Mercy Living Center
June 29, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the recertification survey, the facility did not ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including functional communication systems for three (Resident #'s 14, 24, and 25) of five residents reviewed for communication. Specifically, the facility did not ensure that hearing aids were in place when residents were attempting to communicate with staff and peers. This is evidenced by: A facility Policy titled, Vision and Hearing dated 5/7/18, documented that the purpose was to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities. The nurse will place the hearing device on the resident after Activities of Daily and will remove and store the device in the medication cart when the resident choses. Resident #14: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set assessed the resident as having intact cognitive skills, able to be understood and understand and was able to hear adequately with hearing aids. The Comprehensive Care Plan dated 1/6/18, documented that the resident was hearing impaired and to put her hearing aids in every AM and remove every PM. During an observation on 6/28/18 at 10:58 AM, the resident was in her room sitting in a recliner. When the surveyor attempted to have a conversation, the resident stated that she was having a hard time hearing the surveyor due to not having her hearing aids. During an interview on 06/28/18 at 10:58 AM, the resident stated that she could not hear and had worn hearing aids (HA) for years without problems. Staff insist that she give her HAs to them at night, but every time the nurses take them, something happens or she had to wait a long time to get them, and it is pretty hard to function without them. She gave them her hearing aids the previous evening and now they were missing. During an interview on 06/28/18 at 12:08 PM, Registered Nurse (RN) #8 stated that the residents get their HA first thing in the morning. The resident had more that one set of HA and she could not find the set that works only found an old one that was broken. The nurses sign that they are put in in the morning and taken out at night. She thinks residents are not allowed to keep their own HAs at night because they are easily lost or broken. During an interview on 06/28/18 01:50 PM, the resident stated they still have not located the HAs. During an interview on 06/28/18 03:42 PM, RN #9 stated the resident's daughter requested that the resident's HAs be left with nurse at night because the resident will leave them on the dresser and one was found under the dresser broken. Additionally, RN #9 stated she heard that the HAs were missing, but did not know what happened, but the resident was forgetful. During an interview on 06/28/18 at 04:29 PM, RN #10 stated that she thought she had gotten them back 6/27/18 and that was why she signed that they were removed, but now did not think that she got them so she put an addendum in the chart on 6/28/18 at 12:34 PM. Resident #25: The resident was admitted to the nursing home on 11/16/17, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During observations on 6/25/18 at 12:20 PM, the resident was in his room watching television with the volume extremely high. The surveyor attempted to interview the resident and he stated that he was hard of hearing and wore a hearing aid. He told the surveyor that the HA was lost, then said it was locked up. The resident stated he heard better with the HA. During observations on 6/25/18 at 12:20 PM, 06/26/18 07:41 AM, 06/28/18 07:42 AM, and 06/28/18 10:36 AM, the resident was up out of bed and did not have a HA in the right ear. The Comprehensive Care Plan dated 2/15/18, documented that the resident had a potential for impaired hearing and wore a HA in the right ear. Place HA in the right ear every morning and remove it at bedtime and store in the medication cart. The Treatment Administration Record for (MONTH) (YEAR) documented to place HAs in AM and remove in PM and store in the medication cart. During an interview on 06/28/18 at 10:25 AM, Certified Nursing Assistant (CNA) #5 stated he was not sure if the resident had a HA but thought he did. The nurse kept them and put them in. The CNAs did not ask for them from the nurse when the resident gets up. During an interview on 06/28/18 at 12:11 PM, RN #8, stated the resident did not have a HA and was not aware of him ever having one. When the surveyor asked RN #8 to check in the cart, the resident's HA was in a box with his name on it. During an interview on 06/28/18 at 11:15 AM, RN #6 stated that if a resident wears HAs, they should be placed as soon as they get up in the morning. Resident #24: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident to have moderately impaired cognitive skills, was able to be understood and understand with adequate ability to hear with the use of a device. A physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) titled Communication Problem related to Hearing Deficit initiated on 1/28/2016, documented; I have bilateral hearing aids, ensure they are functioning and in place before communicating with me. On 06/26/18 at 09:15 AM, the resident was observed after breakfast, in the dining room attempting to speak to staff and surveyors. The resident appeared unable to understand what was being said to him. Registered Nurse (RN) #1 placed hearing aids at 9:45 AM. The resident was then able to understand. On 06/28/18 at 07:44 AM, the resident was observed in the television area with other residents, the hearing aids were not in place. RN #1 was checking the resident's blood pressure and he appeared to have difficulty hearing/following her directions. On 06/28/18 at 08:30 AM, the resident was seated at the table in the dining room for breakfast. CNA #5 used a raised voice while assisting the resident with setting up his meal. A resident seated nearby was speaking to him, he did not hear/acknowledge her. CNA #5 reported the resident doesn't hear well especially before his hearing aids are put in and raised voice is needed to communicate with him. 06/28/18 at 09:23 AM, RN #9 was asked if resident's hearing aides were in place she reported they were not and should be prior to staff attempting to talk to him. At 09:26 AM, RN #1 placed the hearing aids and reported she tries to get them in earlier, but didn't get to it today. He gets up early and it would be better if the night shift put them in so he could communicate while he was up and about. 10NYCRR415.12(a)(2)

Plan of Correction: ApprovedJuly 23, 2018

F 676 The facility did not comply with 483.24, ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living including functional communication systems.
Resident #14: Facility purchased new bilateral hearing aids for this resident. Following discussion with resident and her daughter, it was determined that:
1. Resident?s hearing aids will be stored in labeled container in 2nd drawer of bedside stand.
2. CNAs will be responsible for placing hearing aids in resident?s ears during morning care and for removal during HS care.
3. If nursing staff witness a resident remove his/her hearing aids, nursing staff will place hearing aids in labeled container in 2nd drawer of bedside stand. Discussion with resident included allowing only staff to apply and remove hearing aids, resident agreed to not attempt to apply or remove her hearing aids independently to help ensure they remain intact and functional.
4. Care Plan/Cardex updated to reflect these changes.
Resident #25:
1. Resident?s right hearing aid will be stored in labeled container in 2nd drawer of bedside stand.
2. CNAs will be responsible for placing hearing aid in resident?s ear during morning care and for removal during HS care.
3. If nursing staff witness a resident remove his/her hearing aids, nursing staff will place hearing aids in labeled container in 2nd drawer of bedside stand.
4. Care Plan/Cardex updated to reflect these changes.
Resident #24:
1. Resident?s bilateral hearing aids will be stored in labeled container in 2nd drawer of bedside stand.
2. C.N.A.s will be responsible for placing hearing aids in resident?s ears during morning care and for removal during HS care.
3. If nursing staff witness a resident remove his/her hearing aids, nursing staff will place hearing aids in labeled container in 2nd drawer of bedside stand.
4. Care Plan/Cardex updated to reflect these changes.

Measures put in place to ensure these deficiencies will not recur:
1. A facility-wide audit was conducted to identify all residents who currently have hearing aids and all residents CCP were updated to include will be stored in labeled container in 2nd drawer of bedside stand.
2. Unless these interventions do not meet a specific resident?s needs. In these cases the CCP will reflect individualized interventions that may vary from the norm.
3. Policy and procedure on Hearing Aid care and storage was updated on 7/13/18 by the Educator.
4. Nursing staff to be educated on the policy during Competency month, by 8/17/18, and upon return to work and annually thereafter.
5. Overall, observation audits will be conducted daily for 1 week, followed by weekly for 1 month, followed by monthly for 3 months to monitor effectiveness of policy updates and ensure staff comprehension and adherence to updated policy and procedures.
6. Audit results will be reported to QI Committee monthly for monitoring of effectiveness and determination of further audit needs.
Measures and monitoring put in place to ensure these deficiencies will not recur:
1. Intervention was added to the hearing aid CCP and the Kardex in resident rooms stating ?if hearing aid is unable to be located, perform a thorough search of bedroom and bathroom. If still unable to locate, fill-out a Missing Item form and give form to Social Services Director.?
2. The above instruction also shows up on the C.N.A. documentation (electronic health record) as a PRN task for individuals with hearing aids.
3. All Kardexes in resident rooms were replaced completed 7/23/18.
4. Revised Plan of Care Updates form to include ?Care Plan Updated in PCC and Kardex printed and placed in resident room.?
5. All Kardexes will be printed weekly (Tuesdays) by Unit Secretary/designee for 2 months.
6. An audit of the Plan of Care Updates and Kardex cards will be conducted weekly for 2 months and monthly for the remainder of the year.
7. Re-education of policy and procedures provided to staff who do ensure that resident has hearing aids to optimally carry out activities of daily living as needed.
8. Audit results will be reported at the monthly QI Committee meetings.

Responsible Party: Director of Nursing and Mercy Educator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during the recertification survey, the facility did not ensure a comprehensive person-centered care plan was developed and implemented to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #'s 11, 14, 24 and 25) of 23 residents reviewed. Specifically, for Resident #'s 14, 24 and 25, the facility did not ensure that the comprehensive care plan (CCP) for the resident's hearing aids was followed, for Resident #24, the facility did not ensure there was a care plan in place for a pressure ulcer. For Resident #11, the facility did not ensure that the CCP for positioning of a catheter bag was comprehensive and that the interventions were followed. This is evidenced by: Finding #1 The facility did not ensure that the comprehensive care plan (CCP) for the resident's hearing aids was followed. Resident #24: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident to have moderately impaired cognitive skills, was able to be understood and understand with adequate ability to hear with the use of a device. A physician's orders [REDACTED]. Store hearing aids in medication cart, top drawer, two times a day for hearing loss. The Comprehensive Care Plan (CCP) titled Communication Problem related to Hearing Deficit initiated on 1/28/2016, documented; I have bilateral hearing aids, ensure they are functioning and in place before communicating with me. On 06/26/18 at 09:15 AM, the resident was observed after breakfast, in the dining room attempting to speak to staff and surveyors. The resident appeared unable to understand what was being said to him. Registered Nurse (RN) #1 placed hearing aids at 9:45 AM. The resident was then able to understand. On 06/28/18 at 07:44 AM, the resident was observed in the television area with other residents. The hearing aids were not in place. RN #1 was checking the resident's blood pressure and the resident appeared to have difficulty hearing/following her directions. On 06/28/18 at 08:30 AM, the resident was seated at the table in the dining room for breakfast. Certified Nursing Assistant (CNA) #5 used a raised voice while assisting the resident with setting up his meal. A resident seated nearby was speaking to him, and he did not hear/acknowledge her. CNA #5 reported the resident doesn't hear well especially before his hearing aids are put in and a raised voice is needed to communicate with him. On 06/28/18 at 09:23 AM, RN #9 was asked if the resident's hearing aides were in place. RN #9 stated they were not and should be prior to staff attempting to talk to him. At 09:26 AM, RN #1 placed the hearing aids and reported she tries to get them in earlier, but didn't get to it today. He gets up early and it would be better if the night shift put them in so he could communicate while he was up and about. Resident #14: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessed the resident as having intact cognitive skills, able to be understood and understand and was able to hear adequately with hearing aids. The Comprehensive Care Plan dated 1/6/18, documented that the resident was hearing impaired and to put her hearing aids in every AM and remove every PM. The Medication Administration Record [REDACTED]. The scheduled times were to put in at 7:00 AM and remove at 10:00 PM. The record showed initials in the box for 6/27/18 at 10:00 PM indicating that the HAs were collected by the nurse. During an interview on 06/28/18 at 10:58 AM, the resident stated that she could not hear and had worn hearing aids (HA) for years without problems. Staff insist that she give her HAs to them at night, but every time the nurses take them, something happens or she had to wait a long time to get them, and it is pretty hard to function without them. During an interview on 06/28/18 12:08 PM, RN #8 stated that she could not find the resident's HAs. During an interview on 06/28/18 03:42 PM, RN #9 stated that on 4/10/18, they gave specific times for the HAs to be placed and removed due to issues with getting the HAs at the time the resident wanted them. During an interview on 06/28/18 at 04:29 PM, RN #10 stated that she thought she had gotten them and that was why she signed that they were removed, but did not think that she did get them so she put an addendum in the chart on 6/28/18 at 12:34 PM. During an interview on 06/28/18 at 11:15 AM, RN #6 stated that residents should have their HAs placed as soon as they get up in the morning. Resident #25: The resident was admitted to the nursing home on 11/16/17, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During observations on 6/25/18 at 12:20 PM, 06/26/18 07:41 AM, 06/28/18 07:42 AM, and 06/28/18 10:36 AM, the resident was up out of bed and did not have a HA in the right ear. The Comprehensive Care Plan dated 2/15/18, documented that the resident had a potential for impaired hearing and wore a HA in the right ear. Place HA in the right ear every morning and remove it at bedtime and store in the medication cart. The Treatment Administration Record for (MONTH) (YEAR), documented to place HAs in AM and remove in PM and store in the medication cart. During an interview on 06/28/18 at 10:25 AM, Certified Nursing Assistant (CNA) #5 stated he was not sure if the resident had a HA but thought he did. The nurse kept them and put them in. The CNAs did not ask for them from the nurse when the resident gets up. During an interview on 06/28/18 at 12:11 PM RN #8, who was the nurse on that of the hall, stated the resident did not have a HA was not aware of him ever having one. When the surveyor asked RN #8 to check in the cart, the resident's HA was in a box with his name on it. During an interview on 06/28/18 at 11:15 AM, RN #6 stated that residents should have their HAs placed as soon as they get up in the morning. Finding #2 Resident #24: The facility did not ensure there was a care plan in place for a pressure ulcer. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident to have moderately impaired cognitive skills, was able to be understood and understand with adequate ability to hear with the use of a device. A wound care note dated 06/17/18, documented a facility acquired stage 2 pressure area on the left metatarsal measuring 0.3x0.5 was being treated with [MEDICATION NAME]. During an interview on 06/28/18 at 09:40 AM, RN #9 reported there was not a CCP to address the resident's wound care needs there should have been. The wound is now healed. Finding #3 The facility did not ensure that the CCP for positioning of a catheter bag was comprehensive and that the interventions on the care plan were followed. Resident #11: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident was sometimes able to understand, sometimes able to be understood, and had severe cognitive impairment. The Comprehensive Care Plan (CCP) titled Foley Catheter related to [MEDICAL CONDITION] and [MEDICAL CONDITION] last revised on 6/28/18, documented the following intervention; position catheter bag and tubing below the level of the bladder and away from entrance of door. On 06/28/18 at 07:29 AM, the catheter bag was observed on the bed with the resident. On 06/25/18 at 01:25 PM and O06/28/18 at 10:45 AM, the resident's catheter bag was observed on the floor without a barrier. During an interview on 06/28/18 at 10:46 AM, Certified Nursing Assistant (CNA) #5 reported sometimes the catheter bag is put on the bed and there are no instructions about letting the bag touch the floor. During an interview on 06/29/18 at 09:34 AM, CNA #8 reported that catheter bags should never be on the floor. During an interview on 06/29/18 at 09:44 AM, RN #9 reported staff should follow the CCP for positioning of the catheter bag and it is not acceptable to allow the bag to be on the floor even though that is not in the CCP. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 656 The facility did not comply with 483.21, ensure a comprehensive person-centered care plan was developed and implemented to meet the resident?s medical, nursing, mental and psychosocial needs.
Finding #1: Specifically, the facility did not ensure that the comprehensive care plan (CCP) for the resident?s hearing aids was followed.
Resident #24:
1. Resident?s bilateral hearing aids will be stored in labeled container in 2nd drawer of bedside stand.
2. C.N.A.s will be responsible for placing hearing aids in resident?s ears during morning care and for removal during HS care.
3. If nursing staff witness a resident remove his/her hearing aids, nursing staff will place hearing aids in labeled container in 2nd drawer of bedside stand.
4. Care Plan/Cardex updated to reflect these changes.

Resident #14: Facility purchased new bilateral hearing aids for this resident. Following discussion with resident and her daughter, it was determined that:
1. Resident?s hearing aids will be stored in labeled container in 2nd drawer of bedside stand.
2. CNAs will be responsible for placing hearing aids in resident?s ears during morning care and for removal during HS care.
3. If nursing staff witness a resident remove his/her hearing aids, nursing staff will place hearing aids in labeled container in 2nd drawer of bedside stand. Discussion with resident included allowing only staff to apply and remove hearing aids, resident agreed to not attempt to apply or remove her hearing aids independently to help ensure they remain intact and functional.
4. Care Plan/Cardex updated to reflect these changes.
Resident #25:
1. Resident?s right hearing aid will be stored in labeled container in 2nd drawer of bedside stand.
2. CNAs will be responsible for placing hearing aid in resident?s ear during morning care and for removal during HS care.
3. If nursing staff witness a resident remove his/her hearing aids, nursing staff will place hearing aids in labeled container in 2nd drawer of bedside stand.
4. Care Plan/Cardex updated to reflect these changes.
Measures put in place to ensure these deficiencies will not recur:
1. A facility-wide audit was conducted on 7/13/18 to identify all residents who currently have hearing aids and all residents CCP were updated to include will be stored in labeled container in 2nd drawer of bedside stand.
2. Unless these interventions do not meet a specific resident?s needs. In these cases the CCP will reflect individualized interventions that may vary from the norm.
3. Policy and procedure on Hearing aid care and storage was updated on 7/12/18 by the Educator.
4. Nursing staff to be educated on the policy during Competency month, by 8/17/18, and upon return to work and annually thereafter.
Finding #2: The facility did not ensure there was a care plan in place for a pressure ulcer.
Resident #24: RN who discovered wound and initiated treatment for [REDACTED].
Measures put in place to ensure this deficiency does not recur:
1. A facility-wide audit was conducted on 7/13/18 to identify all residents who currently have pressure ulcers to ensure their CCP is updated to reflect current interventions according to facility policy and procedure.
2. Policy and procedure on writing and updating the Care Plan will be completed by 7/31/18.
3. Nursing staff to be re-educated on the policy regarding pressure ulcer during Competency month, by 8/17/18, and upon return to work and annually thereafter.
Finding #3: The facility did not ensure that the CCP for positioning of a catheter bag was comprehensive and that the interventions on the care plan were followed.
Resident #11: All nursing staff has been re-educated on catheter placement/care including appropriate placement of catheter bag to maintain residents dignity and infection control. Update residents CCP to include appropriate interventions.
Measures put in place to ensure this deficiency does not recur:
1. A facility wide audit was conducted on 7/13/18 to identify all residents who currently have an indwelling catheter. 100% of those with catheters had their CCP updated to reflect use of dignity bag.
2. Catheter policy and procedure revised to include use of dignity bag completed 7/17/18.
3. Nursing staff on duty were re-educated on facility policy and procedure for catheter care and placement to ensure that adherence to maintaining resident dignity and infection control is followed on 7/13/18 by nursing management.
4. Re-education of nursing staff will continue during Competency month, by 8/17/18, and upon return to work and annually thereafter.
5. New nursing staff will be educated on this policy during their departmental orientation.
Measures put in place to ensure these deficiencies will not recur:
1. Overall, observation audits will be conducted daily for 1 week, followed by weekly for 1 month, followed by monthly for 3 months to monitor effectiveness of policy updates and ensure staff comprehension and adherence to updated policy and procedures.
2. Audit results will be reported to QI Committee monthly for monitoring of effectiveness and determination of further audit needs.
3. Changes to the Plan of Care Updates (green sheets) will be reviewed by Nursing Management/designee and approved by the IDT in Morning Report.
4. All Kardexes in resident rooms were replaced completed 7/23/18.
5. Revised Plan of Care Updates form to include ?Care Plan Updated in PCC and Kardex printed and placed in resident room.?
6. All Kardexes will be printed weekly (Tuesdays) by Unit Secretary/designee for 2 months.
7. An audit of the Plan of Care Updates and Kardex cards will be conducted weekly for 2 months and monthly for the remainder of the year.
8. Re-education provided to nursing staff who do not promptly communicate changes as needed.
9. Audit results will be reported at the monthly QI Committee meetings.

Responsible Party: Director of Nursing and Mercy Educator

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

Citation Details

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food temperature thermometers shall be calibrated, food contact surfaces shall be cleaned after use, a chemical test kit (test papers) is to be provided for checking chemical sanitizer levels, and handwashing sinks are to provided (accessible) in food preparation areas. Specifically, food temperature thermometers were not in calibration, food contact surfaces were not clean, test papers were not provided, and the handwashing sink was obstructed from use. This is evidenced as follows. The main kitchen was inspected on 06/25/2018 at 11:11 AM. Six of 8 in-use thermometers were found out of calibration when checked by the standard ice-bath method as follows: 29 degrees Fahrenheit (F), 22 F, 25 F, 27 F, 29 F, 27 F. The table mixer, slicer, can opener and holder, table fan, dishwashing machine room walls and ceiling vent, and fire extinguisher not clean. The sanitizing solution utilized was QT-40 and the test papers proved were QT-10. The handwashing sink was obstructed with food service carts. The Food Service Director stated in an interview conducted on 06/25/2018 at 11:11 AM, that she will address the cleaning items found, will properly calibrate the thermometers, get the correct test papers, and instruct staff to keep the handwashing sink unobstructed. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.85, 14-1.110, 14-114(c), 14-1.143

Plan of Correction: ApprovedJuly 27, 2018

F 812 The facility did not comply with 483.60, ensure Food Procurement, Store/Prepare/Serve-Sanitary.
Specifically, food temperature thermometer were not in calibration.

1. All dial thermometers which were not calibrated, were discarded and replaced with new digital thermocouple thermometers, as certified sealed instruments on 6/26/18.
2. The thermocouple thermometers will automatically be replaced every 2 years to guarantee quality and accuracy by the Clinical Nutrition Manager/designee.
3. The thermocouple thermometers will be checked monthly for accurate calibration by the Assistant Manager/designee to begin 8/24/18.
4. Alcohol wipes ordered for proper cleaning of the wands.

Specifically, food contact surfaces were not clean.
1. Table mixer, slicer, can opener/holder and fire extinguisher have been taken apart and cleaned.
2. Table fan and ceiling vent were cleaned by maintenance on 6/26/18.
3. Dishwashing machine room walls were cleaned on 6/26/18 and a work order was put in for the wall to be scraped and painted.
Specifically, test papers were not provided.
1. The wrong sanitizing test strips (QT-10) have been discarded and were replaced with the proper test strips (QT-40) on 6/26/18.
Specifically, the handwashing sink was obstructed from use.
1. The food service cart which was obstructing the hand washing sink, has been relocated to a more appropriate location.
2. Education to staff about maintaining access to handwashing area was completed on 6/27/18
Measures put in place to address this deficiency:
1. All dietary staff will be educated and re-introduced to the policy and procedure addressing proper sanitation of all food contact equipment and food prep surfaces and their surroundings by 8/2/18, and in departmental meetings annually, and to new staff in the departmental orientation.
2. All dietary staff will be educated on the new documentation logs and proper prep area cleaning and storing of food items by 8/2/18, and in departmental meetings annually, and to new staff in the departmental orientation.
3. All dietary staff will be educated on the proper care and maintenance of food temperature thermometers by 8/2/18, and in departmental meetings annually, and to new staff in the departmental orientation.
4. The cook or designee will perform a check at the start of each shift daily, of all food contact equipment and work areas. Anything not satisfactory, will be cleaned immediately and reported to their food service manager.
5. The food service manager will perform an audit of the cleanliness of the food contact equipment, prep areas and food storage daily for 2 weeks, 1X week for 1 month and then monthly for 3 months and ongoing as needed.
6. Results of this audit will be reported to the facilities QI Committee.
Responsible Party: Director of Food Service and Clinical Nutrition Manager

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #46) of ten residents reviewed for accidents. Specifically, for Resident #46, the facility did not ensure the resident was given fluids in a manner that did not put her at risk for aspiration. This is evidenced by: Resident #46: The resident was admitted to the nursing home on 5/23/18, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident as having severely cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an observation on 06/27/18 AM at 08:30 AM, the surveyor walked past the resident's room and observed that Certified Nursing Assistant (CNA) #1 had a syringe (later identified as a 10 cc) with red liquid in it and was attempting to feed it to the resident via the syringe. The surveyor entered the room and asked CNA #1 what the syringe was for. CNA #1 stated that was the way they were giving her fluids, because she was too weak to suck from straw. The medical record did not include a Physician (MD) Order or a Comprehensive Care Plan (CCP) to feed or administer medication to the resident via a syringe. The Care Tracker (a guide for CNAs regarding what care to give the resident) did not include an entry to give fluids via a syringe. The resident Kardex (a written review of what care to be done by CNAs) documented under eating: Supervision throughout meals with verbal cues of encouragement to eat items on tray. A Medication Administration note dated 6/24/18 at 8:35 PM, documented the resident's [MEDICATION NAME](a narcotic pain medication) was held because the resident was not alert enough to swallow medications safely. Progress Note dated 6/25/18 10:02 AM, documented medications were held due to the residents inability to swallow or awaken enough to swallow safely. The MD was notified. Progress Note dated 6/26/18 5:44 AM, written by RN #3, documented the resident was complaining she couldn't breathe. Her oxygen saturation (a measurement of how much oxygen is circulating in the blood) was 83% (normal approximately 90% for someone with [MEDICAL CONDITION]), the resident was anxious and her oxygen was moved to her mouth. The resident's as needed (PRN) [MEDICATION NAME] (an antianxiety medication) was crushed, mixed with water, and given via syringe. Fluids offer and refused. The resident took about 5 cc juice via syringe. Progress Note dated 6/27/18 at 4:14 am, written by Registered Nurse (RN) #4, documented the resident refused all evening medications and had a minimal intake of 60 cubic centimeters (cc) this shift. A Chest X-Ray dated 6/27/18, documented that the resident has a significant deterioration when compared to previous film of 5/16/18. There are moderate to large bilateral pleural effusions and the first consideration was for [MEDICAL CONDITIONS] and/or aspiration, given the resident's history. During an interview on 06/27/18 08:37 AM, Licensed Practical Nurse (LPN) #1 stated that the nurse gave liquids with a syringe, but she did not know if a CNA could do it. There was one resident that was fed medications via syringe, but she didn't know if there was a policy for it and had never received training. During an interview on 06/27/18 08:39 AM, CNA #1 stated that this resident was the only one she ever fed with a syringe. RN #3 told them to do it and that the syringes were in the room. CNA #1 stated she had no training prior to using the syringe, and that everyone was doing it without training. During an interview on 06/27/18 08:43 AM, CNA #9 stated that she saw a syringe in the room yesterday, but did not touch it, and did not know where the direction came from to use the syringe. During an interview on 06/27/18 08:46 AM, CNA #2 stated that she was informed today, that they were to use a syringe to feed the resident. During an interview on 06/27/18 08:47 AM, CNA #3 stated she was aware that staff were using a syringe to give the resident liquids but had never done it herself. During an interview on 06/27/18 08:53 AM, RN #1 stated she found out yesterday that staff were feeding the resident with a syringe, but did not know how long it was going on. It was part of a verbal report at the change of shift. RN #3 told her the only way they could get liquids in the resident was with a syringe. She did not believe staff were trained to give fluids via syringe, and she was not aware that the CNAs were doing it. She did not believe CNAs should be doing it unless trained because of the increased risk of aspiration. During an interview on 06/27/18 09:11 AM, the Director of Nursing (DON) was not aware that staff were feeding the resident with a syringe, because the facility does not use syringes to feed residents. During an interview on 06/27/18 09:29 AM, the Speech Pathologist (SP) stated that she had just been made aware that that staff were giving fluids via syringe and that she would be the person to assess for its use, but she would never suggest that they did because of the risk for aspiration. During an interview on 06/27/18 10:50AM, the MD stated that it was not appropriate to use a syringe for fluids or medications when the resident was in respiratory distress or if the resident seemed lethargic. Using the syringe would put the resident at a higher risk for aspiration. During an interview on 06/27/18 12:29 PM, RN #3 stated that she thinks that on Monday the 25th, LPN #3, who was not available for interview, told her the resident was not safe to take her medications, because she was either lethargic or not swallowing but she had the idea to give some liquids via a syringe. She did not think LPN #3 had asked the MD and they had not been trained. She gave the resident her [MEDICATION NAME] with the syringe and that the documentation regarding the juice given via the syringe on 6/26/18 at 5:44 AM, was based on what the CNAs told her. During an interview on 06/27/18 04:41 PM, CNA #6 stated that on 6/25/18, LPN #3 recommended that the resident be given fluids via the syringe because she had such a poor intake. When she came to work on 6/26/18, the syringe was in the room, so she used it during the dinner meal. She had not received training on using a syringe. During an interview on 06/28/18 01:54 PM, the MD stated that in looking at the chest x-ray, he feels it is from an exacerbation of her [MEDICAL CONDITION], but is possible that it could be from aspiration.

Plan of Correction: ApprovedAugust 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 689 The facility did not comply with 483.25, ensure resident receives adequate supervision and assistance devices to prevent accidents. Specifically, for Resident #46, the facility did not ensure the resident was given fluids in a manner that did not put her at risk for aspiration.
Measures put in place to address this deficiency:
1. Immediately, upon notification by DOH surveyor?s on 6/27/18 syringes were removed from resident?s room.
2. All staff on duty received written and verbal notice regarding no PO food or fluids to be administered via syringe to any resident. All staff on duty signed indicating understanding of above information and willingness to comply.
3. A complete investigation was completed by DON and Nurse Manager to determine root cause of incident. Statements obtained from all staff working with that resident for previous 2 days.
4. Immediate re-education was provided to each of those staff members by Nurse Educator in regard to 1) Understanding Scope of Practice; 2) Understanding the necessity of receiving physician orders [REDACTED].
5. Nursing and activities staff on-duty was provided education as above to ensure no resident receive PO food or fluids via syringe.
6. Nursing staff will be provided re-education on professional processes and communication during Competency week (8/3),as part of the departmental new hire orientation, and annually.
Measures and monitoring put in place to ensure these deficiencies will not recur:
7. RN Mgr/DON to review 24 Hr. Summary Reports daily.
8. Registered Dietician will continue to run the weekly Weights Report for close monitoring of nutritional status, which is reviewed in IDT meetings.
9. The Therapy Watch form is used on the units for staff to identify and monitor residents who exhibit a decline in ADL function and is reviewed in the IDT meeting (weekdays). The form will be revised by 7/27/18, to the Nutrition/Therapy Watch form where staff can also identify and monitor residents who exhibit a change in PO intake, have a change in their ability to take PO, or who are unable to eat/drink independently.
10. Nursing staff education on the revised form will be completed by 8/27/18.
Responsible Party: Director of Nursing, Registered Dietician, and Mercy Educator

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

Citation Details

Based staff interview and record review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessments be updated annually, and Section 4-2.4 requires that by (MONTH) 1, (YEAR) facilities shall adopt and implement a Legionella sampling and management plan. Specifically, the facility did not adopt a Legionella sampling and management plan and did not maintain a current Legionella Environmental Assessment Form (EAF) as required by New York State regulation. This is evidenced by the following. When requested on 06/25/2018, an EAF and a Legionella sampling and management plan were not available for survey review. The Administrator stated in an interview conducted on 06/25/2018 at 2:30 pm, that she was not aware of the requirements regarding an EAF and the development and implementation of a Legionella sampling and management plan. 415.19(a)

Plan of Correction: ApprovedJuly 23, 2018

I 210 The facility shall comply with Part 4, Protection Against Legionella, Section 4-2.3 requiring that environmental assessments be updated annually, and Section 4-2.4 requiring that by (MONTH) 1, (YEAR) facilities shall adopt and implement a Legionella sampling and management plan. Specifically, the facility did not adopt a Legionella sampling and management plan and did not maintain a current Legionella Environmental Assessment Form (EAF) as required by NYS regulation.
Measures put in place to address this deficiency:
1. An environmental assessment form will be completed by 8/27/18.
2. A legionella policy and management plan will be in place by 8/27/18.
3. Sampling of water from 10 locations in the facility as designated by the sampling plan will be completed on a quarterly basis for the first year.
4. A work order for the annual environmental assessment as well as the quarterly sampling will be created in the work order system.
5. Results of the testing and the environmental assessment will be reported to the Safety Committee as indicated.
Responsible Party: Director of Plant Operations

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

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not develop and implement a Water Management Plan (WMP) in accordance with adopted regulations. Additionally for 1 (Resident # 42) of 4 residents reviewed for pressure ulcers, the facility did not ensure standard precautions were maintained during wound care. This is evidenced as follows. Finding #1 The facility did not develop and implement a Water Management Plan (WMP) in accordance with adopted regulations. When requested on 06/25/2018, the potable water WMP (which includes a graphic and written description of the potable water system and a description of the Legionella growth control measures) was not available for survey review. The Administrator and the Manager of Plant Operations stated in an interview conducted on 06/25/2018 at 2:30 PM, that a potable water WMP had not been developed. Finding #2 Resident #42: The facility did not ensure standard precautions were maintained during an observed dressing change for a stage 2 decubitus ulcer on the resident's left buttock This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated ,[DATE], documented the resident was severely cognitively impaired for decision making, was able to understand others and was able to be understood. The facility's policy for Pressure Ulcer Treatment dated 8/20/2008, documented: Adhere to Standard Precauctions while providing pressure ulcer treatment. Clean technique shall be utilized during all pressure ulcer treatments unless specified sterile technique in an order written [REDACTED]. The facility's Policy and Procedure for Clean Dressing Technique dated 8/30/11, documented the following: 1. Establish clean field, wash hands, apply clean gloves, 2. Remove old dressing and discard, remove gloves, wash hands and apply clean gloves. 3. Cleanse wound using no touch technique, cleaning the wound from the center to the periphery, then remove gloves wash hands, apply clean gloves. 4. Apply any medication ordered and apply dressing. 5. Dispose of soiled materials in a plastic bag, remove gloves and wash hands. The Policy and Procedure for Dressing Change with a revision date of 11/2009, documented the policy of following standard principles of asepsis per Centers for Disease Control and Prevention (CDC). Clean technique and equipment is used to reduce or prevent the transmission of microorganisms from the environment to the wound or from the wound to the environment. Set up supplies needed for treatment and dressing on a clean field. Open dressings, using open package as a field. Assess need for antiseptic gel on a barrier on bedside stand, place if needed. Put on non-sterile gloves. If contamination occurs, discard and start over at step prior to the contamination point with new equipment and supplies. A physician's orders [REDACTED]. The electronic Treatment Administration Record (eTAR) dated (MONTH) (YEAR), documented cleanse wound on left buttocks with wound cleanser, apply [MEDICATION NAME] gel to open area on wound and apply border gauze every 3 days or as needed for soiling. During observation on 6/28/18 at 10:45 AM, Licensed Practical Nurse (LPN) #4 performed wound care to the residents left buttock. With gloved hands, LPN #4 removed wound cleanser from the treatment cart, placed items on the clean field and began wound care. LPN #4 did not change gloves. LPN #4 began to clean the wound, applied wound cleanser to the gauze and wiped in and out of the wound several times, and using the same gauze began to clean the wound again using the same method. The LPN removed her gloves, applied clean gloves, applied [MEDICATION NAME] gel and applied the outer dressing. LPN did not wash her hands. During interview on 6/28/18 at 11:30 AM, LPN #4 stated she realized she should have changed her gloves and washed her hands more during the dressing change. She stated she did not know of any policy or procedure the facility used for clean technique during dressing changes. During interview on 6/28/18 at 12:00 PM, the RNUM stated when cleaning the wound LPN #4 should not have gone back into the wound with the same gauze. The accepted practice to prevent contamination of the wound is to wipe once, dispose of the gauze and if repeated cleaning was needed a clean gauze should be used. Once the wound is cleaned, gloves are removed, hands should be washed and clean gloves applied before applying a topical medication and a dressing placed on the wound. During interview on 6/29/18 at 9:00 AM, the Registered Nurse Staff Development/ Infection Control Nurse stated the nurses are taught to use clean technique when doing wound care. Hand washing to prevent infection is taught at annual inservices. Hands should be washed everytime gloves are removed and before putting clean gloves on. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f)

Plan of Correction: ApprovedJuly 23, 2018

F 880 The facility did not comply with 483.80, establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infections.
Finding #1: Specifically, the facility did not develop and implement a Water Management Plan (WMP) in accordance with adopted regulations.
Measures put in place to address this deficiency:
1. A water management plan, which will include the completed potable water system flow chart and potable water system description will be completed by 8/27/18.
2. The water management plan will be reviewed by the Safety Committee on 8/27/18.
3. Sampling of water from 10 locations in the facility as designated by the sampling plan will be completed on a quarterly basis for the first year.
4. A work order for the annual environmental assessment as well as the quarterly sampling will be created in the work order system.
5. Results of the testing and the environmental assessment will be reported to the Safety Committee as indicated.
Responsible Party: Director of Plant Operations and Infection Control & Patient Safety Officer
Finding #2: Specifically, for Resident #42, the facility did not ensure standard precautions were maintained during wound care.
Measures put in place to address this deficiency:
1. Observed staff, LPN #4, was re-educated on the facilities policy on pressure ulcer treatment and clean dressing technique.
2. Clean Dressing Change policy and procedure was revised on 7/12/18.
3. Nursing staff will be educated on the revision and will perform a clean dressing change by 8/3/18 (Competency Week).
4. Audit of all licensed staff providing wound care was conducted to identify any immediate need for further education or re-education.
5. Audits will be conducted daily for 1 week, followed by weekly for 1 month, followed by monthly for 3 months to monitor effectiveness by the nurse manager/designee.
6. Audit results will be reported monthly at the QI Committee meeting.
Responsible Party: Director of Nursing and Mercy Educator

FF11 483.20(k)(1)-(3):PASARR SCREENING FOR MD & ID

REGULATION: §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(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. §483.20(k)(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. §483.20(k)(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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 27, 2018

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 a level 1 screen, was completed prior to admission to the nursing home for 1 (Resident #25) of 23 residents reviewed for pre-admission screening. Specifically, for Resident #25, the facility did not complete a level I screen, prior to the resident's admission to the facility. This is evidenced by: Resident #25: The resident was admitted to the nursing home on 11/16/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The resident's medical record did not include a level I screen. During an interview on 06/28/18 at 08:24 AM, the Director of Social Services stated she was responsible for checking admission paperwork to ensure it was complete. The resident should have had a level 1 screen done prior to admission.

Plan of Correction: ApprovedAugust 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 645 The facility did not comply with 483.20(k)(1), ensure that a level 1 screen was completed prior to admission to the nursing home. Specifically, for Resident #25, the facility did not complete a level 1 screen prior to the resident?s admission to the facility.
Measures put in place to address this deficiency:
1. Resident #25 was admitted [DATE]. The permissible period to have completed a level 1 screen is passed.
Measures put in place to ensure this deficiency does not recur:
1. Audit of 100% of records to ensure presence of level 1 screen was completed.
2. Director of Social Services to review all referral packets and ensure all pertinent documentation is present prior to admission.
3. Policy and procedure about PRI/Screen regulations will be developed by 8/1/18.
4. Admissions Team to be educated on PRI/Screen policy by 8/10/18.
Measure put in place to ensure this deficiency does not recur:
Responsible Party: Director of Social Services and AVP Long Term Care

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: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on staff interview during the recertification survey, the facility did not protect all cooking facilities in accordance with adopted regulations. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Section 11.1.4 requires that instructions for manually operating the kitchen fire-extinguishing system shall be reviewed with employees by the management. Specifically, 2 of 2 kitchen staff interviewed did not know how to manually activate the kitchen fire-extinguishing system and the facility management had not reviewed the procedure with the employees. This is evidenced as follows. When interviewed on 06/24/2018 at 12:30 PM, the Cook #1 did not know how to manually operate the kitchen fire-extinguishing system. When interviewed on 06/24/2018 at 12:35 PM, the Clinical Nutrition Manager stated she had not received instruction on how to manually operate and did not know how to manually operate the kitchen fire-extinguishing system. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.2.3; 2011 NFPA 96 11.1.4; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.2.6; 1998 NFPA 96

Plan of Correction: ApprovedJuly 26, 2018

K324 The Facility shall comply with NFPA 96 section 11.1.4 requiring that instructions for manually operating the kitchen fire-extinguishing system shall be reviewed with employees by the management. Specifically, kitchen staff did not know how to manually activate the kitchen fire-extinguishing system and the facility management had not reviewed the procedure with the employees.
Measure put in place to correct this deficiency:
1. A policy and procedure will be created to address instructions for manually operating the kitchen fire-extinguishing system by 8/10/18.
2. All kitchen staff will be educated through demonstration on the manual activation of the kitchen fire extinguisher (suppression) system by 8/24/18.
3. Education/training for new dietary staff will be added to the departmental orientation by 8/24/18.
4. The policy and procedure and demonstration on the manual activation of the kitchen fire extinguisher (suppression) system will be reviewed with all kitchen staff every six months (at the (MONTH) and (MONTH) meetings).

Responsible Party: Food Services Director and Clinical Nutrition Manager

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: June 29, 2018
Corrected date: September 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall. Specifically, non-compliant power strips were used to power patient care equipment and other electrical devices in patient care areas, and power strips in use throughout the facility were not secured as required. This is evidenced as follows. Observations on 06/27/2018 at 12:00 PM, and again at 3:20 PM, revealed non-compliant power strips were used to power medical devices (nebulizer, bed alarm, bed) in resident room [ROOM NUMBER], the bed and lamp in resident room [ROOM NUMBER], and a lamp in resident room [ROOM NUMBER]. Other observations throughout survey revealed a power strip dangling in the laundry room and in not connected to walls in the Physical Therapy treatment room and in all offices. The Manager of Plant Operations stated in an interview conducted on 06/27/2018 at 3:20 PM, that families sometimes bring in power strips unbeknownst to facility staff, but otherwise cannot account as to why non-compliant power strips were in use. Additionally, he stated that he will attach all power strips to walls as required. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 2011 NFPA 70 400.8, 400.7, 368.56(B);10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3; 1999 NFPA 70

Plan of Correction: ApprovedJuly 26, 2018

K 920 The Facility shall comply with NFPA 70 Articles 400.8, 400.7, and 368.56(B) requiring relocatable power taps (power strips) be secured to the wall. Specifically, non-compliant power strips were used to power patient care equipment and other electrical devices in patient care areas, and power strips in use throughout the facility were not secured as required.
Measures put in place to correct this deficiency:

1. Policy on the use of acceptable power strips will be completed by 8/15/18.
2. Plant Ops staff will be trained on the new policy by 8/27/18.
3. Acceptable power strips per NFPA 101 Standards will be purchased and installed in areas where required in the facility. Power strips will be mounted to the wall in both resident and non-resident areas. This will be accomplished by 8/27/18.
4. An audit of the facility to assess the proper placement of acceptable power strips will be conducted by 8/15/18 and once again on 10/15/18 by the Manager of Plant Operations.
5. The results of the audit will be reviewed by the Safety Committee on 8/27/18.
6. Information about acceptable power strips and procedures to address needs in resident rooms will be included in the resident/patient admissions packet by 8/27/18.
7. An audit of the facility to assess rooms for additional outlets will be conducted by 8/27/18 by the Manager of Plant Operations.
8. All other staff will be trained in their departmental staff meetings by 8/27/18.
Responsible Party: Manager of Plant Operations

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 more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee interview and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities maintain PCREE with consideration of the owner's manual. Specifically, three of 3 PCREE observed were not maintained as prescribed in the owner's manuals. This is evidenced as follows. Observations on 06/27/2018 at 12:00 PM revealed that electric inhalation-treatment nebulizer # found in resident room [ROOM NUMBER] was not in use and was plugged into an electrical outlet, and oxygen concentrator # was in use in the(NAME)e Unit dining room and placed directly next to the wall. Record review of the owner's manual for nebulizer # on 06/27/2018 revealed that to reduce the risk of electrocution, the unit is to be unplugged immediately after each use. Record review of the owner's manual for oxygen concentrator # on 06/27/2018 revealed that the unit is to be kept 3-inches minimum from walls while in use. The Director of Nursing stated in an interview conducted on 06/27/2018 at 3:20 PM that staff are trained on the safe use of PCREE, but more training is needed. Suction machine # was inspected and the Biomed Supervisor was interviewed on 06/27/2018 at 12:15 PM. The Biomed Supervisor stated that his department is responsible for the maintenance of the suction machines and that the pump air filter has not ever been checked or replaced. Record review of the owner's manual for suction machine # on 06/27/2018 revealed that the pump air filters and gasket are to be checked or replaced annually. The facility maintenance policies for PCREE were reviewed on 06/27/2018. These policies state that the preventative maintenance for PCREE will be consistent with the manufacturer recommendations. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedJuly 26, 2018

K921 The Facility shall comply with NFPA 99 section 10.3 requiring that facilities maintain PCREE with consideration of the owner?s manual. Specifically, PCREE was not maintained as prescribed in the owner?s manual.
A. Nebulizer # found in resident room was not in use and was plugged into an electrical outlet, an oxygen concentrator # was in use in the(NAME)e Unit dining room and placed directly next to the wall.
Measures put in place to address this deficiency:
1. Policy and procedure will be created to address maintenance of PCREE per owner?s manual instructions by 7/27/18.
2. An equipment manual will be developed and located on each floor for review of safety features as needed by 8/28/18.
3. Nursing staff will be educated on the new policy during Competency Day, by 8/3/18 and annually thereafter.
B. Suction machine # pump air filter has not ever been checked or replaced.
Measures put in place to address this deficiency:
1. The Suction machine will be maintenanced/repaired by 8/20/18.
2. Biomed Technician will inspect on an annual basis per the owner?s manual.
3. Nursing staff will be educated on the procedure for reporting equipment that needs maintenance/repair during Competency Day, by 8/3/18, and annually thereafter utilizing the equipment manual located on each floor as a resource and guide.
Responsible Party: Director of Nursing and Mercy Educator

EP TESTING REQUIREMENTS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan was not revised as needed after analyzing the response after an actual emergency event. This is evidenced as follows. The after-action report (analysis) of the snow emergency on (MONTH) 14, (YEAR) and the Emergency Plan were reviewed on 06/26/2018. This review revealed that the analysis of the snow emergency warranted a revision to the Snow Emergency portion of the Emergency Plan that included a determination of which employees are essential on site and revision of the overall Emergency Plan that determines which staff could work at home. The Administrator and Emergency Preparedness Coordinator stated in an interview conducted on 06/26/2018 at 12:45 PM, that the Emergency Plan has not yet been updated to reflect necessary modifications determined after in the snow emergency of (MONTH) 14, (YEAR). 42 CFR: 483.73(d)(2)(iii)

Plan of Correction: ApprovedJuly 25, 2018

E 039 The Facility shall comply with developing emergency preparedness plans, and will analyze the Facility?s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the emergency plan, as needed. Specifically, the Emergency Plan was not revised as needed after analyzing the response after an actual emergency event.
Measures put in place to address this deficiency:
1. The Blizzard and Ice Storm Plan was amended to include language based on weather conditions that force road closures or that make it unsafe for staff to drive to work or drive home by 7/12/18.
2. The revised plan will be reviewed and approved by the Environment of Care Committee meeting on 08/08/18.
Responsible Party: Emergency Preparedness Coordinator

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the staff were not familiar with the basic response to fire. NFPA 101 Life Safety Code 2012 edition section 19.7.2.3 states that employees shall be trained in the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire). Specifically, 4 of 8 employees interviewed were not familiar with the code phrase for fire. This is evidenced as follows. Clinical Nutrition Manager stated she would announce fire upon discovery of fire when interviewed on 06/24/2018 at 12:35 PM. Occupational Therapist #1 stated she would announce fire upon discovery of fire when interviewed on 06/24/2018 at 12:40 PM. Environmental Services Technician #1 stated he would announce fire upon discovery of fire when interviewed on 06/24/2018 at 12:50 PM. Certified Nursing Assistant #1 did not know the code phrase for fire when interviewed on 06/24/2018 at 12:55 PM. The facility emergency fire procedure was reviewed on 06/24/2018. The policy requires that employees are to announce, Code Red and the location upon discovering a fire situation. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.2.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7.2.3

Plan of Correction: ApprovedJuly 25, 2018

K712 The facility shall comply with NFPA 101 section 19.7.2.3 which states that employees shall be trained in the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire). Specifically, employees interviewed were not familiar with the code phrase for fire.
Measures put in place to address this deficiency:
1. All staff will be trained on Fire response procedures by 8/27/18.
2. A monthly audit of 10 employees will be conducted for 3 months and retraining of individuals will be conducted if necessary.
3. The results of the audit will be shared with the Safety Committee on 8/27/18.
4. New employees will continue to receive fire response training as part of New Hire Orientation and annually thereafter through Health Streams and in Departmental meetings.
Responsible Party: Manager of Plant Operations and Mercy Educator

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - INFORMATION AN

REGULATION: Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on observation and staff interview during the recertification survey the facility did not maintain the piped medical gas system in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 5.1.11 requires that piping serving medical gas systems have every twenty (20) feet green labels with white lettering. Specifically, the piping serving the medical oxygen system was not labeled. Observations on 06/25/2018 at 11:30 AM, revealed that the piping serving the medical oxygen system on and about resident rooms 202, 203, 215, and 216 did not have required labeling. The Manager of Plant Operations stated in an interview conducted on 06/25/2018 at 11:30 AM, that he checked the same oxygen system piping as the survey observations and also could not see labeling on the piping. 42 CFR 483.70 (a) (1); 2012 NFPA 99 5.1.11; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-4

Plan of Correction: ApprovedJuly 25, 2018

K 909 The Facility shall comply with NFPA 99 section 5.1.11 requiring that piping serving medical gas systems have every twenty (20) feet green labels with white lettering. Specifically, the piping serving the medical oxygen system was not labeled.
Measures put in place to correct this deficiency:
1. Labels will be applied to Oxygen piping per the standards in the McAuley wing. This will be completed by 8/27/18.
2. An audit of the wing will be conducted after the completion of labeling by the Manager of Plant Operations.
3. The results of the audit will be reviewed by the Safety Committee on 8/27/18.
Responsible Party: Manager of Plant Operations

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - MAINTENANCE PR

REGULATION: Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not maintain the piped medical gas system in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 5.2.14 requires that facilities have a routine maintenance program for piped medical gas systems and waste anesthetic gas disposal (WAGD) systems. Specifically, the facility did not have maintenance programs for their piped medical oxygen system and WAGD system. This is evidenced as follows. When requested on 06/27/2018, documentation of a routine maintenance program for piped medical oxygen system and a WAGD system was not available for survey review. The Manager of Plant Operations stated in an interview conducted on 06/27/2018 at 12:15 PM, that the piped medical oxygen system was not maintained via a documented maintenance program and that the (parent) hospital WAGD was inspected but was not certain of the facility WAGD. 42 CFR 483.70 (a) (1); 2012 NFPA 99 5.2.14; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-4.4

Plan of Correction: ApprovedJuly 26, 2018

K 907 The facility shall comply with NFPA 99 section 5.2.14 requiring that facilities have a routine maintenance program for piped medical gas systems and waste anesthetic gas disposal (WADG) systems. Specifically, the facility did not have maintenance programs for their piped medical oxygen system and WAGD system.
Measures put in place to correct this deficiency:
1. A medical gas system routine maintenance program will be completed for piped medical gas systems and waste anesthetic gas disposal systems by 8/27/18.
2. Medical gas inspections will be completed by 7/19/18.
3. Work orders will be generated in the work order system for inspections needed per the medical gas program as registered.
4. The results of the certification testing will be reviewed by the Safety Committee on 8/27/18.
Responsible Party: Manager of Plant Operations

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include sharing emergency preparedness policies and procedures with residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 06/27/2018, revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with family members and resident representatives. The Administrator and the Emergency Preparedness Coordinator stated in an interview conducted on 06/62/2018 at 12:45 PM, that the Emergency Plan has not yet, but will be communicated to residents' families or their representatives. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedJuly 25, 2018

E 035 The Facility shall comply with developing emergency preparedness communication plan for sharing information from the emergency plan that the facility has determined is appropriate, with residents and their families or representatives. Specifically, the Emergency Plan, communication plan did not include sharing emergency preparedness policies and procedures with residents and their families or representatives.
Measures put in place to address this deficiency:
1. A flier of emergency preparedness information will be developed to share with residents and their families/representatives by 8/1/18.
2. The flier will be shared with the Management Team on 8/2/18.
3. The flier will be shared at Family Council meeting on 8/3/18.
4. The flier will be mailed to all families/representatives/advocates by 8/10/18.
5. The flier will be added to the Resident/Patient Welcome packet which is presented to all new admissions to the facility by 8/10/18.
6. Emergency preparedness information will be shared with the residents at Resident Council meeting on 8/22/18.
Responsible Party: AVP Long Term Care

POLICIES/PROCEDURES FOR SHELTERING IN PLACE

REGULATION: (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on observation, interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, did not include a policy and procedure for shelter in place staff and volunteers. This is evidenced as follows. A review of the Emergency Plan on 06/26/2018, did not include a policy and procedure to shelter in place staff and volunteers. The Administrator and Emergency Preparedness Coordinator stated in an interview conducted on 06/26/2018 at 12:45 PM, that the Emergency Plan will be revised to include a policy to shelter in place staff and volunteers. 42 CFR: 483.73(b)(4)

Plan of Correction: ApprovedJuly 25, 2018

E 022 The Facility shall comply with developing emergency preparedness policies and procedures, based on the emergency plan and communication plan. The Emergency Plan policies and procedures will address a means to shelter in place for patients, staff, and volunteers who remain in the facility. Specifically, the Emergency Plan, did not include a policy and procedure for shelter in place staff and volunteers.
Measures put in place to address this deficiency:
1. The Shelter in Place Plan will be amended to include language about the provision of beds/bedding and meals for any employee or volunteer required to shelter-in-place by 8/6/18.
2. The revised plan will be reviewed and approved by the Environment of Care Committee meeting on 08/08/18.
3. The policy will be reviewed annually
4. All staff will be educated on the revised policy by 8/27/18 and will receive annual training thereafter.
Responsible Party: Emergency Preparedness Coordinator and Mercy Educator

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include provisions for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 06/27/2018, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator and the Emergency Preparedness Coordinator stated in an interview conducted on 06/26/2018 at 12:45 PM, that the Emergency Plan does not currently have, but will be revised to include provisions for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedJuly 25, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E 026 The Facility shall comply with developing emergency preparedness policies and procedures, based on the emergency plan and communication plan. The Emergency Plan policies and procedures will address the 1135 Waiver Request, in the provision of care at an alternative care site. Specifically, the Emergency Plan did not include a Section 1135 Waiver Plan that included provisions for the care and treatment of [REDACTED].
Measures put in place to address this deficiency:
1. The Requesting a Section 1135 Waiver Plan will be amended to include language about the need to evacuate part or all of the facility to an alternate (non-healthcare) care site by 8/6/18.
2. The revised plan will be reviewed and approved by the Environment of Care Committee meeting on 08/08/18.
3. The policy will be reviewed annually.
4. All staff will be educated on the revised policy by 8/27/18 and will receive annual training thereafter.
Responsible Party: Emergency Preparedness Coordinator and Mercy Educator

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: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on staff interview and review of inspection records during the recertification survey, 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 5.3.2 requires gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Section 4.3 requires that records shall be made for all inspections, tests, or maintenance; the organization that performed the work; the results; and the date. Specifically, no records were maintained documenting that the sprinkler system gauges were replaced or checked for calibration in the past 5 years. This is evidenced as follows. The sprinkler system inspection records were reviewed on 06/27/2018. No records were available documenting that the sprinkler system gauges were replaced or checked for calibration during this 5-year period. The Manager of Plant Operations stated in an interview conducted on 06/27/2018 at 10:20 AM, that the sprinkler system gauges have not been checked or replaced within the past 5 years. 2012 NFPA 101 9.7.5; 2011 NFPA 25 4.3, 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6; 1998 NFPA 25 1-8, 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedJuly 25, 2018

K 353 The facility shall comply with NFPA 25, section 5.3.2 requiring gauges to be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge and section 4.3 requiring records be made for all inspections, tests, or maintenance: the organization that performed the work; the results; and the date. Specifically, no records were maintained documenting that the sprinkler system gauges were replaced or checked for calibration in the past 5 years.
Measures put in place to correct this deficiency:
1. The gauges were replaced 7/10/18 by the Fire Tech Sprinkler Company.
2. An internal inspection of the pipes was completed by Fire Tech Sprinkler on 7/10/18.
3. The results of the inspections will be reviewed by the Safety Committee on 8/27/18.
4. A preventive maintenance task will be created for the both the gauge replacement and the internal inspection of the sprinkler piping on a 5 year basis per NFPA 101 Standards. Kept in Preventive Maintenance Program by 8/27/18.
Responsible Party: Manager of Plant Operations

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not address the provision of subsistence needs; such as food, water, medical, and pharmacological supplies, for staff and residents after an evacuation. This is evidenced as follows. A review of the Emergency Plan on 06/26/2018, revealed the policies and procedures did not include the provision of subsistence needs for staff and residents after an evacuation. The Administrator and Emergency Preparedness Coordinator stated in an interview conducted on 06/27/2018 at 12:45 PM, that the Emergency Plan will be revised to include provisions for the subsistence needs of residents in an evacuation. 42 CFR: 483.73(b)(1)

Plan of Correction: ApprovedJuly 25, 2018

E 015 The Facility shall comply with developing emergency preparedness policies and procedures, based on the emergency plan and communication plan. Specifically, the Emergency Plan, policies and procedures did not address the provision of subsistence needs; such as food, water, medical, and pharmacological supplies, for staff and residents after an evacuation.
Measures put in place to address this deficiency:
1. The Facility Evacuation Plan will be amended to include specific language about the provision of subsistence needs for staff and patients by 8/1/18.
2. The revised plan will be reviewed and approved by the Environment of Care Committee meeting on 08/08/18.
3. The policy will be reviewed annually.
4. All staff will be educated on the revised policy by 8/27/18 and will receive annual training thereafter.

Responsible Party: Emergency Preparedness Coordinator and Mercy Educator

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: September 6, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be continuous. Section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Section 8.3.5.6.3 restricts the installation of metal electrical boxes in fire-rated walls when the required fire resistance is reduced. Specifically, rated ceilings were not continuous and did not maintain a 1-hour fire resistance rating, and stairwells did not maintain the minimum fire-resistance rating. This is evidenced as follows. Observations on 06/25/2018 at 11:30 AM, revealed unsealed penetrations for piping and ventilation ducts in the rated ceiling between the 1st and 2nd floors located in the McAuley Unit mechanical room; and in the center stairwell, an 8-foot by 8-inch unprotected metal support beam and a 9-inch by 14-inch unprotected metal electrical box for the exit sign. The Manager of Plant Operations stated in an interview conducted on 06/25/2018 at 12:05 PM, that he will seal the holes found in the rated ceiling and fire-protect the metal beam and electrical box in the stairwell. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.3, 8.5, 8.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1, 8.2

Plan of Correction: ApprovedJuly 26, 2018

K311 The facility shall comply with NFPA 101 sections 8.6.1 and 8.5 requiring that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be continuous. Section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Section 8.3.5.6.3 restricts the installation of metal electrical boxes in fire-rated walls when the required fire resistance is reduced. Specifically, rated ceilings were not continuous and did not maintain a 1-hour fire resistance rating, and stairwells did not maintain the minimum fire-resistance rating.
Measures put in place to correct this deficiency:
1. The beam will be sealed with appropriate fire stopping materials. The exit sign will be removed, the area sealed, and a new sign installed. Both will be completed by 8/27/18.
2. The penetrations through the floor in the McAuley wing that were identified will be sealed with the appropriate fire stopping materials. This will be completed by 8/27/18
3. The area will be inspected by the Manager of Plant Operations after the work is completed to ensure that it meets code. An additional audit of all vertical openings will be conducted. These audits will be documented and will include unsealed penetrations and their corrections. This will be completed by 8/27/18.
Responsible Party: Manager of Plant Operations