Bethlehem Commons Care Center
April 20, 2017 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure that it developed a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 (one) (Resident #66) of 5 (five) residents reviewed for pressure sores. Specifically, for Resident #66, the facility did not ensure that a comprehensive care plan (CCP) for the resident's Stage IV pressure ulcer to her left heel and left gluteal fold wound were developed. This is evidenced by: Resident #66: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severely impaired for cognition, usually understands others and sometimes is understood. The MDS also documented the resident had two stage 2 unhealed pressure ulcers. A physician's orders [REDACTED]. The dressing was to be changed daily and as needed (PRN). Review of Wound Rounds documented the resident was assessed and treated for [REDACTED]. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) (YEAR), documented the resident received dressing changes to her left heel wound every day on 7-3 shift. The TAR for (MONTH) (YEAR) documented the resident received a treatment to her inner buttocks three times every day. Review of CCP's did not include a CCP for the stage IV pressure wound to resident's left heel or a CCP for the left gluteal fold wound. During an interview on 4/18/17 at 8:40 am, Licensed Practical Nurse (LPN) #2 stated the resident had the left heel ulcer for the last couple of months. During an interview on 4/18/17 at 8:55 am, the Nurse Manager (NM) stated the pressure ulcer to the resident's left heel was discovered on 11/10/16. The NM reviewed the resident's record for CCPs for the stage IV pressure ulcer to resident's left heel and for the open area to the resident's left gluteal fold and stated she could not locate the care plans stating they should have been done. The NM, who is a LPN) stated she was recently a floor nurse who became nurse manager and received a crash course on how to do care plans. She initiated, reviewed and updated the care plans and the Director of Nursing (DON) signed off on them. During an interview on 4/19/17 at 3:00 pm, the Director of Nursing (DON) stated she oversees the care plans which the LPN NM writes. She stated the care plans are reviewed by her prior to the care plan meeting. The DON stated there should have been a careplan and will investigate why where was not. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Resident #66 care plan was reviewed and missing care plan replaced immediately on finding on 4/18/17 to reflect the interventions for the pressure ulcer.
Other residents:
Residents sustaining pressure ulcers are at risk. All records of residents with pressure ulcers were reviewed and found compliant.
Systemic Changes:
Staff education will be performed by the Staff Education Coordinator and Nursing Managers regarding assuring the care plan remains in the treatment books through monthly change over of records until area is resolved.
Monitoring:
Monthly audit will be performed by Nurse Manager or designee of all pressure wounds to ensure that care plan remains in place. DNS will report results to Quality Assurance committee quarterly and upon 100% compliance, will continue to report to the Quality Assurance Committee until determined as resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Compliance date: (MONTH) 19, (YEAR)

FF10 483.60(i)(4):DISPOSE GARBAGE & REFUSE PROPERLY

REGULATION: (i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose refuse in accordance with standard sanitary practice. Facilities are assure that garbage and refuse be properly disposed. Specifically, the refuse in the dumpster was not adequately enclosed. This is evidenced as follows. The dumpster was inspected on 04/17/2017 at 11:25 am. Refuse was found in the dumpster, the lid was open, and liquid waste was leaking from the drain hold with a missing plug leaving an opening for pest infestation. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 11:25 am, that he will notify dietary that the dumpster was not closed and contact the company to install a drain plug. 10NYCRR415.14(h)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Plant Operations Director placed a temporary plug in bottom of dumpster to prevent liquid waste from leaking on 4/17/2017. Waste Management Company who supplies dumpsters was contacted 4/17/2017 and notified of concern with plug. Waste Management Company to deliver new dumpster.
Maintenance/housekeeping/dietary staff directed to close dumpster after refuse deposited in dumpster 4/17/2017.
Identification of other potential areas:
None identified.
Systematic changes:
Maintenance/housekeeping/dietary staff will be re-educated on the proper disposal of refuse in accordance with the standard of sanitary practice.
Monitoring for Corrective Action:
To ensure this deficient practice does not recur Plant Operations Director/Designee will audit proper disposal of refuse and ensure plug is in dumpster to prevent leakage of liquid waste weekly x 3 months. The results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA Committee will review the audits and determine need to continue the audits.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Director/ Designee

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 22, 2017
Corrected date: July 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure it maintained each resident's drug regimen free from unnecessary drugs for one (Resident #130) of 7 resident's reviewed for psychoactive medications. Specifically, there was a lack of adequate indications for use and lack of adequate monitoring of effectiveness for an as needed (PRN) antianxiety medication [MEDICATION NAME] (generic name [MEDICATION NAME]). This is evidenced by: Resident #130: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 3/25/17, assessed that the resident understands, was understood and had a BIMS of 15/15 or no cognitive impairment. This MDS also documented the resident received antianxiety medication for 3 of the previous 7 days. admission orders [REDACTED]. The Medication Administration Record [REDACTED]. The back of the MAR indicated [REDACTED]. There was no follow up monitoring of the effectiveness of the medication on the MAR Nurses notes for (MONTH) (YEAR) documented: on 3/21/17 at 9:00 pm, the resident requested the [MEDICATION NAME]. There was no follow up monitoring of the effectiveness of the medication. On 3/22/17 at 10:30 pm, the resident requested [MEDICATION NAME] ([MEDICATION NAME]) stating she felt anxious and afterward she was resting quietly. On 3/24/17 at 10:00 pm, the resident requested [MEDICATION NAME] stating she needed it to help her sleep. There was no follow up monitoring of the effectiveness of the medication. The MAR for (MONTH) (YEAR) documented: The PRN [MEDICATION NAME] given on 4/1, 4/2, 4/3, 4/4, and 4/5/17. The back of the MAR indicated [REDACTED]. There was no follow up monitoring of the effectiveness of this medication on this MAR. Nurses notes for (MONTH) documented: 4/2/17 at 10:00 pm, the resident requested [MEDICATION NAME]. On 4/4/17 at 10:00 pm, the resident requested [MEDICATION NAME] for sleep. On 4/6/17 at 10:00 pm, the resident requested [MEDICATION NAME] for sleep. There was no documentation of the effectiveness of the PRN medication in the nurses notes. During interview on 4/20/17 at 9:30 am, the Registered Nurse Manager (RNM) was asked about the PRN [MEDICATION NAME] for this resident. She stated the resident had been on it at home. The RNM stated she believed the resident wanted the [MEDICATION NAME] at night and could ask for it herself. The RNM was asked to look at nurses notes. She looked at the 4/2/17 note. She was asked why the resident requested the [MEDICATION NAME]. She said she didn't know from the note. The RNM was asked if the [MEDICATION NAME] was effective. She said she couldn't tell. She stated there should be a documented reason the [MEDICATION NAME] was given and follow up documentation of the effectiveness. 10NYCRR415.12(I)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a post survey revisit, the facility did not ensure it maintained each resident's drug regimen free from unnecessary drugs for one (Resident #76) of 8 resident's reviewed. Specifically, the facility did not ensure that as needed (PRN) medications prescibed for anxiety, muscle spasms and pain were adequately monitored for their effectiveness. This is evidenced by: Resident #76: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. Physician order [REDACTED]. [MEDICATION NAME] 5 milligrams; Give one tablet three times a day PRN for lower extremity pain or muscle spasms. [MEDICATION NAME] 0.5 mg: give one daily PRN. A Medication Administration Record [REDACTED]. Of those administrations, the effectiveness of [MEDICATION NAME] was documented on two occasions and there was no documentation for [MEDICATION NAME]. During interviews: On 6/22/17 at 3:30 pm, the Licensed Practical Nurse (LPN) stated that she should have documented the effectiveness of the PRN medications. On 6/22/17 at 3:35 pm, the Nurse Manager stated that she would expect that staff would document responses to the [MEDICATION NAME] and [MEDICATION NAME] about 1 hour after administering. 10NYCRR 415.12(l)(1)

Plan of Correction: ApprovedJuly 5, 2017

Corrective Action:
Nurses will be educated regarding recording the reason and response for administering an as needed medication. Medication Error forms were filled out for the identified incomplete documentation.
Other Residents:
All Residents receiving as needed medications are at risk.
Systemic Changes:
All facility nurses will be educated regarding the documentation of as needed medications.
Monitoring:
Weekly random audit will be performed by Nurse Manager or designee of 20% of Resident medication and treatment records to ensure that as needed medications given have been documented appropriately. Any findings will be followed up with the nurse(s) to improve compliance. DNS will report results to Quality Assurance committee quarterly until determined as resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Compliance date: (MONTH) 19, (YEAR)

FF10 483.70:EFFECTIVE ADMINISTRATION/RESIDENT WELL-BEING

REGULATION: 483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, the facility failed to provide operative oversight to ensure that an effective system was in place to communicate malfunction of equipment essential to maintain health, safety and the highest practicable well-being of residents. Food service and maintenance staff did not report to the administrator that the kitchen walk-in refrigerator was malfunctioning and was not effectively repaired in a timely manner to ensure that potentially hazardous foods (PHF) and temperature control for safety (TCS) foods were stored at 41 degrees Fahrenheit (F) or less, in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness. This resulted in immediate jeopardy potentially affecting all the residents of the facility. This is evidenced by: The findings are: Cross References: F371 - Food Procurement, Storage, Preparation and Serving Food = L F465 - Essential Equipment = L During the initial tour of the main kitchen on 07/18/2017 at 8:00 am, ham was found to be 58 F, pureed vegetables were found to be 58 F, and cartons of milk were found to be 57 F. The temperature log for the walk-in refrigerator was reviewed on 04/17/2017. The log documented refrigerator temperatures of between 45-50 degrees Fahrenheit from 04/10/2017 through 04/17/2017 (acceptable temperature is 41 degrees Fahrenheit or below). The Maintenance Department work orders were reviewed on 04/17/2017. The work orders dated 04/12/2017 and 03/27/2017. stated that the walk-in freezer is running at a high temperature. The work order dated 04/10/2017, documents that the cooler at Dietary 141 Rock is running at 60 F. The work order dated 03/06/2017, asks that the refrigerator coils and air curtains be cleaned. During an interview conducted on 04/17/2017 at 8:00 am, the Food Service Director stated that over the last several weeks the walk-in refrigerator temperatures were fluctuating and on 04/10/2017 the walk-in refrigerator coils were icing up requiring maintenance. Over the past weekend, experienced staff were in charge when the walk-in refrigerator temperatures spiked. The persons in charge should have notified the Food Service Director, the Administrator, and the Maintenance Department via a work order to repair the walk-in refrigerator. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 9:00 am, that when called on 03/29/2017, he believed the walk-in refrigerator wasn't maintaining temperatures from staff not closing the door; he thought a work order dated 04/10/2017, was for another building on the campus; and he was not aware of any temperature problems with the walk-in refrigerator from the previous weekend. The Administrator stated in an interview conducted on 04/17/2017 at 9:27 am, that she was not aware of issues with the walk-in refrigerator, maintenance staff are always on call regardless of any particular day, and that the proper procedure would have been for the kitchen staff to submit a work order with the Maintenance Department. Maintenance Employee #1 stated in an interview conducted on 04/17/2017 at 9:27 am, that he was on duty during the past weekend and was not made aware of any problems with the walk-in refrigerator. 10NYCRR415.26

Plan of Correction: ApprovedJune 2, 2017

Corrective actions:
The following corrective actions were accomplished on 4/18/17:
?Dietary Department cooks were disciplined for failure to communicate refrigerator temperature deviations to the Food Service Director, Maintenance Staff or the Administrator.
?All food in the walk-in cooler and milk in the milk cooler were discarded. (4/17/2017)
?Our refrigeration repair vendor was contacted, and repairs were made to the walk-in cooler were completed. Following the repairs, the temperature in the refrigerator was 36 degrees. No cooling issues were identified in the milk cooler.(4/17/2017)
?All Dietary Staff was re-inserviced regarding acceptable cooler temperatures and required monitoring and reporting of deviant temperatures to Supervisory/Administrative staff.
?Cooler temperatures will be measured each shift and documented. Any deviant temperatures results will be reported to the Food Service Director, Plant Operations Director/Designee, RN Nursing Supervisor during off-hours and Administrator for action.
*Policy and Procedure for Food Storage and Food Temperatures were reviewed and revised.
Identifying other potential issues:
No other equipment was affected, and no residents were affected by the deficient practice. Refrigerator temperature readings will be measured hourly and documented to identify potential issues.
Systemic Chagnes:
?The Daily Temperature Log Form was reviewed and revised to include a column ?Reported to Administrator,? and the cooks, maintenance staff and nursing supervisors were inserviced on their responsibility to measure, record, and report deviant kitchen refrigerator temperatures during their assigned shifts.
?Discrepancies in acceptable refrigerator temperature ranges will be reported immediately to the Food Service Director and/or the Plant Operations Director/Designee, RN Nursing Supervisor during off shifts and Administrator.
*Any work orders for refrigeration will be given priority. The Administrator/Designee will be notified of temperature discrepancies as soon as they are identified.
Monitoring of Corrective Action:
To ensure the identified practice does not recur:
?Completed kitchen refrigerator temperature logs and work orders will be audited and signed off by the Food Service Director daily and the Administrator monthly to ensure reporting requirements were fulfilled. The results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA Committee at quarterly meetings to ensure compliance. Audits will be ongoing.
Date of Correction: 06/19/2017
Responsible Person: Food Service Director/Designee

FF10 483.90(d)(2)(e):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation, interview and record review during the recertification survey, the facility failed to ensure that essential equipment was maintained in safe operating condition to prevent potential harm to residents from food borne illness. Specifically, the facility's malfunctioning walk-in refrigerator was not effectively repaired in a timely manner to ensure that potentially hazardous foods (PHF) or temperature control for safety (TCS) foods were stored at 41 degrees Fahrenheit (F) or less, in accordance with professional standards for food service safety, to prevent the potential for development of food borne illness. For a period of 5 days, from 04/13/2017 to 04/17/2017, the walk-in refrigerator temperatures ranged between 44 F to 50 F. Multiple food items were stored during that time period and available for use, including ham found to be 58 F and pureed vegetables found to be 58 F. This resulted in immediate jeopardy potentially affecting all 107 residents of the facility. This is evidenced by: The findings are: Cross References: F371 - Food Procurement, Storage, Preparation and Serving Food = L F490 - Effective Administration / Resident Well-Being = L During the initial tour of the main kitchen on 04/17/2017 at 8:00 am, ham was found to be 58 F, pureed vegetables were found to be 58 F, and cartons of milk were found to be 57 F. The temperature log for the walk-in refrigerator was reviewed on 04/17/2017. The log documented refrigerator temperatures of between 45-50 degrees Fahrenheit from 04/10/2017 through 04/17/2017 (acceptable temperature is 41 degrees Fahrenheit or below). The Maintenance Department work orders were reviewed on 04/17/2017. The work orders dated 04/12/2017 and 03/27/2017, documented that the walk-in freezer is running at a high temperature. The work order dated 04/10/2017 states that the cooler at Dietary 141 Rock is running at 60 F. The work order dated 03/06/2017, asks that the refrigerator coils and air curtains be cleaned. During an interview conducted on 04/17/2017 at 8:00 am, the Food Service Director stated that over the last several weeks the walk-in cooler temperatures were fluctuating above the 30's and on 04/10/2017, the walk-in refrigerator coils were icing up requiring maintenance. Beginning last Monday, (MONTH) 10, (YEAR), temperatures in the walk-in refrigerator were increasing above the 30's. Over the past weekend experienced staff were in charge when the walk-in refrigerator temperatures spiked. The persons in charge should have notified the Food Service Director, the Administrator, and the Maintenance Department via a work order to repair the walk-in cooler. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 9:00 am, that when called on 03/29/2017, he believed the walk-in refrigerator wasn't maintaining temperatures from staff not closing the door; he thought a work order dated 04/10/2017, was for another building on the campus; and he was not aware of any temperature problems with the walk-in refrigerator from the previous weekend. The Administrator stated in an interview conducted on 04/17/2017 at 9:27 am, that the proper procedure is for the kitchen staff to submit a work order with the Maintenance Department when refrigeration problems arise. Maintenance Employee #1 stated in an interview conducted on 04/17/2017 at 9:27 am, that he was on duty during the past weekend and was not made aware of any problems with the walk-in refrigerator. 10NYCRR415.5(e)(1)(2)

Plan of Correction: ApprovedJune 2, 2017

Corrective actions:
The following corrective actions were accomplished on 4/17/17:
?All food in the walk-in cooler and milk in the milk cooler were discarded.
?Refrigeration repair vendor was contacted, and repairs made to the walk-in cooler were completed. Following the repairs, the temperature in the refrigerator was 36 degrees. No cooling issues were identified in the milk cooler.
?All Dietary Staff was re-inserviced regarding acceptable cooler temperatures and required monitoring and reporting.
?Cooler temperatures will be measured each shift and documented. Any inequities in temperature will be reported immediately to Food Service Director; Plant Operations Director/Designee and to the Nursing Supervisor during off-hours for action, and Administrator.
Identifying other potential issues:
No other equipment was affected, and no residents were affected by the deficient practice. All current residents were monitored for any signs or symptoms of foodborne illnesses. No residents identified.
Systemic Changes:
?The Daily Temperature Log Form was reviewed and revised, and the cooks, maintenance staff and nursing supervisors were inserviced on their responsibility to measure and record kitchen refrigerator temperatures as assigned.
?Deviant readings of food temps will be investigated to determine if the problem can be easily corrected, i.e., closing door properly, and temperatures will be remeasured shortly.
?Discrepancies in acceptable refrigerator temperature ranges will be reported to the Food Service Director and/or the Plant Operations Director/Designee, RN Nursing Supervisor during off hours and Administrator immediately for follow-up. Any work orders for refrigeration will be given priority.
?Potentially hazardous food suspected of exceeding 41 degrees for more than 2 hours will be discarded.
?Food in refrigerators deemed to be unaffected by temperature discrepancies will be moved to working refrigerators, if possible, until repairs can be made. If necessary, our food distributor will provide a refrigerated truck to maintain products if the facility is without refrigeration and until repairs are completed.
Monitoring Corrective Action:
?Results of the refrigerator temperature logs will be audited by the Food Service Director/Designee daily. Audit results will be presented to the QA Committee at quarterly meetings to ensure compliance. Audits will be ongoing.
Date of Correction: 06/19/2017
Responsible Person: Food Service Director/Designee

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

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

Scope: Widespread
Severity: Immediate jeopardy to resident health or safety
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview, during the recertification survey, the facility failed to store and serve potentially hazardous food under sanitary conditions. Specifically, the facility failed to recognize that the walk-in cooler and milk cooler were not operating properly, that food items were warm, and to notify appropriate staff to facilitate repairs. Ham was found to be 58 degrees Fahrenheit (F) after being held in the walk-in refrigerator for 3 days, pureed vegetables were found to be 58 F after being held in the walk-in refrigerator for 1 day, and cartons of milk were found to be 57 F, after being held in the milk refrigerator for an indeterminate period. Additionally, after identifying warm temperatures in the walk-in cooler, the kitchen staff did not institute emergency procedures to ensure food was held at 41 degrees F or less. Accepted safe food handling practice dictates that food be cold-stored at 41 F or less and requires that facilities provide refrigeration sufficient in number and capacity to cold-hold food at 41 F or less. This had the potential to effect 107 of 107 residents. This resulted in no actual harm but had the potential for more than serious harm that is Immediate Jeopardy to the health and safety of the residents. This is evidenced by the following: Cross References: F465 - Essential Equipment = L F490 - Effective Administration / Resident Well-Being = L During the initial tour of the main kitchen on 04/17/2017 at 8:00 am, ham was found to be 58 F, pureed vegetables were found to be 58 F, and cartons of milk were found to be 57 F. The temperature log for the walk-in refrigerator was reviewed on 04/17/2017. The log documented refrigerator temperatures of between 45-50 degrees Fahrenheit from 04/10/2017 through 04/17/2017 (acceptable temperature is 41 degrees Fahrenheit or below). The Maintenance Department work orders were reviewed on 04/17/2017. The work orders dated 04/12/2017 and 03/27/2017 stated that the walk-in freezer is running at a high temperature. The work order dated 04/10/2017 states that the cooler at Dietary 141 Rock is running at 60 F. The work order dated 03/06/2017, asks that the refrigerator coils and air curtains be cleaned. During an interview conducted on 04/17/2017 at 8:00 am, the Food Service Director stated that over the last several weeks the walk-in refrigerator temperatures were fluctuating and on 04/10/2017 the walk-in refrigerator coils were icing up requiring maintenance. Over the past weekend, experienced staff were in charge when the walk-in refrigerator temperatures spiked. The persons in charge should have notified the Food Service Director, the Administrator, and the Maintenance Department via a work order to repair the walk-in refrigerator. The Director of Plant Operations stated in an interview conducted on 04/17/2017 at 9:00 am, that when called on 03/29/2017, he believed the walk-in refrigerator wasn't maintaining temperatures from staff not closing the door; he thought a work order dated 04/10/2017, was for another building on the campus; and he was not aware of any temperature problems with the walk-in refrigerator from the previous weekend. The Administrator stated in an interview conducted on 04/17/2017 at 9:27 am, that she was not aware of issues with the walk-in refrigerator, maintenance staff are always on call regardless of any particular day, and that the proper procedure would have been for the kitchen staff to submit a work order with the Maintenance Department. Maintenance Employee #1 stated in an interview conducted on 04/17/2017 at 9:27 am, that he was on duty during the past weekend and was not made aware of any problems with the walk-in refrigerator. The Immediate Jeopardy was removed on 04/18/2017, prior to the survey exit. The facility discarded all food from the walk-in refrigerator, milk refrigerator, and unit nourishment refrigerators. The facility in-serviced staff on food cold-holding temperatures, monitoring of food temperatures and refrigeration temperatures, and internal reporting procedures for faulty equipment. The facility contracted repairs of the compressor servicing the walk-in refrigerator and returned the walk-in refrigerator to operation with 100% fresh food stock. 10NYCRR415.14(h)

Plan of Correction: ApprovedJune 2, 2017

Corrective actions:
The following corrective actions were accomplished on 4/17/17:
?All food in the walk-in cooler and milk in the milk cooler were discarded.
?Our refrigeration repair vendor was contacted, and repairs made to the walk-in cooler were completed. Following the repairs, the temperature in the refrigerator was 36 degrees. No cooling issues were identified in the milk cooler.
?All Dietary Staff was re-inserviced regarding acceptable cooler temperatures and required monitoring and reporting.
?Cooler temperatures will be measured each shift and documented. Any inequity in temperatures taken will be immediately reported to Food Service Director; Plant Operations Director, RN Supervisor during off-hours and Administrator.
?Monitoring of all residents for signs/symptoms of any foodborne illness was instituted by the Medical Director and the Infection Control nurse was alerted. Line list for each unit was completed for 7 days.
Identifying other potential issues:
No residents were affected by the deficient practice. All current residents were monitored for any signs or symptoms of foodborne illnesses. Any identified residents will be evaluated by their primary physician and treated, as necessary.
Systemic Changes:
?The dietary policy's and procedure's on Food Storage and Food Temperature were reviewed and revised and the Dietary staff was re-inserviced on the revisions.
Policy and Procedure specifically revised to include mal-function of essential equipment. Dietary Personnel will immediately notify Maintenance personnel;Food Service Director/Administrator to address concern/issue. Maintenance will contact vendor if warranted for repair. If unable to repair emergency protocol for food storage will be implemented by facility.
?The Daily Temperature Log Form was reviewed and revised, and the cooks were re-inserviced on their responsibility to measure and record kitchen refrigerator temperatures hourly.
?Maintenance staff and Nursing supervisors were inserviced regarding their responsibility to record kitchen refrigerator temperatures during assigned off-hours. Maintenance will monitor and record temperatures hourly from 8 pm until 11 p.m., and nursing supervisors will be held accountable for monitoring and recording kitchen refrigerator temps hourly on the 11 p.m. to 7 a.m. shift daily.
?Discrepancies in acceptable refrigerator temperature ranges will be reported to the Food Service Director and/or the Maintenance Supervisor/Designee and RN Supervisor immediately for follow-up. The Administrator will be notified of temperature discrepancies as soon as they are identified.
?Food in refrigerators deemed to be unaffected by temperature discrepancies will be moved to working refrigerators, if possible, until repairs can be made. If necessary, our food distributor will provide a refrigerated truck to maintain products if the facility is without refrigeration and until repairs are completed.
Monitoring of Corrective Action:
To ensure the identified practice does not recur:
?Results of the refrigerator temperature logs will be audited by the Food Service Director/Designee daily. Audit results will be presented to the QA Committee at quarterly meetings to ensure compliance. This audit will be ongoing.
Date of Correcton: 6/19/2017
Responsible Person: Food Service Director/Designee

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and interview during the recertification survey, the facility did not ensure that the environment remained as free of accident hazards as possible on one unit of three units observed. Specifically: the door to the visitor lounge on Unit BC was open; the window in the lounge was open; and the screen behind the window was bowed out from the track. This created a potential elopement hazard. This is evidenced by: During the initial tour of the BC unit, Daffodil wing, on 4/17/17 at 9:00 am, the visitor lounge door was open. The window was open approximately 14-16 inches on the right hand side. The screen behind the open window was bowed out from the track approximately a foot in length. Approximately 45 minutes later the visitor lounge door, window and screen were in the same position. The window was closed by the surveyor at this time. On 4/18/17 at 10:00 am, the group meeting with residents was held in the visitor lounge on BC Unit. The right side of the window was still closed. The left side of the window was open a crack (approximately .5 to 1 inch). On 4/19/17 at 7:45 am, the window in the visitor lounge of the BC Unit was closed all the way on both sides and there was a sign on it that said do not open the window. During interview on 4/18/17 at 8:45 am, the Maintenance Director was asked if he checked the window screens on a regular basis. He stated that yesterday he did a walk around with a surveyor and did not find any problems. He stated that housekeeping staff are supposed to let him know if any are broken. He stated the screens are removable so the windows can be cleaned. During this interview the visitor lounge door was open. During interview on 4/18/17 at 4:15 pm, Licensed Practical Nurse (LPN) #1 was asked who used the visitor lounge. He said visitors and families use it. He stated he had not seen residents in there by themselves. He stated that staff may use the room for break. During interview on 4/18/17 at 4:18 pm, a Certified Nurse Aide, for the unit, was asked about the visitor lounge. She said families use it, just a while ago a resident had a birthday party in there. She was asked if residents used the room. She said yes, there were a couple of residents who had coffee in there. During interview on 4/20/17 at 10:40 am, LPN #2 was asked if the window in the visitor lounge should be left open. She said no, because of the heat and air conditioning. She was asked if it would be an elopement concern. She said no, she had never seen or thought of that as a concern. She stated the residents use the room with their families. The door to the visitor lounge was open at this time. During interview on 4/20/17 at 10:50 am, the Registered Nurse Manager stated the residents use the visitor lounge, usually with their families. He stated he has not seen residents in there by themselves. He also stated there are wanderers on the unit. He was asked if the window should have been left open and said probably not. 10NYCRR415.12(h)(1)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Window in the visitor lounge on Unit C was closed. The screen was replaced by maintenance.
Other Residents:
All rooms have windows to the outside per regulation and may be operable per regulation.
Systemic Changes:
Maintenance will place thumb screws in all windows in resident areas. This will correct the potential elopement risk as cited.
Monitoring:
To ensure this deficient practice does not recur Plant Operations Director/Designee will audit the windows and screens monthly x 3 months to ensure there is no potential elopement hazard. The results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA Committee will review the analysis of the audits and determine the need to continue the audits.
Responsible person: Plant Operations Director/Designee
Compliance date: (MONTH) 19, (YEAR)

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, for 3 of 3 resident units, common area and resident room floors were not clean and furniture was in disrepair. This is evidenced as follows. The resident areas of the facility were inspected on 04/18/2017 at 10:30 am and again at 1:30 pm. The resident room and corridor floors on the A/D-Unit, B/C-Unit, and G-Unit floors were soiled where door frames meet the floor and along corridor walls.(NAME)robes and night stands in resident rooms 107, 108, and 116 were scrapped and pitted. The Director of Plant Operations stated in an interview conducted on 04/18/2017 at 11:55 am, that the floor person was on sick leave and that the remaining staff do not have enough time to keep up with the cleaning. 483.15(h)(2)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
The corridors floors on Units A/D; B/C and G, where the door frames meet the floor and along corridor walls are in process of being cleaned, stripped and waxed and will be ongoing.
Resident Rooms are in process of being cleaned, stripped and waxed and will be ongoing.
Wardrobes and night stands in resident rooms 107, 108 and 116 are in process of being re-stained and and the pitted furniture filled with wood filler and re-stained and will be ongoing.
Identification of other areas affected:
All residents have the potential to be affected by the identified practice. All resident rooms and furniture will be inspected and any areas of disrepair will be documented with work orders.
Systemic Changes:
To ensure the identified practice does not recur all housekeeping and maintenance staff will be re-educated on the Environmental Policy and Procedure. Environmental Rounds will produce work orders, work orders will be completed and completion will be tracked. New burnisher and floor scrubber will be leased to assist in the floor cleaning process.
Monitoring of Corrective Action:
An audit will be completed weekly x 3 months to identify any environmental concerns and correction. The results of the audits will be presented to the QA Committee at the next quarterly meeting. Audits will be ongoing.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Director/ Designee

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection determined for 5 of 5 dressing changes observed. Specifically, for Resident #'s 13, 21, 66, 90 and #105 the facility did not ensure proper precautions were maintained during dressing changes. This is evidenced by: Resident #66: This 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, could sometimes understand others and could usually be understood. The MDS dated [DATE], documented under Section G, Functional Status, the resident required total assist for bed mobility and transfer with 2 assist. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an observation of a dressing change to resident's left heel decubitus ulcer on 4/18/17 at 10:15 am, LPN #2 washed her hands, sanitized the overbed table and placed a barrier on the table. The barrier was sticking up in the middle and the LPN used the outside of the unopened package of border gauze to flatten down the barrier drape. She then opened and placed the supplies on the barrier. She placed the bag for used dressing supplies on top of the bed. She then washed her hands and put on gloves. The LPN applied the zinc oxide to resident's buttocks stating the area had recently healed. She then took off her gloves, washed her hands and reapplied another pair of gloves. The small bottle of normal saline, which had been on the barrier, spilled and saturated approximately half of the barrier. The LPN replied this side is fine referring to the part of the barrier which had not gotten wet, and continued the dressing change without setting up a dry barrier. She took the old dressing off, washed her hands and applied new gloves. Part of the plastic bag was lying on top of the barrier, where it remained. The LPN washed the wound with 4 x 4's wet with normal saline, then dried the wound with a 4 x 4. She then washed her hands and applied gloves, applied a small amount of hydrogel with a 2 x 2 to the wound as the cotton swabs had become wet. She covered the wound with a border gauze dressing which had been initialed and dated. During an interview on 4/18/17 11:10 am, LPN #2 stated she should have changed the barrier when it became saturated with normal saline. LPN #2 stated she should not have placed the plastic bag for used dressings in such close proximity to the overbed table. She also stated she should not have touched the drape with the outside of a package of a dressing supply. During an interview on 4/19/17 at 8:45 am, the Nurse Manager (NM) stated the plastic bag should have been placed farther away from the resident during the dressing change. She stated infection control measures should be followed during a dressing change. The NM stated she would not have changed the barrier after it had become saturated as the part where most of the dressing supplies were located was still dry. During an interview on 4/19/17 at 3:00 pm, the Director of Nursing (DON) stated when the barrier became saturated, the LPN should have changed everything and started again. She will educate nursing. Resident #105: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Inventory for Mental Status (BIMS) score of 2 as indicative of a severe cognitive impairment. The resident is able to understand others and have others be understood by him. Physician orders [REDACTED]. During observation on 4/18/17 at 10:05 am. the treatment Licensed Practical Nurse (LPN) prepared 3- 4 inch by 4 inch (4 by 4) gauzes on the treatment cart by opening one end of the gauze packages and pouring sterile water into the packages and then squeezing excess water into the trash receptacle on the cart. The LPN then placed the 4 by 4 gauze packages onto the top of the treatment cart and gathered remaining materials (gloves,etc) and proceeded into the resident's room. The LPN then placed the dressing materials onto the the resident's overbed table. The LPN did not sanitize the top of the overbed table and did not place a barrier between the overbed table top and the dressing materials. The LPN placed a pair of clean gloves on and proceeded to move the resident's left heel into position for removing the old dressing by moving the bed sheets and a side rail safety mat. The LPN then removed the old dressing from the resident's left heel and placed the contaminated old dressing onto the bed sheets. The LPN did not change gloves or did not wash her hands at which time she obtained the wet 4by 4 gauzes and cleaned the open wound. The LPN dried the left heel wound with a 4by 4 gauze and opened the Silver Alginate container and applied the Silver Alginate pad to the left heel wound. The LPN continued and placed contaminated waste products into the Silver Alginate container, removed her gloves, and proceeded into the hallway to dispose of waste products into the trash receptacle on the treatment cart. The LPN did not wash her hands after removal of her gloves. During interview on 4/19/17 at 10:00am the LPN stated that she did not sanitize the over bed table or apply a barrier to the overbed table. The LPN stated she did not change her gloves after the initially placing them on and did not wash her hands during the procedure. The LPN stated that she should have sanitized the overbed table, placed a barrier down between the top of the overbed table and the dressing materials, and changed her gloves and washed he hands after the gloves became contaminated. During interview on 4/19/17 at 2:00pm the Registered Nurse Manager (RNM) said that not sanitizing the over bed table and applying a barrier to the establish a clean field is an infection control problem. The RNM also stated the LPN should have changed her gloves and washed her hands at points her gloves became contaminated, as this is also an infection control problem. Resident #13: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS of 4/11/17, assessed that the resident understands, was understood and had no cognitive impairment. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) documented cleanse peg tube site with NS, pat dry, apply drainage sponge every shift and PRN. The MDS dated [DATE], documented under Section G, Functional Status, the resident required total assist for bed mobility and transfer. During an observation of the resident's peg tube site dressing change on 4/18/17 at 8:15 am, the Licensed Practical Nurse (LPN) placed her supplies (3 packages of sterile 4 x 4, one package 4 x 4 drainage sponge, 1 small bottle NS, one roll of tape) on the over bed table prior to cleaning the table, no barrier was applied. The LPN opened the 4 x 4 gauze, poured NS into the package squeezing the package and replaced it on the unclean over bed table. She washed her hands and put on gloves, removed the old drainage sponge from the peg tube stoma, removed her gloves and placed the soiled drainage sponge in the garbage can on the floor and reapplied gloves. The LPN proceeded to clean the stoma with the NS soaked gauze from the package that had been placed on the soiled bedside table, touching the outer package before cleaning the stoma. The LPN cleaned the stoma. Without changing her gloves the LPN patted the stoma several times and placed the soiled 4 x 4 on the bedside table, removed the drainage sponge from the package on the bedside table and placed it around the peg tube site and taped it in place. The LPN then picked up the half used bottle of NS and one unused package of 4 x 4 from the soiled bedside table and left the residents room. The bedside stand was not cleansed and the trash with the soiled dressing material was not emptied. The LPN proceeded to return the contaminated 4 x 4 and the used NS to the treatment cart. During an interview on 4/18/17 at 8:50 am, the LPN stated she should have cleaned the bedside tray before beginning the dressing and prior to placing supplies on it. She further stated she needed to throw out the 4 x 4 that was in the residents room as it was contaminated and should not have been returned to the treatment cart. She stated she frequently did not use a barrier for the peg tube dressing change, because it was not a sterile procedure. She also stated she should have emptied the garbage with the soiled drainage sponge and should have cleaned the bedside table after the procedure was completed. The LPN stated that she had never been inserviced on dressing changes since coming to work at the facility. She did however receive infection control inservices once a year, but that they did not specifically cover dressing changes. During an interview on 4/18/17 at 9:45 am, the Registered Nurse Unit Manager (RNUM) stated the first thing a nurse should do before gathering supplies is to clean the area being used. He stated if a bedside table is used, it should be cleaned and dried to prevent contamination of supplies. He further stated the bedside table should be cleaned after the dressing change is completed and that the garbage should be removed from the room. He also stated nurses are inserviced on how to do proper dressing changes and that the LPN would need to be reducated on the way to set up properly. During an interview on 4/19/17 at 2:00 pm, the Director of Nursing (DON) stated that the nurses are inserviced yearly on infection control and that this does included proper procedures to use during dressing changes. She stated that all nurse should know to clean off their bedside tables before beginning any type of dressing change. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Dressing change policy and dressing change competency was revised and education begun and ongoing to all nurses with emphasis on infection control.
Other Residents:
All residents with wounds are at risk.
Systemic Changes:
All nurses are in process of having a new dressing competency completed. Dressing change competencies are repeated on change in status (new hire, per-diem to permanent) and at least annually in month of anniversary date of hire. A new skills checklist which reflects the dressing change competency will be in the employee record and a master list maintained by Staff Education Coordinator.
Monitoring:
Monthly random observations of 20% of employees will be completed throughout the year with a focus on infection control practices in the context of a dressing change will be performed by Staff Development Coordinator or designee. DNS will report results to Quality Assurance committee quarterly until it is determined resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Compliance date: (MONTH) 19, (YEAR)

FF10 483.20(e)(k)(1)-(4):PASRR REQUIREMENTS FOR MI & MR

REGULATION: (e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: (1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident?s assessment, care planning, and transitions of care. (2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. (k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. (1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. (2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. (3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter. (k)(4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure pre-admission screening and resident review (PASRR) was performed on all residents prior to admission for 3 (Resident #'s 130,131, and #132) of 22 residents reviewed. Specifically: Resident #'s 131 and 132 did not have PASRRs and Resident #130 did not have a complete PASRR. This is evidenced by: Resident #131: The resident was admitted on ,[DATE]/, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 1/18/17, assessed that the resident understands, was understood and had a Brief Interview of mental Status of 11/15 or moderately impaired cognitive ability. The resident's medical record was reviewed and did not include a preadmission screen. On 4/19/17, approximately 3:30 pm, the pre-admission screen was requested from the facility. On 4/20/17, the facility had not provided the screen. During interview on 4/20/17 at 10:27 am, a Social Worker was asked about the pre-admission screens. She stated it would be Admissions who looks to make sure the pre-admission screen is here. She said Social Work does not do that. She also stated that they do not keep copies of the pre-admission screens. During interview on 4/20/17 at 11:18 am, the Admissions Director stated she makes sure the PRI (Patient Review Instrument) and pre-admission screen come from the hospital. She said she brings it to the Nurse Manager with the Admission packet for the resident. She stated she did not keep a copy of the pre-admission screen. She said she used to keep a copy when she worked in the Social Work Office. but was not sure what happens now. She stated it was usually the Social Workers who check the pre-admission screens. During interview on 4/20/17 at 1:12 pm, the Registered Nurse Manager for the resident's unit said the Admissions Director checks the pre-admission screens. She said they (unit staff) put them in the medical records as part of the paperwork that comes with the resident. Resident #132: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 2/17/17, assessed that the resident understands, was understood and had a BIMS of 10/15 or moderately impaired cognitive ability. A review of the resident's medical record did not include a preadmission screen. On 4/19/17, approximately 3:30 pm, the pre-admission screen was requested from the facility. On 4/20/17, the facility had not provided the screen. During interview on 4/20/17 at 10:27 am, a Social Worker was asked about the pre-admission screens. She stated it would be Admissions who looks to make sure the pre-admission screen is here, they do not do that. She also stated that they do not keep copies of the pre-admission screens. During interview on 4/20/17 at 11:18 am, the Admissions Director said she makes sure the PRI (Patient Review Instrument) and pre-admission screen come from the hospital. She stated she brings it to the Nurse Manager with the Admission packet for the resident. She stated she did not keep a copy of the pre-admission screen. She said she used to keep a copy when she worked in the Social Work Office, but was not sure what happens now. She said it was usually the Social Workers who check the pre-admission screens. During interview on 4/20/17 at 1:12 pm, a Registered Nurse Manager said the Admissions Director checks the pre-admission screens. She stated they (unit staff) put them in the medical records as part of the paperwork that comes with the resident. Resident #130: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Dat Set (MDS) of 3/25/17, assessed that the resident understands, was understood and had a Brief Interview for Mental Status (BIMS) of 15/15 or no cognitive impairment. The pre-admission screen was found in the medical record was incomplete. The section for the resident/representative signature and date of the signature was blank. During interview on 4/20/17 at 10:27 am, a Social Worker was asked about the pre-admission screens. She stated it would be Admissions who looks to make sure the pre-admission screen is here, they do not do that. She also stated that they do not keep copies of the pre-admission screens. During interview on 4/20/17 at 11:18 am, the Admissions Director stated she makes sure the PRI (Patient Review Instrument) and pre-admission screen come from the hospital. She stated that she brings it to the Nurse Manager, with the Admission packet, for the resident. She stated she did not keep a copy of the pre-admission screen. She said it was usually the Social Workers who check the pre-admission screens. During interview on 4/20/17 at 1:12 pm, a Registered Nurse Manager stated the Admissions Director checks the pre-admission screens, she does not. She said they (unit staff) put them in the medical records as part of the paperwork that comes with the resident. 10NYCRR415.11(e)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Screen/PRI is expected to be received and maintained in the medical record going forward by Admissions Coordinator prior to and upon acceptance of admission to the facility.
Other Residents:
All newly admitted residents are at risk.
Systemic Changes:
Admissions Coordinator will be educated regarding obtaining and maintaining a record of the screen/PRI prior to a bed offer being made and assuring that it is placed in the permanent medical record for all residents.
Monitoring:
Weekly audit of 80% of new admissions will be performed by DNS to ensure that screen/PRI is in the medical record. Findings will be followed up with the admissions coordinator. Admissions Coordinator will report results to Quality Assurance committee quarterly and will continue to report to the Quality Assurance Committee until determined as resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Compliance date: (MONTH) 19, (YEAR)

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (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 (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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 22, 2017
Corrected date: July 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure that clinical records were complete and accurately documented for 2 (Resident #'s 97 and 131) of 13 residents reviewed during the first phase of the survey. Specifically: For Resident #97, the facility did not ensure a pharmacy recommendation for the discontinuance of an as needed (prn) medication was available for review: For Resident #131 the Medication Administration Record [REDACTED]. This is evidenced by the following: Resident #97: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15; indicating full cognition. The resident is able to understand others and is able to be understood by others. The medication section assessed the resident received antipsychotic medication for the seven day look back time for the MDS dated [DATE]. Physician orders [REDACTED]. A comment in the order section of the physician orders [REDACTED]. The Proof of Pharmacy (RPh) review individual page dated 12/19/16, documented under the physician (MD) section recommendation that the current order for [MEDICATION NAME] 0.5 mg required review for indication psycho- social distress. The recommendation further documented MD to discontinue as needed [MEDICATION NAME] at this time? The Proof of Pharmacy (RPh) review did not include documentation that the physician reviewed this recommendation. During interview on 4/20/17 at 9:00 am, the Registered Nurse Manager (RNM) stated that Pharmacy reviews concerning medication changes or recommendations are kept in a three ring binder on the nursing unit. The RNM stated recommendations are reviewed by the MD who will initial to acknowledge review of the recommendations. The RNM stated that after an extensive search an initialed copy of the recommendation to discontinue the as needed [MEDICATION NAME] was unavailable for review. During interview on 4/20/17 at 10:00 am, the Director of Nursing (DON) stated that the nurse managers are responsible for reviewing pharmacy recommendations with the physician. The DON stated she would have expected the initialed copy of the pharmacy recommendations to be kept in the three ring binder on the nursing unit. Resident #131: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 1/18/17, assessed that the resident understands, was understood and had a Brief Interview of Mental Status (BIMS) of 11/15 or moderately impaired cognitive ability. Physician orders [REDACTED]. The MAR for (MONTH) (YEAR) documented: Quetiapine 25 mg one tablet 9:00 pm two times a day at 9:00 am and at 9:00 pm; Senna 8.6 two tablets every HS at 9:00 pm; Polyethylene [MEDICATION NAME] 17 gm one packet every 12 hours at 8:00 am and 8:00 pm. [MEDICATION NAME] 20 mg one tablet every 12 hours at 8:00 am and at 8:00 pm. The 1/12/17 MAR for the evening doses of these medications were blank indicating the medications were not signed as being given. During interview on 4/18/17 at 4:40 pm, the Director of Nurses (DON) was asked why the medications were not given the evening of the resident's admission. She stated it would depend on when the resident came in to the facility. She said not all medications were in the Pixis (medication storage system). She stated that the resident came at 2:00 pm on the 12th. She also stated that if medications were not available the nurse should call the MD for directions. During interview on 4/19/17 at 7:55 am, the DON stated she had called the nurse about the medications that were not signed for on 1/12/17. He told her he must have given the medications and forgotten to sign for them. She stated he wrote up a statement and provided a copy. She said the Senna and Polyethylene [MEDICATION NAME] were house stock so were available to give. She was asked for the list of medications in the Pixis. This list indicated the other two medications were also available. 10NYCRR 415.22(a)(1-4)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the post survey revisit, the facility did not ensure that clinical records were complete and accurately documented for one (Resident #134) of eight residents reviewed. Specifically: the facility did not ensure the Medication Administration Record (MAR) documented the administration of [MEDICATION NAME] (a blood pressure medication) and/or in the Interdisciplinary Progress Notes (IPN) regarding the reason [MEDICATION NAME] was not given on the evening of the resident's admission. This is evidenced by the following: Resident #134: The resident was admitted to the nursing home on 6/21/17, with [DIAGNOSES REDACTED]. The resident was assessed as being alert and oriented times three. The hospital Medical Discharge Instructions dated 6/21/17, documented [MEDICATION NAME] XL 60 mg (cardiac medication); give one tablet every twelve hours. It documented the last dose of [MEDICATION NAME] was given on 6/21/17 at 9:00 am, and that the next dose of [MEDICATION NAME] was due on 6/21/17 at 9:00 pm. A Physician order [REDACTED]. A Medication Administration Record for (MONTH) (YEAR), was blank in the box for the [MEDICATION NAME] dose on 6/21/17 at 9:00 pm. There was no comment on the back of the MAR indicating a reason for not administering the medication. There was no documentation in the Interdisciplinary Progress Notes (IPN) regarding this medication. During interviews: On 6/22/17 at 4:54 pm, the Licensed Practical Nurse stated that none of the resident's medications came in that evening and that she should have documented on the MAR and also the IPN, that the medication was not given. On 6/22/17 at 5:10 pm, the Administrator stated that the nurse should have documented on the MAR and IPN that medication was not given, and that a medication error would be done and the doctor would be notified. 10NYCRR 415.22(a)(1-4)

Plan of Correction: ApprovedJuly 5, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action:
Resident #131 medication record reviewed with nurse that did not initial medications as given. Medication error was documented. Resident #97 pharmacy recommendation for as needed [MEDICATION NAME] was reviewed by MD.
Other residents:
Residents requiring medication administration are at risk.
Systemic Changes:
Staff education will be performed by the Staff Development Coordinator and Nursing Managers on nursing staff assuring the medication and treatment records are complete with initials to signify whether medications and treatments have been administered and initialed and circled with reason on back if not administered. Nurses will be educated to check that medication administration records and treatment records are completely filled out prior to end of shift.
Nurse Managers are required to maintain a binder for pharmacy review on the unit and review recommendations with the MD at least every 60 days with the MD signifying review by initials or change in orders. Nurse Managers will audit all pharmacy review recommendations at least monthly to assure all recommendations over 60 days have been addressed and acknowledged by the MD.
Monitoring:
Weekly random audit will be performed by Nurse Manager of 20% of Resident medication and treatment records to ensure that they are completely documented.
Monthly audit of pharmacy review records will be performed by the Nurse Manager to verify all pharmacy review recommendations over 60 days have been addressed and acknowledged by MD. DNS will report results to Quality Assurance committee quarterly until it is determined resolved for the purposes of the Committee.
Responsible person: Director of Nursing
Compliance date: (MONTH) 19, (YEAR)

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on record review and staff interview, the facility did not take appropriate actions after the termination of employees. Chapter 10 of the New York State Codes Rules and Regulations section 402.9 (b)(2) Responsibilities of Providers; Required Notifications requires that any employee who was subject to, and underwent, a criminal history record check (CHRC) in accordance with this Part is no longer employed by the provider, the provider must immediately, but within no later than 30 calendar days after the event, notify the New York State Department of Health (The Department), and document such notification occurred. Specifically, the facility did not notify The Department within 30 calendar days of the withdrawn of an offer of employment of 2 of 3 employees reviewed receiving a negative CHRC. The records for employee #1 were reviewed on 04/17/2017. This record review revealed that employee #1 was considered for employment until 08/01/2016. The Department was notified on 04/17/2017, seven months and 16 days after the offer of employment was not longer considered. The records for employee #2 were reviewed on 04/17/2017. This record review revealed that employee #1 was considered for employment until 07/01/2016. The Department was notified on 01/23/2017, five months and 22 days after the offer of employment was not longer considered. The facility policy Criminal History Record Check was reviewed on 04/17/2017. This policy states that The Department will be notified within 10 days from when it has been determined that an individual's eligibility for employment is denied. The Human Resources Coordinator stated in an interview conducted on 04/17/2017 at 3:00 pm that she missed notifying The Department about employees #1 and #2 in a timely manner. 10 NYCRR 402.7(a) (2) (i)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Human Resources Director received disciplinary action and re-education regarding following facility policy of checks to be completed prior to offer of employment.
Other Residents:
All residents are at risk. Personnel records going forward from date of survey were reviewed and are compliant.
Systemic Changes:
A checklist of pre-offer of employment and post-offer of employment activities is being added to new applicant folders.
Monitoring:
Monthly random review of 20% of applicants will be audited for compliance with facility policy. Administrator or designee will report results to Quality Assurance committee quarterly until determined as resolved for the purposes of the Committee.
Responsible person: HR Director
Compliance Date: (MONTH) 19, (YEAR)

FF10 483.10(e)(1), 483.12(a)(2):RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS

REGULATION: §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). 42 CFR §483.12, 483.12(a)(2) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms. (a) The facility must- (1) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident?s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation conducted during the recertification survey, the facility did not ensure, for 2 (two) (Resident #'s 44 and #51) of 4 (four) residents reviewed for restraints, that a physician's orders [REDACTED]. Specifically: For Resident #44, who had a Velcro alarmed seat belt, did not have a restraint assessment or a signed consent form for this restraint; For Resident #51, who had a Velcro alarmed seat belt, the facility did not ensure that a physician order [REDACTED]. This is evidenced by: The Policy and Procedure for Restraint Use with a revision date of 3/26/14, documented the use of a restraint required a physician's orders [REDACTED]. Additionally, a verbal consent via phone may be obtained and documented until a representative is able to physically sign the authorization. Resident #44: The resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severely impaired for cognition and usually understood others and was usually understood. This MDS dated also documented that the resident had a trunk restraint used daily while in a chair. The Comprehensive Care Plan (CCP) for Restraints dated 10/19/16 documented the resident had a Velcro alarmed seat belt. Revision date of 4/18/17 documented, in quarterly review, the resident was unable to undo the seatbelt alarm at this time. The Morse Fall Scale dated 4/18/17, scored the resident as a 40; moderate risk for falling. The physician's orders [REDACTED]. During an observation on 4/19/17 at 10:30 am, the resident was unable to release his alarmed seat belt upon command. The resident did not appear to understand that the nurse manager (NM) was asking him to release his seat belt. The resident smiled occasionally while the NM was talking to him, but did not make any attempt to reach for his seatbelt. The NM looked through the resident's chart and was unable to locate a consent for the Velcro alarmed seat belt or an assessment regarding the seat belt. During an interview on 4/19/17 at 10:10 am, the NM stated she thought there was a verbal consent for the seatbelt. She stated it is ultimately the nurse manager's responsibility to ensure that the consent and assessment for the Velcro seat belt were completed. She stated there should have been a signed consent and assessment for use of a seat belt used as a restraint. During an interview on 4/19/17 at 3:00 pm, the Director of Nursing, (DON) stated the restraint documents should be in place as the NM and rehabilitation work together. The DON stated she would check to see if she could find the assessment and consent forms. Resident #51: This resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident is severely impaired and usually understood others and was rarely understood. The Resident's Care Card with a revision date of 2/2017, documented the resident had a Velcro alarmed seat belt. Physician order [REDACTED]. The MDS dated [DATE], documented under Section P, Restraints, that the resident had a trunk restraint used daily while in a chair. During an observation on 4/19/17 at 10:30 am, the resident was unable to release his Velcro alarmed seat belt upon command. The resident did not appear to understand what the NM was asking him to do. He continually made vocal outbursts. The NM looked through the resident's chart and was unable to locate a physician's orders [REDACTED]. During an interview on 4/18/17 at 3:20 pm, the NM stated the Velcro alarmed seat belt should have had a physician's orders [REDACTED]. She also stated she couldn't find a consent signed by the resident's family. The NM stated the resident had the seat belt since readmission to the nursing home from the hospital on [DATE]. During an interview on 4/19/17 at 3:00 pm, the Director of Nursing, (DON) stated the restraint documents should be in place as the NM and rehabilitation work together. The DON stated she would check to see if she could find the physician's orders [REDACTED]. 10NYCRR415.4(a)(2-7)

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
For Residents #44 and #51, Restraint assessments, Provider orders and consents were obtained immediately by the Nurse Manager.
Other Residents:
Residents with a restraint are at risk. All residents with restraints were reviewed and found to be compliant.
Systemic Changes:
Nursing staff are being re-educated whole house on the documentation required in the use of restraints; including the requirement for an MD order, restraint assessment and signed consent form. Restraints will be added as an annual education subject.
Monitoring:
The DNS or designee will conduct monthly audits of restraint documentation to ensure compliance. Observation findings will be reported at the quarterly QA Meeting until resolution is determined by the Committee.
Responsible person: Director of Nursing
Compliance date: (MONTH) 19, (YEAR)

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

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the standard recertification survey, the facility did not maintain plumbing fixtures in accordance with adopted regulations. 10 NYCRR 713-3.24(e) requires that all plumbing systems shall be in accordance with the requirements of the local or municipal building code authority having jurisdiction. Specifically, the commode servicing a public restroom did not flush in a sanitary operation. This is evidenced as follows. When tested on [DATE] at 8:00 am and again on 04/18/2017 at 12:00 pm, the commode servicing public restroom [ROOM NUMBER] in the central core area would bubble and splash back when flushed. The Director of Plant Operations stated in an interview conducted on 04/19/2017 at 10:15 am that he was not aware that the wastewater from the commode in public restroom [ROOM NUMBER] would splash up when flushed, and it might be an issue with the plumbing vent pipe. 10 NYCRR 713-3.24(e)

Plan of Correction: ApprovedMay 23, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action:
The commode servicing public restroom [ROOM NUMBER] was permanently taken out of service.
The commode was removed and the plumbing connections will be shut off and capped.
Identification of other potential areas affected:
No other areas identified.
Systemic Changes:
Corrective action is complete with removal of commode and plumbing connections will be shut off and capped.
Monitoring of Corrective Action:
To ensure practice does not recur Plant Operations Director/Designee will monitor facility commodes quarterly to ensure prober flushing in a sanitary operation. Quarterly audits will be done x 1 year. the results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA Committee will review the analysis of the audits and determine the need to continue the audits.




Date of Correction: 4/20/2017
Person Responsible: Plant Operations Director

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on record review and staff interview during the recertification survey, it was determined that the facility did not protect the cooking facilities in in accordance with the adopted regulations. NFPA 17A Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2009 Edition section 7.3.3.4 requires that where the maintenance reveals defective parts that could cause an impairment or failure of proper operation, the affected parts shall be replaced or repaired in accordance with the manufacturer's recommendations. Specifically, the fire suppression system test reports state that a corrective action is required that is not yet completed. This is evidenced as follows. The kitchen fire suppression system tests reports were reviewed on 04/19/2017. The 01/12/2017 report reveals that the hood filters are coming apart and require replacement. The Director of Plant Operations stated in an interview conducted on 04/19/2017 at 11:15 am that the quote for the repairs was given to the corporate offices but no word was yet received back. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.5.5, 9.2.3; 2011 NFPA 96 10.2.6; 2009 NFPA 17A 7.3.3.4; 10 NYCRR 415.29, 711.2(a)(1) and (25); 2000 NFPA 101 19.3.2.6, 9.2.3; 1998 NFPA 96 1-3.1

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
The hood filters have been ordered through B-Lann Equipment. As soon as they are manufactured B-Lann Equipment will replace identified hood filters.
Identification of other potential area:
No other areas identified by B-Lann Equipment during inspection.
Systemic Changes:
Reports that reveal defective parts that could cause an impairment or failure of proper operation for the kitchen fire suppression system will be corrected immediately.
Monitoring of Corrective Actions:
To ensure this practice does not recur Plant Operations/Designee will address/correct any reports that reveal defective parts that could cause an impairment or failure of proper operation. Audits will be conducted concurrently when B-Lann inspects our kitchen fire suppression system. Audits will be presented to QA Committee at the next quarterly meeting. Monitoring will be ongoing.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Director/Designee

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the exit discharges to the public way were not free of all impediments for full instant use. NFPA 101 Life Safety Code 2012 edition section 7.1.10.1 requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, 3 of 8 exits were not available for full instant use. This is evidenced as follows. The exit doors were checked for impediments on 04/18/2017 at 10:30 am. The exit doors serving the A Unit, C Unit, and D Unit were obstructed with permanently placed large man shaped caution signs. The Director of Plant Operation stated in an interview conducted on 04/18/2017 at 11:55 am that he was not aware that the floor signs were obstructions to the exits. 42 CFR 483.70 (a) (1); 2012 NFPA 101 7.1.10.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
All exit door mobile impediments were removed 4/18/2017.
Identification of other potential areas:
All exit doors were checked for mobile impediments. No further mobile impediments found.
Systematic Change:
All staff will be inserviced on the prohibitive use of impediments by exit doors.
Monitoring of Corrective Action:
To ensure this deficient practice does not recur Plant Operations Director/Designee will monitor all exit doors monthly to ensure there are not impediments in front of exit doors. Monthly audits will be done for 3 months. The results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA committee will review the analysis of the audits and determine the need to continue the audits.
Date Of Correction: 6/19/2017
Responsible Person: Plant Operations Manager/designee

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: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, it was determined that the facility did not utilize extension cords and power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.4 requires that all electrical adapters be listed for the purpose. 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, and the use of multi-plug adapters is prohibited. Specifically, extension cords, non-compliant power strips, and multi-plug adapters were used to power non-patient care electrical devices in 4 of 11 resident care areas checked. This is evidenced as follows. A selection of resident areas was inspected for the use of power strips, extension cords, and multi-plug adapters on 04/18/2017 at 1:30 pm. A non-compliant power strip was used to power computer equipment in the Physical Therapy room. An extension cord was used to power a lamp in resident room [ROOM NUMBER]. And multi-plug adapters were used to power personal electronics in resident room [ROOM NUMBER] and 103. The Director of Plant Operations stated in an interview conducted on 04/18/2017 at 2:40 pm that the extension cord, multi-plug adapters, and power strip would have been removed but were not reported to his department. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.4; 2011 NFPA 70 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
All non-compliant power cord strips, extension cords, and multi-plug adapters identified have begun to be removed from any affected rooms/areas.
Replacement UL Approved 1363 & 1363A power strips will be ordered for affected rooms/areas. Rooms 59, 15, 103 and Physical Therapy room were corrected
Identification of other potential areas affected:
An audit of all the entire facility for unapproved power strips, extension cords and multi-plug adapters has begun. the location of any of the above identified items was documented for follow-up action.
Systemic Change:
-The regulation and policy were reviewed with staff and Resident Council Members, and flyers were distributed and posted. New residents will receive notification via the admission packet. Responsible parties will also receive written communication regarding regulation and policy.
-Resident's choosing to use a compliant power strips for their own personal items will be permitted to bring their own or will be offered the opportunity to purchase an approved power strip from the facility.
-An ample supply of the UL approved power strips will be maintained in the facility inventory for ongoing requests.
-The facility will provide approved power strips at no cost for residents requiring them to power any medical equipment/devices.
-The Housekeeping and Maintenance staff will conduct regularly scheduled rounds to identify and unapproved power strips, extension cords or multi-plug adapters and will identify any unapproved items in use and will document and report any violations to the Director of Plant Operations/Designee.
Monitor for Corrective Action:
To ensure this practice does not recur the Plant Operations Director/Designee will audit regularly scheduled rounds monthly to ensure compliance. The results of the audits will be presented to QA for their review. The QA Committee will review the audits and determine the need to continue.
Date of Correction: 6/19/2017
Person Responsible: Plant Operations Director/Designee
Date of Correction: 6/19/2017
Person Responsible: Plant Operation Director/Designee

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: Widespread
Severity: Potential to cause minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on employee interview and policy record review during the recertification survey, it was determined that the facility did not develop maintenance policies for and provide records for all testing and repairs of all patient-care electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.5.2.1 requires that facilities shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment (PCREE). Section 10.5.6 requires that records and a log shall be maintained of the tests and associated repairs or modifications of all patient-care electrical equipment. Specifically, the facility did not develop maintenance policies and record all testing and repairs for all patient-care related electrical equipment. This is evidenced as follows. The facility maintenance policies and records were reviewed on 04/18/2017. No maintenance records or policy for PCREE and was available for survey review. The Administrator stated in an interview conducted on 04/18/2017 at 3:00 pm that the facility does not have a specific maintenance policy for PCREE. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.5.2.1.1, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedMay 23, 2017

Corrective Action:
Policy and Procedure written for Patient Care-related Electrical Equipment addressing all protocols cited.
Identification of other areas affected:
All PCREE is affected.
Systemic Changes:
All maintenance and licensed nursing staff will be inserviced on Policy and Procedure for PCREE.
PCREE Log will be created to identify PCREE in facility by Plant Operations Director/Designee.
All PCREE will be labeled and recorded in PCREE Log by Plant Operations Director/Designee.
All PCREE will be maintained per manufacture suggested guidelines by Plant Operations Director/Designee.
All PCREE will be assigned a schedule for maintenance per manufacture suggested guidelines with type of test and intervals for testing by Plant Operations Director/Designee.
All PCREE repairs or modifications will be documented in the PCREE Log by Plant Operations Director/Designee.
All PCREE will be inspected/tested at a minimum annually or per manufacturer recommendations.
Monitoring of Corrective Action:
To ensure the practice does not recur protocols for PCREE will be audited monthly.
Audits will be presented to the QA Committee at the next quarterly meeting. Monitoring will be ongoing.
Date of Correction: 6/19/2017
Person Responsible: Plant Operations Director/Designee

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on record review and interview during the recertification survey, it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 Edition section 14.4.5 requires annual tests for duct smoke detectors. Specifically, 2 first floor duct smoke detectors were not tested annually. This is evidenced as follows. The fire alarm testing records were reviewed on 04/19/2017. This review revealed that the duct smoke detectors located in the physician office and kitchen were not tested within the past year. The Director of Plant Operations stated in an interview conducted on 04/19/2017 at 11:15 am that the duct detectors were not tested as the facility did not provide access and did not reschedule an inspection. 42 CFR 483.70 (a) (1); 2010 NFPA 72: 14.4.5, Table 14.4.5; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-3.2

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
FS & S (Fire Sound and Security) will conduct inpections of the duct smoke detectors located in the physician office and kitchen on (MONTH) 17,2017.
Identification of other potential areas affected:
No other areas were affected as inspections were complete on all other duct smoke detectors.
Systematic Changes.
To ensure the identified practice does not recur the inspections of the duct smoke detectors all areas will be available to FS & S.
Monitor of Corrective Action:
To ensure this practice does not recur Plant Operations Director/Designee will correct any inequities with FS & S inspections. Audits will be conducted concurrently when FS &S inspections our duct smoke detector system. Audits will be presented to QA Committee at the next quarterly meeting. Monitoring will be ongoing.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Director/ designee

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, it was determined that the facility did not store pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.6.2.3 requires that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart, and section 11.6.5.3 requires that empty oxygen cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Specifically, empty oxygen cylinders were not marked in 2 of 3 oxygen cylinder storage areas, and empty cylinders were not supported in a stand or cart. This is evidenced as follows. The oxygen storage areas were inspected on 04/18/2017 at 10:30 am. The empty cylinders in these areas were not marked. On 04/19/2017 at 9:15 am, empty oxygen cylinder was observed unsecured in the corridor outside resident room [ROOM NUMBER]. LPN #1 stated in an interview conducted on 04/18/2017 at 9:15 am that she placed the cylinder in the corridor unsecured because she was busy and could not attend to its proper placement immediately. The Director of Plant Operations stated in an interview conducted on 04/18/2017 at 11:55 am that he noticed with the survey observations that the empty cylinders were not marked but this will be corrected. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.6.5; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-3.1.1.1, 4-3.5.2.2(b)2

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
All oxygen cylinders storage areas were marked with full and empty signs on 4/18/2017.
All nursing staff directed to utilize oxygen carrier when changing out oxygen tanks.
Identification:
An inspection of all rooms storing oxygen were inspected and signs hung indicating full and empty oxygen cylinders.
Systemic Changes:
To ensure the identified practice does not recur all oxygen storage rooms will be inspected weekly by Plant Operations Director/Designee. The inspection will ensure all pressurized oxygen cylinders are stored in segregated racks that are marked full and empty. The inspections will be ongoing. All nursing staff will be re-educated on the appropriate storage of pressurized oxygen cylinders in the marked areas and utilization of an oxygen carriers when transporting or changing out oxygen tanks.
Monitoring of Corrective Action:
The Director of Plant Operations/Designee will conduct weekly audits ongoing. The results of the audits will be presented to QA Committee at the next quarterly and ongoing.
Date of Correction: 6/16/2017

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on staff interview during the recertification survey, it was determined that the facility did 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 the required training and continuing education associated with the handling medical oxygen cylinders. This is evidenced as follows. The Administrator stated in an interview conducted on 04/18/2017 at 3:00 pm that no training or continuing education is provided on the usage requirements and risks associated with handling medical gas oxygen cylinders. 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Policy and Procedure written to regarding the usage requirements and risks associated with handling medical gas oxygen cylinders.
Identification of other potential areas;
None
Systemic Changes:
Trained representative from our oxygen supplier, Linde Gas, will provide inservice training to those affected personnel. Trained Representative will provide facility with Inservice training materials which will be added to the yearly Inservice Education Program.
Monitoring of Corrective Action:
To ensure this practice does not recur the Staff Educator will audit the yearly inservice training on usage requirements and risks associated with handling medical gas oxygen cylinders. This audit will be ongoing and results of audit will be presented to the QA Committee at the next quarterly meeting.
Date of Correction: 6/19/2017
Person Responsible: Staff Educator

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 22, 2017
Corrected date: July 7, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that hazardous areas were not protected in accordance with adopted regulations. NFPA 101, Life Safety Code 2012 edition section 19.3.2.1.3 requires that doors to hazardous areas be self-closing or automatic-closing. Specifically, the doors to the Central Storage room and the Medical Records room, both hazardous areas, did not self-close. This is evidenced as follows. The doors to the Central Storage room and the Medical Records room were inspected on 04/18/2017 at 10:30 am. The door to the Central Storage room was held open with a plastic bucket, and the door to the Medical Records room did not self-close when tested . The Director of Plant Operations stated in an interview conducted on 04/18/2017 at 11:55 am that he was just noticing during these survey observations that the doors to the Central Storage and Medical Records rooms did not self-close. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.1.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.3.2, 7.2.1.8.2Based on observation and staff interview during the post survey revisit, it was determined that the hazardous areas were not protected in accordance with adopted regulations. NFPA 101, Life Safety Code 2012 edition section 19.3.2.1.3 requires that doors to hazardous areas be self-closing or automatic-closing. Specifically, the door to the Central Storage room did not self-close. This is evidenced as follows. The door to the Central Storage room was inspected on 06/21/2017 at 9:40 am. The door to the Central Storage room was held open with a plastic container. The Director of Plant Operations stated in an interview conducted on 06/21/2017 at 9:40 am, that a delivery was being received which would take about 3 trips from the receiving area, and the plastic container was used to hold the door open during this process. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.2.1.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.3.2, 7.2.1.8.2

Plan of Correction: ApprovedJune 29, 2017

Corrective Action:
The doors to the Central Storage room and the Medical Records room were repaired. Both doors are now self-closing effective 4/20/2017.
Identification of other potential areas:
Survey of all self-closing doors will be completed to ensure they are working properly and no impairments to the doors. Any doors identified will be repaired and impairments removed.
Systemic Changes:
To ensure the identified practice does not recur all self-closing doors will be inspected monthly.
All staff will be inserviced on no impairments to self-closing doors.
Monitoring of Corrective Action:
To ensure practice does not recur Plant Operations Director/Designee will monitor self-closing doors monthly x 3 months to ensure proper functioning and no impairments to the doors. The results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA Committee will review the analysis of the audits and determine the need to continue the audits.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Director/ Designee

K307 NFPA 101:RAMPS AND OTHER EXITS

REGULATION: Ramps and Other Exits Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the exit passageways were not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 7.1.3.2.3 requires that exit passageways shall not be used for any purpose that has the potential to interfere with its use as an exit. Specifically, the exit passageway from the B/C Unit was used for storage. This is evidenced as follows. The B/C Unit exit passageway was inspected on 04/18/2017 at 10:30 am. This area was utilized for the storage of wooden furniture, hospital beds, plastic shower chairs, and similar equipment. The Director of Plant Operations stated in an interview conducted on 04/18/2017 at 11:55 am that he would remove all storage from the passageway. 42 CFR 483.70 (a) (1); 2012 NFPA 101 7.1.3.2.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.3.2.3

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
All items found in the B/C Unit exit passageway were removed on 5/12/2017.
Identification of other potential areas:
No other areas identified.
Systemic changes:
All staff will be inserviced that this area is not to be utilized for the storage of any equipment.
Monitoring of corrective actions:
To ensure this practice does not recur Plant Operations Director/Designee
will monitor B/C Unit exit passageway weekly to ensure deficient practice does not recur. Weekly audits will be done x 3 month. The results of the audits will be presented to the QA Committee at the next quarterly meeting. The QA Committee will review the analysis of the audits and determine the need to continue the audits.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Manager/designee

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: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 101 Life Safety Code section 19.3.5 requires that nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.6.5.1.2 permits particular limitations on obstructions to the sprinkler system discharge pattern. Specifically, not all areas were provided with sprinkler protection, and the automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows. An assessment of the sprinkler system was conducted on 04/18/2017 at 10:30 am. Light fixtures obstructed the automatic sprinkler spray area in the B/C Unit nourishment room; the A/D Unit medical machine room, lounge, nourishment room, and janitor closet; G Unit oxygen storage room; and women's locker room. Ductwork obstructed the automatic sprinkler spray area in the maintenance shop. Additionally, a 90-minute fire rated self-closing door did not separate the non-sprinklered crawl space located in the women's locker room. The Director of Plant Operations stated in an interview on 04/18/2017 at 11:55 am that no obstructions should have been found after the contracted company addressed this issue last year. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-13.3.2

Plan of Correction: ApprovedMay 24, 2017

Corrective Action:
All identified unacceptable obstructions to automatic sprinkler system,, specifically sprinkler heads, will be replaced, installed or extended in accordance with regulations by 6/19/2017.
The 90 minute fire rated self-closing door for the non-sprinkled crawl space in the women's locker room has been special ordered from(NAME)Dilorenzo, General Contractor on (MONTH) 5,2017 and will be installed by 6/19/2017.
Identification:
No other affected areas identified.
Systemic Changes:
To ensure this deficient practice does not recur the plant operations staff was re-educated on the requirements of automatic sprinkler system. To prevent a recurrence when any alterations to the ceiling is made specifically alterations below the ceiling line, the Plant Operations Director/Designee will have a professional assessment of the sprinkler discharge pattern conducted.
Monitor of Corrective Action:
Monthly audits will be conducted to ensure requirements of automatic sprinkler system are met. Audits will be submitted to the QA Committee at next quarterly meeting. Audits will be ongoing.
Date of Correction: 6/19/2017
Person Responsible: Plant Operations Director/ Designee

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: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on staff interview and review of inspection records during the recertification survey, it was determined that the automatic sprinkler system was not tested and maintained in accordance with adopted regulations. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust, and section 5.3.3.1 requires that alarming devices servicing sprinkler systems shall be tested quarterly. Specifically, 1 of the past 4 required sprinkler system flow alarm device tests was not conducted, and sprinkler heads were dusty. This is evidenced as follows. The sprinkler system inspection records were reviewed on 04/19/2017. The records showed that the flow alarm devices were not tested during the second quarter of (YEAR). The sprinkler system was evaluated for foreign materials on 04/18/2017 at 10:30 am. Sprinkler heads were dusty in the laundry room. The Director of Plant Operations stated in an interview conducted on 04/19/2017 at 11:40 am that the sprinkler system testing company waited to test the flow alarms during the second quarter of (YEAR) until the obstructions found last year were addressed. Additionally, he stated that he will clean the sprinkler heads. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5, 9.7.7, 9.7.8; 2011 NFPA 25 5.2.1.1.1, 5.3.3.1; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6, 4.6.12, 9.7.5; 1998 NFPA 25 2-3.3

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
R.B.M. will inspect Sprinkler System quarterly.
Maintenance/housekeeping will clean sprinkler heads in laundry room with compressed air.
Identification of other potential area:
R.B.M. didn't inspect sprinkler system 4 out 4 quarters.
Survey of facility sprinkler heads will be completed to identify any further issues.
Systemic Changes.
R.B.M. will be scheduled for quarterly inspections.
Maintenance and housekeeping have scheduled cleaning of sprinkler heads with compressed air.
Monitor for Corrective Action:
To ensure the practice does not recur Plant Operations Director/Designee will confirm scheduled inspections quarterly with R.B.M. via e-mail verification. Audits will be conducted concurrently when R.B.M. conducts quarterly inspection.
Plant Operations/Designee will conduct weekly audits x 3 months of cleaning of sprinkler heads. Audits will be presented to the QA Committee at the next quarterly meeting . Monitoring will be ongoing.
Date of Correction: 6/19/2017
Responsible Person: Plant Operations Director/ Designee

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: April 20, 2017
Corrected date: June 19, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that 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 be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. Specifically, 1 of 1 smoke barriers observed were not continuous through concealed spaces. This is evidenced as follows. The Daffodil Unit smoke barrier wall (wall) was inspected on 04/18/2017 at 9:30 am. Above the ceiling in the Beauty Shop two 1½-inch holes were found. The Director of plant Operations stated in an interview conducted on 04/18/2017 at 9:30 am that he did not did not realize the smoke barrier wall extended into the Beauty Shop but will repair the holes immediately. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.2.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedMay 12, 2017

Corrective Action:
Identified penetrations in smoke barrier walls were sealed on 4/20/2017.
Identification of other potential areas affected.:
An inspection of all smoke barriers walls will be conducted and all penetrations will be properly sealed by 6/19/2017.
Systemic Changes:
To ensure the identified practice does not recur the smoke barrier walls will be inspected monthly.
Monitor of correction Action:
The Plant Operations director /designee will conduct monthly audits and report results to the QA Committee. The QA Committee will review the audits and determine the need to continue the audits.
Date of Correction: 6/19/2017
Responsible Person: Director of Plant Operations/Designee

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE COMPAR

REGULATION: Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 20, 2017
Corrected date: June 19, 2017

Citation Details

The following requirement of the Life Safety Code has been previously waived. The results of the current survey and review of the facility's previously submitted justification reaffirm that adequate safeguards remain in place to safeguard residents, staff, and visitors. Correction would pose an undue hardship. The continued waiver of the following item is recommended. Please indicate your request for renewal or submit a plan of correction in the space provided on this form. The area of each smoke compartment cannot exceed 22,500 square feet. The smoke compartment on the G residential unit measures approximately 22, 840 square feet. This condition was accepted by the New York State Department of Health, Bureau of Architectural and Engineering Facility planning, based on compliance with the LSC. The maximum travel distance to a smoke barrier door is approximately 120 feet less than the 200 feet maximum allowed. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.1; 10 NYCRR 415.29 (a) (2); 10 NYCRR 711.2 (a) (1); 2000 NFPA 101 19.3.7.1

Plan of Correction: ApprovedMay 12, 2017

1.This requirement of Life Safety Code has been previously waived. Adequate safeguards remain in place to safeguard residents, staff and visitors. Correction would pose an undue hardship therefore; we request a renewal of the waiver.