated the resident was turned and positioned every 2 hours because of the sore on her bottom. She stated she was never unable to provide care to the resident or turn and position her due to refusal. During an interview on 1/24/19 2:58 PM, the ADON stated she did not think a physician had seen the wound yet. During an interview on 1/24/19 at 3:00 PM, the Director of Nursing (DON) stated an RN assessment should be completed when a resident returned from the hospital. She stated an RN assessment should also be completed when a resident returned from a leave of absence (LOA) for the day. The DON stated a care plan to address pressure ulcers should have been in place at the time the pressure ulcer was found. During a follow up interview on 1/25/19 at 8:45 AM with the ADON, she stated she did not readmit the resident on 1/10/19 and did not observe the resident's wounds on 1/10/19. She stated she entered the RN wound observation information in the EMR on 1/12/19 after the CNA's notified her of the resident's open areas. She stated the CNA's reported they thought the wounds had been present when the resident was readmitted on [DATE]. She stated that was the reason she documented the wounds were observed on 1/10/19. The ADON stated she could not be sure of the size of the wounds on 1/10/19, since she made her first observation on 1/12/19. She also documented on 1/12/19, that the resident's sacral ulcer initially identified on 12/17/18 was healed based an RN observation on 1/10/19. The ADON stated she observed new sDTIs surrounding the healed sacral area on 1/12/19 and stated the wound observation date in the EMR was incorrect but was not intentional. In addition, she stated when she observed the wound on 1/19/19 the surface tissue started to open and was separating from the base of the wound. The wounds had merged together resulting in the larger measurement. She expected the wound to get larger, darker, deeper, more purple as the tissue began to separate and an air mattress was put on the resident's bed. She stated dietary was part of the wound care process and the RD should have been involved as it was expected the wound would get worse. She stated wounds were discussed in morning report with the interdisciplinary team (IDT) which included the dietician. During an interview on 1/25/19 at 10:20 AM, the Registered Dietician (RD) stated she was not aware of the resident's sDTI until it was discussed in morning report with the IDT on 1/22/19. She stated she should have been made aware of any new areas upon the resident's re-admission but was not. She did not receive a skin discovery form from nursing. She stated any time a wound was discovered, the RN would complete an RN nursing assessment and at that time, the RN would also complete a skin discovery form. After the RN completed the form, the RN would send the form to her to make her aware of the newly discovered. The RD stated when she received a skin discovery form, she re-calculated the resident's nutritional needs and added additional nutritional supplements if needed to assist with wound healing. She stated she should have received a new skin discovery form when Resident #52 was re-admitted to the facility on [DATE]. 10NYCRR415.12(c)(1)(2)

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
Resident #52 is no longer a resident at Rosewood Rehab. and Nursing
The facility RN that admitted Resident #52 received an educational counseling related to failure to provide assessment upon re-admission.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected
A full house audit was completed on the previous 30 days of admission to ensure a full body RN skin assessment, MD orders, and care plans were initiated on admission.
No other concerns identified
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:

The policy and procedure titled Pressure Ulcer prevention was reviewed and revised by the Interim DON
All RN licensed Nurses were educated on the above policy related to a full body RN skin assessment upon admission, receiving MD orders, development of a care plan related to skin impairment/pressure ulcers to prevent worsening or development of pressure ulcers (wounds).
The admitting RN will place any new Resident on the 24-hour report sheet for the IDCPT to receive in the next morning meeting
All new admission Resident?s with wounds are added to and seen weekly on skin rounds until healed. The wound team will ensure that the braiden scale is completed x4 weeks after admission during weekly skin rounds, documentation of the team?s knowledge of the Braiden scale will be completed on the resident individual wound form in Matrix Care until all 4 weeks are completed.
How the corrective action will be monitored to ensure the practice will not recur:

The ADON/designee will complete an audit x12 weeks, then monthly x3 of all new admission Residents to ensure skin assessment is completed, MD orders, and care plans are put in place as needed for those Resident?s admitted with pressure ulcers (wounds).
All results of the above audits will be reviewed by the QA committee monthly for any concerns

Responsible party:
DON

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not utilize extension cords and power strips in accordance with adopted regulations. NFPA 70 National Electrical Code 2011 Edition Article 590 section 590.3 (D) requires that temporary wiring, such as extension cords, shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Specifically, extension cords and power strips were used as permanent wiring to power electrical devices. This is evidenced as follows. Observation on 01/23/2019 at 2:15 PM, revealed that a power strip was being used a temporary wiring, above the suspended ceiling on the second floor by the elevator, to power elopement prevention system. Observations on the basement floor level on 01/25/2019 at 1:45 PM, revealed that an extension cord was used as permanent wiring in the maintenance shop to power a wall mounted fan, and inside the elevator shaft, extension cords were used as permanent wiring to power two sump pumps. The Director of Facilities stated in an interview conducted on 01/25/2017 at 2:20 PM, that permeant wiring will be installed to power wander guard system, maintenance shop's wall mounted fan, and elevator shaft sump pumps. 42 CFR 483.70 (a) (1); 2011 NFPA 70 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 70 527.3(D)

Plan of Correction: ApprovedFebruary 14, 2019

What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
No residents were identified as being affected
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have potential to be affected by the identified practice.
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
All power and extension cords have identified and will be removed and replaced by permanent wiring by an independent contractor.
How the corrective action will be monitored to ensure the deficient practice will not recur:
Audits will be conducted to ensure that no power or extension cords are being utilized in the facility.
These audits will be conducted weekly X 2 months, then monthly times 4 months to ensure facility compliance with the life safety code.
Audit results will be reported to the QAPI Committee monthly. Frequency of on-going audits will be determined by the committee based on these results.
Responsibility: Director of Facilities

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: April 3, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that PCREE is maintained with consideration of the owner's manual. Specifically, PCREE was not maintained as prescribed in the owner's manuals. This is evidenced as follows. Observations on 01/25/2019 at 8:55 AM, revealed oxygen concentrators in use by residents 2-inches from a dresser in rooms [ROOM NUMBERS]. Record review of the oxygen concentrators owner's manual on 01/25/2019 revealed concentrators must be 12-inches from walls and furnishings when in operation. The Director of Nursing stated in an interview on 01/25/2019 at 10:30 PM, that she was unaware that nursing staff was not operating oxygen concentrators in accordance to the owner's manuals and will in-serviced the staff to operate the oxygen concentrators in accordance to the owner's manual. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedFebruary 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
The facility will ensure that the oxygen concentrators must be 12-inches from the dressers or any structures/fixtures that can obstruct the flow of air to the PCREE's air intake ports while being used by residents on rooms [ROOM NUMBERS].

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
The facility will conduct an audit of all residents who use oxygen concentrators and ensure that the equipment is at least 12-inches from any structures or fixtures that will obstruct the concentrator's air intake ports.
The facility will conduct an audit of all residents to determine those that utilize patient care-related electrical equipment (PCREE) not limited to oxygen concentrators and ensure that they are being utilized in accordance to the manufacturers operating guidelines.
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
All staff responsible for placing and/or maintaining placement oxygen concentrators and other patient care-related equipment (PCREE) will be trained on manufacturers guidelines for their utilization.
This training will be included in orientation and annual mandatory education.
How the corrective action will be monitored to ensure the deficient practice will not recur:
Random audits will be conducted to ensure that oxygen concentrators and other PCREEs are being utilized in accordance with manufacturers guidelines.
These audits will be conducted weekly X 3 months, then monthly thereafter to ensure that the facility maintains compliance with the use of PCREE as prescribed in the owners manual.
Audit results will be reported to the QAPI Committee monthly. Frequency of on-going audits will be determined by the committee based on these results.
Responsibility: Director of Facilities

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide emergency power as required by adopted regulations. NFPA 99 Health Care Facilities Code 2012 edition section 6.4.1.1.17 requires that the emergency power source (emergency generator) is to include a remote annunciator that is storage battery powered and provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. Specifically, the emergency generator did not include a remote annunciator at a regular work station. This is evidenced as follows. Observations on 01/24/2019 at 2:00 PM, revealed that the emergency generator remote annunciator is in the basement storage room, not a regular workstation. The Director of Facilities stated in an interview conducted on at 01/24/2019 at 2:12 PM, that a remote annunciator will be installed at a regular work station. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1.1.15

Plan of Correction: ApprovedFebruary 14, 2019

What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
No residents were identified as being affected
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have potential to be affected by the identified practice.
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
The facility has engaged an electrician to relocate the annunciator panel from the basement to the first floor nurses station. This is a permanent repair to the affected area.
How the corrective action will be monitored to ensure the deficient practice will not recur:
The Director of Facilities will report to the QAPI Committee when the panel has been moved.
Responsibility:
Director of Facilities

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not inspect electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Sections 6.3.3.2 and 6.3.4.1 require that receptacles not listed as hospital-grade at patient bed locations shall be tested at intervals not exceeding 12 months; the testing shall include: the physical integrity shall be confirmed by visual inspection; the continuity of the grounding circuit shall be verified; correct polarity of the hot and neutral connections shall be confirmed; the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Specifically, on 2 of 2 units, the facility did not ensure receptacles not listed as hospital-grade were tested as required and when faulty, replaced as required. This is evidenced as follows. Record review of the electrical receptacles not listed as hospital grade on 01/24/2019, revealed no testing was conducted in (YEAR); the 12/05/2018 testing was limited to retention force tests, and receptacles that failed this inspection were not replaced, a period of 50 days as of survey review. The Director of Facilities stated in an interview conducted on 01/25/2019 at 3:30 PM, that the outlets were not tested in (YEAR), and the failed receptacles had not been replaced because he was fielding bids to replace all outlets in resident rooms with hospital grade outlets. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.3.3.2, 6.3.4.1

Plan of Correction: ApprovedFebruary 21, 2019

What corrective action will be accomplished for those residents found to have been affected by the deficient practice:
No residents were identified as being affected
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the identified practice. At the moment, the facility will apply for a waiver due to the facility's existing electrical wiring configuration does not allow for installations of hospital grade receptacles.
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
The facility will consult with an outside electrical contractor to develop a plan on replacing all receptacles that failed the inspection in accordance with the requirement of NFPA 99 Standard for Health Care Facilities 2012 Edition Sections 6.3.3.2 and 6.3.4.1.
All receptacles in resident rooms will be tested in accordance with NFPA 99.
How the corrective action will be monitored to ensure the deficient practice will not recur:
Random audits will be performed on all areas of the building weekly X 2 months, then monthly times 4 months to ensure facility compliance with the life safety code.
Audit results will be reported to the QAPI Committee monthly. Frequency of on-going audits will be determined by the committee based on these results.
Responsibility: Director of Facilities

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, in the past year, the facility did not conduct a community-based drill, facility-based drill, or a tabletop drill and did not experience an actual event that would activate the emergency plan. This is evidenced as follows. A review of the Emergency Plan on 01/23/2019, revealed that the facility did not conduct a community-based drill, facility-based drill, or a tabletop drill and did not experience an actual event that would activate the emergency plan. The Corporate Administrator stated in an interview conducted on 01/23/2019 at 11:30 AM, that she does not have a record that the facility conducted testing of the emergency plan. 42 CFR: 483.73(d)(2)

Plan of Correction: ApprovedFebruary 21, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
No Residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected by the same practice.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The facility will conduct a tabletop drill which will emulate the activation of the Emergency Procedure Plan. This drill will include members of community organizations. The Administrator will be responsible for scheduling and conducting the tabletop exercise. Additionally, the Administrator will be responsible for facilitating participation in a community-based drill.
How the corrective action will be monitored to ensure the practice will not recur:
This will be audited on a semi-annual basis, during the first week of (MONTH) and the first week of November. The results of the audit will be reported to the QAPI Committee during the month in which the audit occurs.

Responsibility: Administrator

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not document staff training in emergency preparedness policies and procedures. This is evidenced as follows. On 01/23/2019, a review of the Emergency Preparedness Plan revealed the plan did not have a method for staff to demonstrate their knowledge of the Emergency Preparedness policies and procedures. The Corporate Administrator stated in an interview on 01/23/2019 at 10:45 AM, that the Emergency Preparedness Program will be updated to include a specific method by which staff will demonstrate knowledge after training. 42 CFR: 4 83.73(d)(1)(ii)

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by the practice:
No residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same practice and what corrective action will be taken:
All residents have the potential to be affected by this practice.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The Emergency Procedure Plan has been revised to include a post-test to be administered at the end of EP training.
How the corrective action will be monitored to ensure the practice will not recur:
Post-test results will be audited for compliance.
The audits will be conducted monthly times X 6 months. The results of the audits will be reported to the QAPI Committee on a monthly basis. Frequency of on-going audits will be determined by the committee based on these results.
Responsibility: Administrator


K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide education on the safety guidelines, usage, and risks associated with the handling of medical oxygen cylinders. This is evidenced as follows. When requested on 01/25/2019 no records were provided documenting that staff responsible for handling oxygen cylinders received training on the safety guidelines and usage requirements and the risks associated with handling oxygen cylinders. The Assistant Director of Nursing stated in an interview conducted on 01/25/2019 at 11:15 AM, that the facility's oxygen safety training does not included information on the risks associated with handling of oxygen cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedFebruary 14, 2019

What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
No residents were identified as being affected
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have potential to be affected by the identified practice.
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
All staff responsible for handling oxygen cylinders will be trained on safety guidelines and usage requirements and the risks associated with handling oxygen cylinders.
This training will be included in orientation and annual mandatory education.
How the corrective action will be monitored to ensure the deficient practice will not recur:
Random audits will be conducted on staff knowledge of safety guidelines and usage requirements and the risks associated with handling oxygen cylinders.
These audits will be conducted weekly X 2 months, then monthly times 4 months to ensure facility compliance with the life safety code.
Audit results will be reported to the QAPI Committee monthly. Frequency of on-going audits will be determined by the committee based on these results.
Responsibility: Director of Facilities

MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.3.1 requires that fire-rated door assemblies be tested not less than annually in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition. Specifically, fire-rated doors were not inspected within the past year. This is evidenced as follows. When requested on 01/24/2019, no records were available for survey review documenting the required inspections of fire-rated doors. The Director of Facilities stated in an interview on 01/24/2019 at 1:30 PM, that the facility has no record that the fire-rated doors were inspected during (YEAR). 42 CFR 483.70 (a)(1); 2012 NFPA 101 19.2.1, 7.2.1.15; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedFebruary 14, 2019

What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
No residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have potential to be affected by the identified practice.
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
The facility has scheduled an outside contractor to inspect the fire doors the week of (MONTH) 18-22, 2019.
How the corrective action will be monitored to ensure the deficient practice will not recur:
The Administrator will keep a binder of all scheduled inspections in their office.
The results of the scheduled inspection will be reported to the QAPI Committee at the next scheduled meeting.
Responsibility: Director of Facilities

PROCEDURES FOR TRACKING OF STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include a system for tracking the location of staff that are part of an emergency. This is evidenced as follows. A review of the Emergency Plan on 01/23/2019, revealed that the policies and procedures did not include a procedure for tracking staff involved in an emergency. The Corporate Administrator stated in an interview conducted on 01/23/2019 at 9:30 AM, that the Emergency Plan will be revisited and revised to include a procedure for tracking staff involved in an emergency. 42 CFR: 483.73(b)(2)

Plan of Correction: ApprovedFebruary 15, 2019

What corrective action will be accomplished for those residents found to have been affected by this practice:
No residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same practice and
what corrective action will be taken:
All residents have the potential to be affected by this practice.
What measures will be put in place or systemic changes will you make to ensure that the practice does not recur:
The Facility has revised the Emergency Procedure Plan to include a mechanism to track staff that are participating in the emergency (be it actual or a drill).
How the corrective action will be monitored to ensure the practice does not recur:
The revised procedure will be evaluated during the after action evaluation.
The results of the after action report will be reported to the QAPI Committee at the first meeting following the completion of the after action evaluation.
At that time, the QAPI Committee will determine what, if any, additional action needs to be taken.
Responsibility: Administrator

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.1.1 requires automatic sprinkler protection throughout the premises. Section 8.15.7 requires automatic sprinkler protection under canopies and overhangs used for combustible storage. Specifically, automatic sprinkler protection was not provided in all areas. This is evidenced as follows. A spot check of the sprinkler system was conducted on 01/25/2019 at 1:30 PM. Automatic sprinkler protection was missing in the fire alarm room and combustible materials were stored under an overhang on the west side of the building, an area without sprinkler protection. The Director of Facilities stated in an interview on 01/25/2019 at 1:45 PM, that automatic sprinkler protection will be added to the fire alarm room and the combustible materials under the overhang will be removed. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.1.1, 8.15.1, 8.15.7

Plan of Correction: ApprovedFebruary 14, 2019

What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
No residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the lack of a sprinkler head in the fire alarm room and with the current position of the sprinkler head in the oxygen storage room. In addition, all residents have the potential of being affected by the storage of combustible material under the overhang.

What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
The contractor for the maintenance of the sprinkler system will perform an audit of the entire building to ensure compliance with NFPA 13, Standard for the Installation of Sprinkler Systems 2010 Edition section 8.1.1. The addition of a sprinkler head in the fire alarm room and the relocation of the sprinkler head in the oxygen room. This is a permanent repair to the affected area.
The combustible material under the overhang was removed on 1/25/19.
How the corrective action will be monitored to ensure the deficient practice will not recur:
Audits on the combustible materials will be performed weekly X 2 months, then monthly for 4 months. Results will be reported on the storage of combustible materials to the QAPI Committee monthly. Frequency of on-going audits will be determined by the committee based on these results.
Responsibility: Director of Facilities


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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on staff interview and review of inspection records during the recertification survey, the automatic sprinkler system was not tested in accordance with adopted regulations. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition section 5.1.3 requires that an internal obstruction test be conducted every 5 years. Section 5.2.1.1.1 requires sprinkler heads be free of foreign materials, such as dust. Specifically, 8 sprinkler heads were found with a coating of dust, and the required 5-year internal obstruction test was not preformed. This is evidenced as follows. The sprinkler system inspection records were reviewed on 01/24/2019. There was no record of an internal obstruction test being conducted within the last five years. A spot check of the sprinkler system on 01/25/2019 at 8:30 AM, revealed five sprinkler heads in the laundry room, two on the loading dock area and one in the clean linen storage closet on the first-floor resident unit were found with a coating of dust. The Director of Facilities stated in an interview on 01/25/2019 at 1:00 PM, that he had no record of an internal obstruction test being conducted in the last 5 years, and staff did not clean all the sprinkler heads in the facility. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5, 9.7.7, 9.7.8; 2011 NFPA 25 4.7, 5.1.3, 5.2.1.1.1; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6, 4.6.12, 9.7.5; 1998 NFPA 25 1-11.1, 2-3.3

Plan of Correction: ApprovedFebruary 14, 2019

What corrective action will be be accomplished for those residents found to have been affected by the deficient practice:
No Residents were identified as being affected.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
All residents have the potential to be affected by the dust accumulating on the sprinkler heads.
The cleaning of the sprinkler heads will be added to the monthly preventive maintenance program
What measures will be put in place or systemic changes will you make to ensure that the deficient practice does not recur:
A competency will be developed for the maintenance staff to ensure that they can demonstrate the
proper technique of cleaning the sprinkler heads.
The internal obstruction test was completed on 1/29/19.
How the corrective action will be monitored to ensure the deficient practice will not recur:
Audits will be performed on the cleaning of the sprinkler heads on a monthly basis. The results of the audits will be reported to the QAPI Committee on a monthly basis for six months. The QAPI will determine the frequency of the audits beyond the six-month period to ensure compliance.
The internal obstruction test will be added to the facility contract service tracker.
Responsibility: Director of Facilities

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition, Section 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Specifically, in 1 of 1 smoke barriers observed, the fire-resistance rating was not maintained. This is evidenced as follows. The second-floor resident unit smoke barrier wall by the elevator was inspected on 01/23/2019 at 2:15 PM. The following items were not fire protected and did not maintain a fire resistance rating; one 20-foot by 6-inch metal beam in resident room 200, one 20-foot by 6-inch metal beam in resident room 201, and one 20-foot by 6-inch metal beam in the second-floor dining room. The Director of Facilities stated in an interview conducted on 01/23/2019 at 11:40 AM, that he was in the process of auditing all the smoke barrier walls and he will ensure that all metal beams will be fire-protected as required. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedFebruary 22, 2019

CORRECTIVE ACTIONS TO BE TAKEN FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE:
The facility fully recognizes all residents have the potential to be affected by the deficient practice. However, there were no residents reported to have been affected by the said deficiency.
CORRECTIVE ACTIONS TO BE TAKEN FOR THOSE RESIDENTS WHO HAVE THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE
The 20-foot by 6-inch metal beam found in the smoke barrier wall in resident?s room 200 will be coated with a fire-resistant material to maintain a minimum of 1-Hour fire-resistant rating.
The 20-foot by 6-inch metal beam found in the smoke barrier wall in the second-floor dining room will be coated with a fire-resistant material to maintain a minimum of 1-Hour fire-resistant rating.
MEASURE TO BE TAKEN TO ENSURE NON-RE(NAME)CURRENCE
The maintenance crew will conduct an inspection of other smoke barrier walls in the facility similar to resident?s room 200 and second-floor dining room to determine if there are other metal beams that does not maintain fire-resistance rating.
All metal beams found in other smoke barrier walls during inspections will be coated with fire-resistant material to maintain a fire-resistant rating.
QUALITY ASSURANCE MEASURE TO MONITOR NON-RE(NAME)CURRENCE
The Director of facilities will develop and implement a weekly audit tool to ensure that any metal beams in any of the smoke barrier walls in the facility are coated with a minimum of 1-hour fire-resistant material.

The audit will be reported to the administrator for compliance review weekly for 4 weeks and once monthly thereafter.
The compliance audits and findings will then be reported to the QAPI committee in each monthly committee meeting.
Audits with negative findings will have corrective actions implemented immediately and will be submitted to the Administrator and QA committee for evaluation, compliance review and follow up.

Person Responsible: Director of Facilities

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 25, 2019
Corrected date: March 15, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies, shall be fire-sealed to maintain a 1-hour fire resistance rating and be continuous from floor to roof. Specifically, stairwells, elevator shafts, and rated ceilings were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations on 01/23/2019 at 2:15 PM, revealed a 6-inch by 15-foot metal beam at the top of the elevator shaft that was not fire protected, one 2-inch unsealed penetration at the top of the of the stairwell by the elevator shaft, one 4-inch and one 3-inch unsealed vertical penetration in the fired rated ceiling in the laundry mechanical room. Observations on 01/25/2019 at 1:45 PM, revealed a 6-inch by 15-foot metal beam at the bottom of the elevator shaft that was not fire protected, one 4-inch unsealed penetration in the shop room fire rated ceiling, and one 3-inch unsealed penetration in the fire rated ceiling in the basement oxygen cylinder storage room. The Director of Facilities stated in an interview on 01/25/2019 at 2:11 PM, that all the unsealed penetrations in fire rated ceilings, the stairwell and elevator shaft will be sealed. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.3, 8.5, 8.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1, 8.2

Plan of Correction: ApprovedFebruary 21, 2019

CORRECTIVE ACTIONS TO BE TAKEN FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE DEFICIENT PRACTICE:
The facility fully recognizes all residents have the potential to be affected by the deficient practice. However, there were no residents reported to have been affected by the said deficiency.
CORRECTIVE ACTIONS TO BE TAKEN FOR THOSE RESIDENTS WHO HAVE THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE
The 6-inch by 15-foot metal beam at the top of the elevator shaft and the 6-inch by 15-foot metal beam found at the bottom of the elevator shaft that was not fire protected will be coated with a fire-proofing material that has a minimum of 1-hour fire-resistance rating.
The 2-inch unsealed penetration at the top of the of the stairwell by the elevator shaft will be sealed with a fire-proofing material that has a minimum of 1-hour fire-resistance rating.
The 4-inch and one 3-inch unsealed vertical penetration in the fired rated ceiling in the laundry mechanical room, the 4-inch unsealed penetration found in the shop room fire rated ceiling, and the 3-inch unsealed penetration in the fire rated ceiling in the basement oxygen cylinder storage room will be sealed with a fire-proofing material that has a minimum of 1-hour fire-resistance rating.
MEASURE TO BE TAKEN TO ENSURE NON-RE(NAME)CURRENCE
The Maintenance staff will conduct planned weekly inspections of other vertical opening walls in the building including rated ceiling assemblies to determine if there are any other penetrations and miscellaneous openings that are unsealed with a fire-resistance-rated material and to apply corrective measures immediately.
QUALITY ASSURANCE MEASURE TO MONITOR NON-RE(NAME)CURRENCE
The Director of facilities will develop and implement a weekly audit and monitoring tool to ensure that there are no unsealed miscellaneous openings and penetrations in all vertical wall openings and rated ceiling assemblies in the building.
The Director of Maintenance added on the routine environmental rounds a weekly inspection and audit to ensure that all miscellaneous openings and penetrations in all vertical wall openings and rated ceiling assemblies are sealed with a UL rated fire-proofing material that has a minimum of 1-hour fire-resistance rating.
The audits will be reported to the administrator for compliance review weekly for 4 weeks and once monthly thereafter.
The compliance audits and findings will then be reported to the QAPI committee during the monthly committee meeting.
Audits with negative findings will have corrective actions implemented immediately and will be submitted to the Administrator and QAPI committee for evaluation, compliance review and follow up.
PERSON RESPONSIBLE: Director of Facilities