Parker Jewish Institute for Health Care & Rehab
July 10, 2017 Certification Survey

Standard Health Citations

FF10 483.90(i)(3):CORRIDORS HAVE FIRMLY SECURED HANDRAILS

REGULATION: (i)(3) Equip corridors with firmly secured handrails on each side; and

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 10, 2017
Corrected date: September 7, 2017

Citation Details

Based on observation and staff interviews during the Recertification survey the facility did not ensure that corridors were equipped with firmly secured handrails on 5 out of 13 nursing units. Specifically, loose handrails were observed on units 8 North, 6 North, 6 South, and 5 South; and on unit 4 North there were no handrails in the alcove area by rooms 424, 425, 426, and 427. The finding is: On 7/3/2017 at 9:15 AM on unit 8 North a loose handrail was observed across from the nursing station. The Registered Nurse (RN) on the unit observed the loose handrail and stated she would alert the maintenance department. On 7/3/2017 at 10:15 AM on unit 6 North a handrail adjacent to Room 624 was observed hanging on the wall in a slanted position. The observation revealed that one side of the handrail was pulled out of the wall. The RN on the unit observed the handrail and stated she would alert the maintenance department. On 7/3/2017 at 10:31 AM on unit 6 South one side of a handrail adjacent to Room 643 was loosely attached to the wall, and on the same unit near the South Service Area corridor a bracket that secures a handrail to the wall was broken and the handrail was loose. Both handrails were observed by the RN on the unit and she stated she would alert the maintenance department. On 7/3/2017 at 10:55 AM on unit 5 South there were loose handrails observed adjacent to Rooms 541 and 539, and a handrail adjacent to Room 538 was loosely attached to the wall. The handrails were observed by the RN on the unit and she stated that she would alert the maintenance department. On 7/3/2017 at 10:59 AM on unit 4 North an observation was made of an alcove area consisting of Rooms 424, 425, 426, and 427. There were no handrails present, rather than handrails there was a wooden ledge that could be leaned on. This was observed by the RN on the unit. She stated she would call the Engineering Department and report the observation. On 7/3/2017 at 11:09 AM the Director of Facilities Management was interviewed regarding the missing handrails on 4 North. He observed the area and stated there should be handrails in this area for rooms 424, 425, 426, and 427. On 7/6/2017 between 8:10 AM and 8:30 AM the loose handrails were identified on Units 6 North, 6 south, 5 South and 4 North and found to be secured to the walls with the exception of the handrail adjacent to Room 538. This handrail remained loosely attached to the wall. The RN on the unit observed the loose handrail and stated she would notify the maintenance department. On 7/7/2017 at 1:00 PM the Director of Facilities Management was interviewed. He stated maintenance workers are constantly monitoring for maintenance problems, and handrails are a number one priority. He stated that any staff member can report maintenance problems and request maintenance work from a computer, and then a work order is created. He provided work orders dated 7/3/17 that were created following the identification of the loose handrails on 6 South and 6 North, however, not for the other nursing units identified with loose handrails. 415.29

Plan of Correction: ApprovedAugust 8, 2017

F468
I. Immediate Corrective Actions
1. Handrails determined to be missing on 4-North, in the alcove area consisting of Rooms 424, 425, 426, and 427, were installed on Tuesday, 7/4/17.
2. Handrails observed to be loose in the area of Rooms, 624, 643, 541, 539, were tightened immediately on 7/5/17.
3. Handrail in the area of Room 538 was tightend on 7/6/17.
II. Identification of other locations:
1. All units had potential for loose or missing hand rails, therefore the entire building was surveyed by the enviromnetal staff and no other patient areas were found to have loose or missing hand rails.
2. Handrails throughout the facility (approximately 1436 handrails in all) were audited and all hand rails determined to be be loose, were tightened immediately.
III. Systemic Changes
1. An audit tool has been created to document any findings pertaining to handrails.
2. Monitoring of handrails has been added to and will be part of the environment of care rounds.
IV. Quality Assurance Monitoring
1. Audits of all handrails will be conducted monthly until three consecutive months of 100% compliance of appropriate placement and tight hand rails have been noted.
2. Thereafter, audits of handrails will be conducted quarterly until 100% compliance is achieved within the facility for six (6) months.
3. Subsequent audits will be semiannually.
4. All audit findings will reported into the Quality Assurance Performance Improvement Committee.
5. All Facility Management staff will be in-serviced on how to conduct the monthly hand rail audits. Staff will be educated on identification of loose rails and to secure railings that when identified.
V. Completion Date:
All items with regard to this tag will be completed by
09/08/2017, with the exception of the ongoing monitoring.
VI. Responsible Party:
The Associate Vice President of Facilities Management/Designee is responsible for implementation and monitoring of the Plan of Correction, and ongoing compliance.

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: July 10, 2017
Corrected date: September 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification survey the facility did not ensure that Comprehensive Care Plans were developed for each resident that included measurable objectives and time frames to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for 1 of 5 residents reviewed for Unnecessary Medications from a total Stage 2 sample of 29 residents. Specifically, a Comprehensive Care Plan (CCP) was not developed for Diabetes Mellitus for Resident #111. The finding is: Resident #111 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The 4/28/2017 Quarterly Minimum Data Set (MDS) assessment documented that Resident #111 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. The resident had Diabetes Mellitus identified as an active [DIAGNOSES REDACTED]. A CCP dated 8/13/2016 titled Nutrition and Hydration Needs documented that the resident was at risk for alteration in hydration and nutritional status due to Diabetes Mellitus. The most recent physician's orders [REDACTED]. The Registered Nurse (RN) Charge Nurse was interviewed on 7/7/2017 at 9:49 AM and stated that the RN on the unit is responsible for creating care plans. She stated that there currently was not a Diabetes care plan developed for Resident #111 and that she would create one. The RN Supervisor for the floor was interviewed on 7/7/2017 at 12:11 PM and stated some areas of Diabetes care are addressed on the Nutrition care plan, but there should be a care plan specifically developed for Diabetes. 415.11(c)(1)

Plan of Correction: ApprovedAugust 8, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following Plan of Correction is submitted in accordance with applicable law and regulation for continued Medicare / Medicaid certification. The facility reserves the right to contest any of the findings or deficiencies set forth in the Statement of Deficiencies.
F 279
I. Immediate Corrective Actions
The person centered care plan for patient # 111 was immediately reviewed by the team and updated to address their Diabetic Management goals.
II. Identification of other Residents:
All diabetic patients, who are potentially affected, will have the following measures implemented:
The Care Plans for all patients with a [DIAGNOSES REDACTED].
III. Systemic Changes
1. The Care Planning Policy and Procedure has been reviewed, to ensure that it includes having measurable goals and interventions, that address the care and monitoring of all individual resident needs.
2 As part of our ongoing education, the Nursing department will re-inservice all Registered Professional Nurses regarding the importance of developing person centered care plans, with measurable goals and interventions, to address the care and monitoring of each resident.
A copy of the in-service Lesson Plan and attendance will be filed, for reference and validation.
IV. Quality Assurance Monitoring
1. The facility's current Diabetes audit tool has been revised, to assure that all patients with this [DIAGNOSES REDACTED].
2. A quality assessment audit will be performed weekly, using 100% sample size of all diabetic patient's, for a period of four weeks or longer to assure that all diabetic patients have a care plan in place.
3. Following the fifth week, (or longer until 100% compliance has been achieved), the sample size will be reduced to 50%, of all diabetic patients, of which will be audited on a monthly basis, for a period of three consecutive months.
4. Thereafter, the sample size will be reduced to 20% for a period of six months.
5. Audit findings will be reported at the Quality Assurance and Perfomance Improvement Committee.
V. Completion Date:
All items with regard to this tag will be completed by Friday, 09/08/2017, with the exception of the ongoing monitoring.
VI. Responsible Party:
The Vice President of Patient Care Services/designee is responsible for implementation and monitoring of the Plan of Correction, and ongoing compliance.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 10, 2017
Corrected date: September 7, 2017

Citation Details

Based on interviews and record reviews during the Recertification survey, the facility did not ensure that a 105 notification form was submitted to the Department of Health (DOH) within 30 days of an employee's termination. The finding is: During a review of employee records for the Criminal History Record Check Program, one of 10 records reviewed was found to have a 105 notification of termination form submitted to the DOH beyond the 30 day requirement. Record #8 involved a Certified Nursing Assistant hired on 7/25/16 and terminated on 9/29/16 following receipt of a negative determination letter from the DOH. A 105 termination notice was submitted to the DOH on 5/9/17. The Director of Human Resources was interviewed on 7/10/17 at 11:30 AM. She stated that she is responsible for 105 submissions to the DOH. She stated the policy of the facility is to submit the 105 termination form within 30 days of termination. She stated that employee record #8 belonged to an employee of an agency that the facility no longer uses and that this fact may have accounted for the lateness in submission. She stated that the problem with employee record #8 was revealed during an audit the facility conducted in (MONTH) of this year. Upon discovery, she submitted the 105 termination form on 5/9/17. The Administrator was interviewed on 7/10/17 at 1:45 PM. He stated that audits were conducted sparsely in the past which may have accounted for the missed submission of the 105 form. 402.9(b)(2)

Plan of Correction: ApprovedAugust 8, 2017

R1022
One individual hired (employee record # 8) did not have the required 105 form submitted to the Department of Health (DOH) via the Criminal History Record Check Program (CHRC) within the thirty (30) day requirement. The 105 form was submitted seven (7) months after the official hire date.
I. Immediate Corrective Actions
1. Employee was terminated in the Criminal History Record Check Program (CHRC) system.
2. All current employees were checked against the Criminal History Record Check Program (CHRC) system to assure that employees were under supervision or cleared.
II. Identification of other Employees:
1. All new employees are potentially affected, therefore the following measure will be implemented:
2. Weekly employee termination reports will be reviewed/monitored for the purpose of updating the Criminal History Record Check Program (CHRC) of the terminated(NAME)employees.
III. Systemic Changes
1. Once per week, the Human Resource Department will run a year to date termination list, to ensure all terminated employees who worked at(NAME)have been updated in the Criminal History Record Check Program system accordingly.
2. Upon notice from the Criminal History Record Check Program system (CHRC), any idividual who has a criminal history that does not qualify them for employment, the Human Resouce Department will assure that appropirate action is taken with the employee and the 105 termination form will be submitted via the Criminal History Record Check Program system (CHRC) to the Department of Health (DOH).
3. A Human Resource Specialist will provide a monthly report confirming review of the monthly and year to date termination list provide it to the Vice-President of Human Resources/Designee, for review confirmation.
IV. Quality Assurance Monitoring
1. An audit will be performed weekly using 100% sample size of all employees subject to, a criminal history record check and are no longer employed by Parker. to ensure that a 105 notification form was submitted to the Department of Health (DOH) via the Criminal History Record Check Program system (CHRC). within 30 days of an employee?s termination for the first four weeks, or until 100% compliance is achieved.
2. Audit findings will be reported at the Quality Assurance and Performance Improvement Committee.
3. All Human Resources employees will be in-serviced on the new policy regarding Criminal History Record Check Program.
V. Completion Date:
All items with regard to this tag will be completed by Friday, 09/08/2017, with the exception of the ongoing monitoring.
VI. Responsible Party:
The Vice President for Human Resources/Designee is responsible for implementation and monitoring of the Plan of Correction, and ongoing compliance.

Standard Life Safety Code Citations

K307 NFPA 101:HORIZONTAL SLIDING DOORS

REGULATION: Horizontal-Sliding Doors Horizontal-sliding doors permitted by 7.2.1.14 that are not automatic-closing are limited to a single leaf and shall have a latch or other mechanism to ensure the door will not rebound. Horizontal-sliding doors serving an occupant load fewer than 10 shall be permitted, providing all of the following criteria are met: o Area served by the door has no high hazard contents. o Door is operable from either side without special knowledge or effort. o Force required to operate the door in the direction of travel is less than or equal to 30 lbf to set the door in motion and less than or equal to 15 lbf to close or open to the required width. o Assembly is appropriately fire rated, and where rated, is self-closing or automatic-closing by smoke detection per 7.2.1.8, and installed per NFPA 80. o Where required to latch, the door has a latch or other mechanism to ensure the door will not rebound. 19.2.2.2.10

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: July 10, 2017
Corrected date: August 31, 2017

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. Include your request for renewal of this waiver, or plan of correction in the space provided on this form. K224, S/S=B The facility has not provided evidence that the horizontal sliding doors to resident family lounge are compliant NFPA [PHONE NUMBER]: 7.2.1.14, 7.2.1.8, 19.2.2.2.10 NYCRR 711.2(a)(1), 483.70(a)

Plan of Correction: ApprovedSeptember 1, 2017

K224
The Facility respectfully requests a continuation of this waiver.
Physical conditions have not changed since last survey.
The Facility respectfully requests a continuation of this waiver.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 10, 2017
Corrected date: August 31, 2017

Citation Details

2010 NFPA 13: 8.15.3.2.1 In noncombustible stair shafts having noncombustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. 2010 NFPA 13: 8.15.3.2.2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and staff interview, the facility was not protected throughout by an approved, supervised sprinkler system in that areas within Stair B were not provided with automatic sprinkler coverage. This was noted in one of three exit stairwells. The findings are: On 7/5/17 at approximately 11:24am during the recertification survey, areas within Stair B were not provided with automatic sprinkler coverage. Sprinklers were lacking at the 1st floor landing and on either side of the door to the stairs down to the basement (lower level) floor. In an interview on 7/5/17 at approximately 11:24am, the Associate Vice President of Facilities Management stated that he would have the sprinklers added if the new codes require it. 2010 NFPA 13: 8.15.3.2.1, 8.15.3.2.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 9, 2017

K351
I. Immediate Corrective Action:
Prior to the completion of the Recertification Survey on 7/10/17 Automatic Sprinklers were added to both sides of the door in Stairwell B from the first floor landing to the lower level (basement). Sprinklers were installed and activated on 7/9/17.
II. Identification of other areas:
Environmental and Life Safety Rounds of the Facility did not reveal any other fire stairwells with the same configuration as Stairwell B.
III. Systematic Changes:
The Facility continues to monitor and address Life Safety Code compliance in all areas.
IV. Quality monitoring:
All corrections and outcomes will be reported at the next Quality Assurance Performance Improvement (QAPI) Meeting. Fire sprinkler company will continue yearly checks of the system.
V. Responsible Party:
The Associate Vice President of Facilities Management.