Beach Gardens Rehab and Nursing Center
June 20, 2017 Certification Survey

Standard Health Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 18, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews during the Recertification Survey the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior on two of four nursing units. Specifically, 1) Resident #7 stated that the hallway training toilet on the 5th floor often does not have soap in the soap dispenser. An observation of the empty soap dispenser was made on 6/15/2017; and 2) multiple observations were made of urine odor and a sticky floor in Resident #134's room on the 4th floor. The findings are: 1) Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/28/2017 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The MDS documented that the resident required extensive assistance for toilet use. On 6/15/2017 at 8:45 AM Resident #7 was interviewed. He stated he prefers to use the training toilet in the hallway because it has more room and he can maneuver better with his wheel chair. He stated that there are two training toilets in the hallway--one that is closer to his room and another further down the hallway. He stated that most of the time when he uses the training toilet bathroom there is no soap in the soap dispenser. He stated that he had told one of the nurses on the unit. On 6/15/2017 at 8:58 AM the hallway training toilets were observed. The training toilet closer to Resident #7's room did not have soap in the dispenser and the adjacent training toilet further down the hallway only had a scant amount of soap that came out of the dispenser. On 6/15/2017 at 9:02 AM the two soap dispensers were observed by the Director of Maintenance and Housekeeping. He refilled the empty soap dispenser and stated that the one with the scant amount of soap would be addressed. On 6/15/2017 at 9:17 AM the Director of Maintenance and Housekeeping was interviewed. He stated the training toilet soap dispensers are checked on a daily basis by the housekeepers on daily rounds and that the soap will last about a week. On 6/15/2017 at 10:04 AM the 5th floor housekeeper was interviewed. He stated the soap dispensers are supposed to be checked at the beginning and end of the housekeepers' shifts. He stated that he had not checked the training toilet soap dispensers yet. On 6/20/2017 at 9:00 AM the Director of Nursing Services was interviewed. She stated that the 5th floor housekeeper's shift on 6/15/2017 started at 7 AM. On 6/20/2017 at 9:09 AM Resident #7's Certified Nursing Assistant (CNA) was interviewed. He stated that the resident uses the training toilet himself and that the training toilets are actively used. 2) Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/22/2017 Annual MDS assessment documented a BIMS score of 4, indicating the resident had severe cognitive impairment. Resident #134 resides in a double-bedded room and has the bed closest to the door. On 6/14/2017 at 1:32 PM, 6/15/2017 at 11:02 AM, 6/16/2017 at 11:38 AM, and 6/19/2017 at 8:29 AM Resident #134's room was observed. There was a urine odor in the room and the floor was sticky. On 6/15/2017 at 11:10 AM the 4th floor housekeeper was interviewed. He stated that he had not gone into Resident #134's room to clean yet. On 6/16/2017 at 11:40 AM the 4th floor housekeeper was re-interviewed. He stated, The resident urinates on the floor all day long. That is why it smells like urine. He stated that he mops the room 3 or 4 times per day and that the floor has to be stripped. He added that the floor is sticky because the residents in the room keep the heat on. On 6/19/2017 at 12:35 PM the Director of Housekeeping and Maintenance was interviewed. He stated that the resident's floors are stripped every 2-3 weeks. He stated that the odor in the room and the sticky floors were because of urine saturation and the humidity. On 6/20/2017 at 10:38 AM a maintenance worker was interviewed who was filling in for the Director of Housekeeping and Maintenance (who was unavailable). He said he was not aware of a log sheet of when floors were stripped. He said that generally 3 or 4 rooms on a unit receive a total cleaning once per week and the other rooms get a spot mopping. He said it would not be documented if a housekeeper mopped a particular room several times per day. 415.5(h)(2)

Plan of Correction: ApprovedJuly 11, 2017

F-253
I. Immediate Corrective Action:
1) The soap dispenser in the 5th floor hallway training toilet was filled immediately and is checked daily.
2) The following actions were completed for Room 404:
o The floor was stripped and waxed.
o The room was repainted
o Both mattresses were replaced
o All curtains were washed and rehung
o Both residents? clothing was rewashed.
o All drawers and closets were thoroughly cleaned
o Both residents received showers
o The floor tiles in the resident?s room were replaced
3) Educational in-service provided to 5th floor housekeeper who failed to check daily and replace soap.
4) Educational in-service provided to the 4th floor housekeeper for the urine smell and sticky floor in room #404.
II. Identification of other residents:
1. The facility respectfully states that all residents have been identified as potentially being affected by the same practice.
2. The Administrator and the Director of Environmental Services made rounds throughout the facility to identify any other housekeeping and maintenance services issues.
3. All soap dispensers in the facility were checked. There were no empty soap dispensers found in the facility.
4. All resident rooms, bathrooms and public areas in the facility were checked for urine odor and a sticky floor. There were no areas found with either of these issues.

III. Systemic changes:
A. The Director of Environment Services and the Administrator will
review and revise, as needed, Policies and Procedures related to the Housekeeping and Laundry Services Manual.
B) The In-service Coordinator/designee will provide education to all Housekeepers, and Maintenance staff and Nursing staff on the above policies.
The in-service will focus on:
1) Ensuring that the soap dispensers do not run out of soap, and
2) Resident rooms are odor free and the floors are not sticky.
3) Nursing Staff will notify the housekeeping/
maintenance departments for any environmental concerns via the Maintenance/Housekeeping Request Book
C) The Lesson Plan and education will be filed for validation.

IV. Quality Assurance Performance Improvement/monitoring:
A. The facility will develop an audit tool to monitor compliance with the facility?s Policy & Procedure for:
1) Ensuring that the soap dispensers do not run out of soap, and
2) Resident rooms are odor free and the floors are not sticky.
B. The audit will be completed weekly for three months then monthly for 3 months, quarterly thereafter. The audits will be completed by the Director of Environmental Services/Designee
C. Audits with negative findings will have immediate corrective actions and will be referred to the Administrator/designee for review and follow up.
D. The Director of Environmental Services/designee will report audit findings to the Quality Assurance and Performance Improvement Committee on a quarterly basis for evaluation and follow-up. Additional corrective action will be implemented immediately, as indicated.
V. Responsible Discipline: Director of Environmental Services/designee

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 18, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure that each resident's Comprehensive Care Plans were reviewed and revised to meet the needs of the resident for 1 of 1 resident reviewed for Urinary Incontinence from a total Stage 2 sample of 29 residents. Specifically, Resident #134's room was observed on multiple occasions with urine odor and sticky floors; however, the Comprehensive Care Plans for Toileting/Continence and Activities of Daily Living (ADLs) did not accurately address the resident's urinary incontinence. The finding is: Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/22/2017 Annual MDS assessment documented a Brief Interview of Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented that the resident required supervision for ADLs, including toilet use, and limited assistance of one staff member for personal hygiene. The MDS documented that the resident was always continent of bowel and bladder. A Comprehensive Care Plan (CCP) dated 4/13/2017 and titled Toileting/Continence documented that the resident was continent of bowel and bladder. The CCP did not indicate that the resident was on a toileting schedule. A CCP dated 4/13/2017 titled ADL Comprehensive Care Plan documented that the resident was continent of bowel and bladder. A CCP dated 4/13/2017 and titled Behavior did not document any behaviors related to the resident urinating on the floor. On multiple occasions (6/14/2017 at 1:32 PM, 6/15/2017 at 11:02 AM, 6/16/2017 at 11:38 AM, and 6/19/2017 at 8:29 AM) Resident #134's room was observed to have a urine odor and a sticky floor. On 6/16/2017 at 11:40 AM the 4th floor housekeeper was interviewed. He stated, The resident urinates on the floor all day long. That is why it smells like urine. On 6/16/2017 at 12:08 PM Resident #134's Certified Nursing Assistant (CNA) was interviewed. He stated the resident is confused. He stated that the resident wets himself all the time and that this was not new. He stated the resident does not purposely urinate on the floor. On 6/19/2017 at 11:30 AM the Registered Nurse (RN) Unit Manager was interviewed. She stated that sometimes Resident #134 cannot make it to the bathroom in time and urine gets on the floor and his clothes. She stated that the resident was having accidents and is incontinent and the care plans needed to be updated. She stated that the resident does not purposely urinate on the floor. She added that Resident #134's roommate requires total care, stays in bed, and does not urinate on the floor. On 6/20/2017 at 9:42 AM the Director of Nursing Services (DNS) and the RN MDS Coordinator were interviewed concurrently. They stated that the resident's Attending Physician did a urinary incontinence assessment last evening (6/19/2017) and a determination was made that the resident has an overactive bladder and overflow incontinence and that the care plans need to be updated. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJuly 11, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 280
1) Immediate Corrective Action:
i. Resident # 134 was seen & examined by his primary physician on 6/19/17. He was diagnosed with [REDACTED]. Consult appointment scheduled.
ii. RN assessment was completed and care plan was revised to reflect resident?s current urinary status.
iii. The Registered Nurse responsible for updating the Care Plan was provided educational counselling by the Director of Nursing regarding updating the Resident?s Care Plan to reflect the current status of the resident whenever a change is observed.
iv. Educational counselling on file.
2) Identification of other Residents:
i. A list was generated on 6/22/17, of all current Residents who were coded as ?continent? on their most recent MDS.
ii. The list will be used to identify any other Residents who may have a discrepancy in their continence status. This will be accomplished by reviewing with the residents? primary CNAs on each shift in order to obtain an accurate current status and RN assessment completion.
iii. Any issues identified will be corrected.
3) Systemic Changes:
i. The DNS reviewed and revised the facility?s P&P for ?Change in Resident Status?. The Policy on ?Urinary Continence and Incontinence Assessment and Management? was also reviewed and is in compliance.
ii. The in-service Coordinator/Designee will in-service all Registered Nurses with regard to the P&P. The focus will address:
? The importance of assessing, updating of Residents Care Plan whenever there is a change in the residents? status.
? The importance of identifying change in resident?s urinary status, updating the plan of care and implementation of appropriate interventions timely.
? In-service records on file for validation
4) Monitoring of the Corrective Action/Quality Assurance:
i. The DNS developed an audit tool to monitor the facility?s compliance with the P&P.
ii. The audit will be completed by the MDS Coordinator/Designee for 4 charts weekly x 4 weeks then 16 charts monthly x 6 months.
All audit findings will be reported to the QA Committee quarterly for follow-up and correction as needed:
5) Responsibility: Director of Nursing/Designee




















Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

The following waiver is on file with this office. Repeat waivers are granted on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. K161 The facility is Type II (000) construction and 5 stories in height. Buildings of Type II (000) construction are limited to 2 stories in height and protected by a complete automatic sprinkler system. 483.70 (a), NFPA [PHONE NUMBER]: 19.1.6.2, 10NYCRR: 711.2(a)(1) NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 2, 2017

K 161
The Facility requests the waiver to be continued and that a renewal is granted.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 99: 10.5.2.1 Testing Intervals. 2012 NFPA 99: 10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. 2012 NFPA 99: 10.5.2.1.2 All patient care-related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety. Based on observation, staff interview and documentation review, the facility did not ensure that policies and procedures were established for testing patient care-related electrical equipment (PCREE) in accordance with NFPA 99. This was noted on five of five floors. The findings are: On 6/19/17 between 8:30am- 2:00pm during the recertification survey, patient care-related electrical equipment, such as oxygen concentrators, feeding pumps and/or suction machines, were observed in resident rooms or resident-use areas lacking inspection stickers. Examples include but are not limited to: 1) Resident room [ROOM NUMBER] and 421- feeding pumps lacked inspection stickers 2) Suction machines in the 4th and 5th floor dining rooms lacked inspection stickers 3) 1st floor rehabilitation room- an oxygen concentrator lacked an inspection sticker There was no documentation provided at the time of survey regarding policies and protocols for the type of test and intervals of testing for PCREE. In an interview on 6/19/17 at approximately 11:45am, the Director of Environmental Services stated that he would call the company to address the medical equipment inspections. 2012 NFPA 99: 10.5.2.1, 10.5.2.1.1, 10.5.2.1.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 921
I. Immediate Corrective Action:
1) The Director of Environmental Services/designee removed the equipment lacking inspection stickers;
a. The feeding pumps from residents rooms [ROOM NUMBERS].
b. The suctions machines from the 4th and 5th floor dining rooms.
c. The oxygen concentrator from the first floor rehabilitation room.
2) All equipment was replaced with inspected and properly labeled and dated inspection stickers.
3) The Director of Environmental Services was provided with Educational Counseling focused on the importance of ensuring that all electrical equipment in use has been inspected and labeled as such, prior to use in resident care areas.
II. Identification of other residents:
The Director of Environmental Services/designee immediately conducted an inspection of all fixed and portable electrical equipment in the patient care areas, to ensure all equipment was labelled with an inspection sticker.
There were no other fixed or portable electrical equipment in the resident care areas found without inspection stickers.
III. Systemic changes:
A. The Administrator and the Director of Environment Services developed a Policy &Procedure for Electrical Equipment-Testing and Maintenance Plan for fixed and portable resident-care related equipment.
B. A Log Binder containing the manufacturer?s maintenance and safety guidelines for all PCREE was formulated.
C. Documentation: As per manufacturer?s recommendation a Maintenance & Safety Check Log Books of all PCREE was created with Equipment name/Model #/ Date of Inspection/Type of Inspection/Safety check/Signature and will be maintained according to Beach Garden?s record keeping policy.
D. In-service education will be provided to all nursing and maintenance/environmental staff with a focus on:
1. The proper use of the Maintenance & Safety Check Log Books. A record of all electrical equipment tests, repairs and modification and results of testing will be filed as per Beach Garden?s record-keeping policy of seven years.
2. Maintaining the Log binder of all PCREE Manufacturer?s Safety and Maintenance Guidelines.
3. The importance of ensuring all electrical devices used in patient/resident care areas are inspected and provided with inspection stickers/safety labels and condensed, legible operating instructions are on the devices.
4. Any equipment removed for repair or modification must be tested prior to putting back into service/usage.
5. Electrical equipment instructions and maintenance manuals will be readily available.
6. Personnel responsible for the testing, maintenance and use of electrical appliances will receive continuous educational training.
7.Attendance Records will be filed for validation.

IV. Quality Assurance monitoring:
A. The Administrator will develop an audit tool to ensure compliance with testing, maintaining and labeling with inspection stickers for all patient care-related electrical equipment (PCREE).
B. The audit will be conducted/completed by the Director of Environmental Services or designee, weekly for three months followed by monthly for 3 months, quarterly thereafter.
C. Any negative findings will be corrected immediately and referred to the Administrator/designee for review and follow up.
D. All findings will be reported to the Quality Assurance and Performance Improvement Committee quarterly for recommendations, as necessary.
V.Responsible Discipline: The Director of Environmental Services/designee is responsible for compliance.