Elderwood at Grand Island
November 2, 2018 Certification Survey

Standard Health Citations

FF11 483.70:ADMINISTRATION

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

Based on interview and record review conducted during an extended survey completed on 11/2/18, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not ensure that all employees were screened through the New York State Nurse Aide Registry prior to employment. The finding is: Refer to F 607 Develop/Implement Abuse/Neglect Policies - Scope/Severity = F 1. On 11/1/18, a record review of twenty personnel files of individuals hired during (YEAR), revealed sixteen employees were not screened through the New York State Nurse Aide Registry prior to their employment. The sixteen employees included four Housekeeping Aides, two Registered Nurses (RNs), three Licensed Practical Nurses (LPNs), one Physical Therapist, three Dietary Aides, one Cook, one Maintenance Assistant, and one certified nurse aide (CNA). Further record review on 11/1/18 revealed the sixteen employees identified had hire dates that ranged from 1/17/18 to 10/9/18, and eleven of sixteen employees were still actively employed at the facility. During an interview on 11/1/18 at 11:05 AM, the Human Resources Coordinator stated she did not screen employees through the New York State Nurse Aide Registry, other than CNAs. Additionally, on 11/1/18 at 1:55 PM, the Human Resources Coordinator stated she was hired during (MONTH) (YEAR), but at that time, her assistant was conducting Nurse Aide Registry verifications. The Human Resources Coordinator's assistant left employment during (MONTH) (YEAR), at which time, the Nurse Aide Registry verifications became one of her tasks. The Human Resources Coordinator stated she was trained by her assistant and by several corporate level Human Resources employees, but was not aware that all employees must be screened through the Nurse Aide Registry. She believed it was only a task to be done for CNAs. During an interview on 11/1/18 at 12:05 PM, the Administrator stated he was aware that the New York State Nurse Aide Registry must be checked for all employees and he thought it was being checked for all employees by the Human Resources Coordinator. Additionally, on 11/1/18 at 12:50 PM, the Administrator stated the sixteen employees identified without Nurse Aide Registry verification prior to employment had worked on all three shifts and had resident access on two of two resident units. During an interview on 11/2/18 at 10:30 AM, the Administrator further stated he should have been aware the checks were not being done for all employees, there were no audits or system checks and balances in place for the Nurse Aide Registry checks, and he was ultimately responsible for the completion of the Nurse Aide Registry checks prior to employment. Record review of the facility policy and procedure entitled, Reference Check, approved 9/28/18, revealed all potential hires are screened by contacting the New York State Nurse Aide Registry or other state registry to verify credentials and/or check for prior history of reported abuse. 415.26

Plan of Correction: ApprovedDecember 8, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. 16 employees identified had their Nurse Aide Registry Check completed. There were no findings or convictions of resident abuse identified. This was completed on 11/1/18.
2. All personnel files of current staff and staff terminated within the last 3 months were audited to assure Nurse Aide Registry Check was completed. No adverse findings were revealed.
3. Facility Administrator was educated on maintaining an audit schedule to monitor and ensure that all employees are screened through the Nurse Aide Registry for all staff. This was provided by the Regional Director of Operations.
4. Administrator will audit new hire files on a biweekly basis to ensure that the deficient practice does not reoccur for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The Regional Director of Operations will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/1/19.

FF11 483.12(b)(1)-(3):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95,

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

Based on interview and record review conducted during the extended survey completed on 11/2/18, the facility did not implement written policies and procedures for screening employees that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, sixteen (four Housekeeping Aides, two Registered Nurses (RNs), three Licensed Practical Nurses (LPNs), one Physical Therapist, three Dietary Aides, one Cook, one Maintenance Assistant, and one Certified Nurse Aide (CNA)) of twenty employees who were subject to the New York State (NYS) Nurse Aide Registry, had not been screened through the New York State Nurse Aide Registry prior to their employment. This resulted in substandard quality of care. The finding is: The facility policy and procedure entitled, Reference Check, approved 9/28/18, documented all potential hires are screened by contacting the New York State Nurse Aide Registry or other state registry to verify credentials and/or check for prior history of reported abuse. 1. On 11/1/18, a record review of twenty personnel files of individuals hired during (YEAR), revealed sixteen employees were not screened through the New York State Nurse Aide Registry prior to their employment. The sixteen employees included four Housekeeping Aides, two RNs, three LPNs, one Physical Therapist, three Dietary Aides, one Cook, one Maintenance Assistant, and one CNA. Further record review on 11/1/18 revealed the sixteen employees identified had hire dates that ranged from 1/17/18 through 10/9/18, and eleven of sixteen employees were still actively employed at the facility. During an interview on 11/1/18 at 11:05 AM, the Human Resources Coordinator stated she did not screen employees through the New York State Nurse Aide Registry, other than CNAs. Additionally, on 11/1/18 at 1:55 PM, the Human Resources Coordinator stated she was hired during (MONTH) (YEAR), but at that time, her assistant was conducting Nurse Aide Registry verifications. The Human Resources Coordinator's assistant left employment during (MONTH) (YEAR), at which time, the Nurse Aide Registry verifications became one of her tasks. The Human Resources Coordinator stated she was trained by her assistant and by several corporate level Human Resources employees, but was not aware that all employees must be screened through the Nurse Aide Registry. She believed it was only a task to be done for CNAs. Record review on 11/1/18, of a Human Resources document entitled Basic Hiring Worksheet, revealed the task Nurse Aide Registry Check * Completed for ALL new hires-print for file appeared in the Interview Process box. During an interview on 11/1/18 at 1:55 PM, the Human Resources Coordinator stated she uses the Basic Hiring Worksheet regularly and her practice was to put a dash through the Nurse Aide Registry line for all new hires except CNAs, because it was not applicable, and she didn't realize it said, All new hires. During an interview on 11/1/18 at 12:05 PM, the Administrator stated he was aware that the New York State Nurse Aide Registry must be checked for all employees and he thought it was being checked for all employees by the Human Resources Coordinator. Additionally, on 11/1/18 at 12:50 PM, the Administrator stated the sixteen employees identified without Nurse Aide Registry verification prior to employment had worked on all three shifts and had resident access on two of two resident units. During an interview on 11/2/18 at 10:30 AM, the Administrator further stated he should have been aware that the checks were not being done for all employees. There were no audits or system checks and balances in place for the Nurse Aide Registry checks, and he was ultimately responsible for the completion of the Nurse Aide Registry checks prior to employment. During an interview on 11/1/18 at 2:25 PM, the Administrator stated the facility performed an audit today (11/1/18) and found an additional twelve current employees who were not screened through the New York State Nurse Aide Registry prior to employment, not inclusive of individuals who are no longer employed at this facility. 415.4(b)

Plan of Correction: ApprovedDecember 8, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. 16 employees identified had their Nurse Aide Registry Check completed. There were no findings or convictions of resident abuse identified. This was completed on 11/1/18.
2. All personnel files of current staff and staff terminated within the last 3 months were audited to assure Nurse Aide Registry Check was completed. No adverse findings were revealed.
3. Facility HR Coordinator was educated on completing Nurse Aide Registry checks for all staff. This was completed by Director of Employee Relations and Compensation on 11/1/18. In the absence of Human Resources Coordinator, Elderwood Administrative Services will have a designee to execute the Nurse Aide Registry Checks.
4. Administrator will audit new hire files on a biweekly basis to ensure that the deficient practice does not reoccur for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/1/19.

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: November 2, 2018
Corrected date: January 1, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an extended survey completed on 11/2/18, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Two (Residents #43, 59) of four residents observed for accidents had issues involving the lack of effective interventions and revisions to the plan of care to prevent accidents (Residents #43). Additionally, providing a resident on aspiration precautions with the incorrect meal consistency (Resident #59). The findings are: 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (minimum data set-resident assessment tool) dated 9/7/18 revealed the resident had severe cognitive impairment, and was at high risk for falls. Review of the policy entitled Accident/ Incident Reporting and Review (Staff/ Visitors/ Residents) dated 6/20/18 revealed an accident/ incident report form is completed and forwarded to director of nursing services. The accident/ incident and plan of prevention is recorded on the care plan. Review of the care plan, identified as current by facility staff, revealed a focus area of safety the resident was at risk for falls related to dementia, orthostatic [MEDICAL CONDITION] (low blood pressure), double vision and history of falls. Interventions included to offer ambulation in the hall after supper as accepted (9/14/18), walker in reach at all times (9/14/18); give soft football or other item to hold at HS (bedtime) to decrease anxiety (9/10/18); low bed (9/10/18); reinforce safety every shift; has poor safety awareness (9/14/18); encourage out of room/ may lounge on couch for comfort as needed (9/10/18 and revised 10/24/18). There was no care plan intervention to prevent further falls on 10/2/18. Review of Kardex (used by staff to provide care) with a print date of 11/2/18 revealed the resident required limited assist of one person with a rolling walker for ambulation, was frequently incontinent of bladder. Review of the accident and incident reports dated 9/7/18 through 10/30/18 revealed the resident had seven falls. During this time frame four of the falls occurred within the resident's room. Three of the four reports documented predisposing factors that included incontinence. Review of a Nurse's Progress Note dated 10/2/18 revealed the resident was found on the floor by an unidentified CNA (certified nurse's aide). The resident stated he got dizzy and fell down. The CNA stated resident got himself up from floor to a seated position in a chair. Two abrasions were noted on the right scapula (shoulder blade), no bleeding was noted. The resident had no complaints of pain, active ROM (range of motion-movement of joints), resident cooperative, neuro checks (assessment to determine a person's neurological status after an injury) initiated and WNL (within normal limits). Further review of a facility accident and incident repot (A/I) dated 10/2/18 at 6:40 AM revealed the RN (Registered Nurse) was called to the unit by the floor nurse reporting that resident was on the floor and trying to get himself up. Resident was seated in chair when the RN arrived on the unit and the CNA was assisting with ADL's, an abrasion was seen on the resident's back. Immediate action taken included the assessment of ROM and was without complaints of pain. A skin assessment was completed and abrasions measured, vital signs were stable, neuro checks were initiated and WNL. The resident was cooperative and went to TV (television) room. During an interview on 11/02/18 at 10:20 AM, RN Unit Manager #1 stated the resident doesn't have good safety awareness and they have done a lot of interventions with him. For the 10/2 fall she couldn't remember what they changed for that fall; we normally do a care plan change after a fall and usually the supervisors are the ones that need to change something immediately to prevent further falls. The RN reviewed the A/I report dated 10/2/18 and reviewed nurse's notes and resident's care plan in the EMR (electronic medical record). RN #1 stated she didn't see anything in the nurse's notes or care plan that documented an intervention after this fall. The RN further stated it would be the supervisor on duty that would put a care plan change in place after a fall, the supervisor that was here on 10/2 is newer to us. During a telephone interview on 11/2/18 at 11:35 AM, RN #2 stated that she did not remember this resident, but in general when someone falls she does an assessment and notifies the doctor. The RN stated she makes sure the things were in place to prevent falls, that were on the care plan. If not, then she lets someone know. The RN also stated when she does an A/I the DON (Director of Nursing) looks it over to see if anything else can be put into place. The RN stated she doesn't know if she did a care plan intervention for this fall, and that she didn't see that there was anything else they could do to stop a fall. During an interview on 11/2/18 at 12:30 PM, the DON stated after a fall an RN assessment is completed. We expect some kind of change, for example medical work up, offering snacks, toileting, an activity box, it could be anything that's resident specific. The DON stated she would expect the supervisor to make that change to the care plan. 2. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with eating. Review of both the undated Comprehensive Care Plan (identified as current) and the Kardex with a print date of 11/2/18 revealed the resident was on aspiration precautions and required extensive assistance with one person physically assisting the resident to eat. Review of a Speech Therapy consult dated 6/18/18 revealed a recommendation for a pureed diet with nectar thick liquids. Review of the lunch menu for (MONTH) 29, (YEAR) for the regular and the pureed diets revealed ham, sweet potatoes and green bean casserole were being served. Observation of a lunch meal on 10/29/18 at 12:20 PM revealed the resident received 4 ounces (oz.) of pureed ham, 4 oz. of pureed sweet potatoes and 4 oz. of pureed green bean casserole. The pureed ham was not fully pureed and had approximately one eighth inch chunks of ham. At the time of the observation a family member returned the meal and asked for another meal with pureed ham. During an interview on 10/29/18 at 12:25 PM, a Food Service Worker (serving food at the servery) revealed the cook had pureed the ham for at least 10 minutes but it was difficult to puree it further. During an interview on 10/31/18 at 3:45 PM with the Registered Dietitian (RD) and Food Service Director, revealed education was being conducted to kitchen staff on preparing proper consistency. 415.12(h)(1)(2)

Plan of Correction: ApprovedNovember 30, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
Observation #1, Resident #43
1. IDT met and reviewed incident, careplan, and Kardex. Activities implemented a fidget box on 10/3/18 as per progress note dated 10/3/18. Careplan has been updated to reflect the change. This was completed on 11/2/18.
2. All resident fall incidents for the past 3 months have been reviewed for care plan changes. All fall incidents have careplan changes in place. This was completed by 11/15/18.
3. All supervisors have been re-educated by the nurse educator on implementing care plan changes at the time of an incident. Completed 11/22/18.
4. Unit Manager or designee will audit all residents falls per unit weekly to ensure all residents with falls have careplan changes to prevent recurrence. This will be done for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/01/19.

Observation #2, Resident #59
1. Not fully pureed ham was returned to kitchen. Kitchen staff pureed ham and returned it to family member with appropriate consistency.
2. On 10/29/18, Dietary Director inspected all pureed food items at the servery to ensure all other foods were pureed to correct consistency.
3. All dietary staff members were re-educated by the dietitian on correct preparation of pureed foods. This was completed by 10/31/18.
4. The dietician or designee will audit pureed food consistency at the point of preparation in the kitchen on a rotating weekly basis to cover all three meals. This will be done for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Director of Nursing will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/01/19.

FF11 483.60(c)(1)-(7):MENUS MEET RESIDENT NDS/PREP IN ADV/FOLLOWED

REGULATION: §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an extended survey completed on 11/2/18 the facility did not meet the nutritional needs of residents in accordance with established national guidelines. Specifically, the facility did not provide adequate meal portions to meet the nutritional needs of the residents on 10/31/18. Additionally, residents on a pureed diet did receive a vegetable as planned on 10/29/18. Resident's A and B are involved. The findings are: 1. Review of the undated policy entitled Menus and diet requirements revealed the following basic three-meal menu pattern used at this facility provides residents with approximately 1800-2000 calories and 90-100 grams of protein daily: Breakfast: - Juice - Cereal - 2 to 3 oz. ounces (oz.) protein (egg, sausage, or bacon) - Toast, waffle, pancake, or French toast - Milk and hot beverage Lunch and Dinner: - Protein 3 to 4 oz. serving - Starch (potato or substitute, ½ cup) - Vegetable, ½ cup - Dessert a. Review of the lunch menu for 10/29/18 for the regular and the pureed diets revealed ham, sweet potatoes and green bean casserole were being served. Observation of the Dinner (noon) meal on Unit 1,10/29/18 from 12:00 PM through 1:00 PM revealed ham, sweet potato and green bean casserole served to most residents. Resident A, on a puree diet, was observed to have two scoops of food items on his plate. One scoop of ham and one scoop of sweet potatoes. During an interview at the time of the observation, Resident A stated he usually had three scoops of food on his plate. The server at this time stated she didn't know if he should have three scoops, and they did not have any pureed green bean casserole on the steam table for service. During an interview on 10/29/18 at 12:22 PM, the Registered Dietitian (RD) stated they should have pureed green bean casserole. During an interview on 10/29/18 at 12:45 PM, the Food Service Director (FSD) stated they planned to call the kitchen and get pureed green bean casserole for the puree diets. A test tray completed at 1:05 PM revealed the residents on puree diets were provided pureed green beans and not green bean casserole as planned. Observation of a Dinner (noon) meal on Unit 2, 10/29/18 at 12:20 PM, revealed Resident B received 4 oz. pureed ham, 4 oz. pureed sweet potatoes and 4 oz. pureed green bean casserole. The pureed ham did not appear fully pureed and had approximately 1/8 (one eighth) inch chunks of ham. A family member returned the meal and asked for another with pureed ham meal. At 1:00 PM, the resident received a second plate as requested containing approximately one fourth cup pureed ham, 4 oz. sweet potato and there was no vegetable. b. Review of the Week 1 Fall/ Winter menu dated (YEAR) revealed the Dinner (noon) menu for 10/31/18 consisted of goulash and mixed vegetables, and the alternate was a crab cake and coleslaw. Review of the Production Counts Week 1 Wednesday -10/31/18 (Dinner meal) revealed the residents would receive 8 oz. of goulash and 4 oz. of mixed vegetables. The alternate meal was 1 crab cake and 4 oz. of coleslaw. During observation of the Dinner (noon meal) service on 10/31/18 from 12:00 PM through 1:00 PM on Unit 1 and Unit 2 the cook/ servers were observed using a grey #8/ 4 oz. scoop to portion out the goulash for regular diets, ground, and puree diets. Each resident received one 4 oz. scoop of goulash and one 4 oz. scoop of mixed vegetable. Residents who preferred the alternate meal received 1 crab cake and 4 oz. of coleslaw. During an interview on 10/31/18 at 1:00 PM, the cook/ server revealed she has been working at the facility for [AGE] years and has been serving 1 scoop of casserole (goulash) for some time. During an interview on 10/31/18 at 1:05 PM, the RD stated the resident should be getting 8 oz. portions of a casserole (goulash) to meet their nutritional needs. That would be two 4 oz. scoops. Review of the product description for the premade frozen crab cakes, provided by the Food Service Director, revealed each crab cake contains 7 grams (gm) of protein equaling 1 oz. total of protein per crab cake. During an interview on 11/1/18 at 10:00 AM, the RD stated the residents should be receiving 3 to 4 oz. of protein at both dinner and supper meal. They should be receiving more than just one crab cake at the meal. Review of the production counts for Week 1 Wednesday- 10/31/18 (supper meal) revealed the residents were scheduled to receive 2 oz. of chicken fingers, 4 oz. of peas, and 4 oz. of potato wedges. Interview with the Registered Dietitian (RD) and Food Service Director on 10/31/18 at 3:45 PM revealed education was being conducted to kitchen staff on preparing proper consistency and proper portion sizes. During an interview on 10/31/18 at 4:30 PM, the RD stated a 2-oz. portion wasn't enough. They went to the grocery store and bought more chicken fingers. The RD stated they would serve the resident 5 to 6 chicken finger portions. During observation of the Supper meal residents received 5 pieces of chicken fingers. Review of the Nutrition labels revealed brand A provided 80 calories and 5 gm of protein per piece equaling a total of 400 calories and 3.6 oz. of protein. Brand B provided 400 calories and 2.6 oz. protein per portion which is below the 3 to 4 oz. of protein planned for the resident's diet requirements. 415.14(c)(1-3)(d)(3)

Plan of Correction: ApprovedNovember 30, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Resident B, facility removed ham and replaced with properly pureed ham. Remaining observations were made aware to facility at end of meal.
2. Dietician checked that other items pureed during meal service were properly prepared. Dietician verified ounce size of all scoops and serving utensils in the kitchen.
3. All dietary staff were educated by the Dietitian on how to properly puree food items, puree food items must reflect what is on the menu, utensil ounce sizes and the amount shown on meal ticket is to be the amount served. This was completed on 10/31/18.
4. The dietician or designee will audit pureed food consistency at the point of preparation in the kitchen, proper serving size at point of service and proper availability of pureed food items on a rotating weekly basis to cover all three meals. This will be done for a period of 12 weeks.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Dietician will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/1/19.

Standard Life Safety Code Citations

K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 11/2/18, oxygen cylinders were not properly restrained. This affected one (Unit One) of two resident units. The finding is: 1. Observation in the Main Oxygen Storage Room, located at the entrance to Unit One, on 10/29/18 at 10:50 AM, revealed two C-sized oxygen cylinders were stored in a metal rack, with regulators hanging on the top of the rack. Continued observation revealed the bottoms of the two cylinders were approximately one inch above the base of the metal rack and approximately two inches above the floor, and the bottoms of the cylinders were able to swing from side to side. Further observation at this time revealed there were also 68 E sized oxygen cylinders, 8 D sized oxygen cylinders, and one H/K sized helium cylinder stored in this room. During an interview at the time of the observation, the Director of Maintenance stated the facility doesn't normally use C sized oxygen cylinders, but they occasionally come in with new residents, and a shorter storage rack was needed in order to store the smaller cylinders properly. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 2012: 19.3.2.4 2012 NFPA 99: 11.6.2, 11.6.2.3, 11.6.2.3(1), 11.6.2.3(11)

Plan of Correction: ApprovedNovember 29, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. C-sized oxygen take was removed from oxygen room and returned to DME immediately.
2. Oxygen room was inspected to ensure no other C-size tanks were improperly stored. There is only one oxygen room to inspect in the facility.
3. Maintenance Staff, LPN,and RN staff are to be educated on proper storage of tanks with in the oxygen room.
4. Maintenance Director will audit oxygen room [ROOM NUMBER] days a week for 12 weeks to ensure that the deficient practice does not occur.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/01/19.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 11/2/18, hazardous area doors would not self-close and latch into their door frames. This affected the Service Corridor and the Basement. The findings are: 1. Observation in the Service Corridor on 10/29/18 at 11:05 AM revealed the door to the Dietary Storage Room would not self-close and latch into its door frame. During an interview at the time of the observation, the Director of Maintenance stated this door needed a new latch. 2. Observation in the Basement on 10/29/18 at 11:45 AM revealed the door to the Building Materials Storage Room would not self-close and latch into its door frame. Further observation revealed this room was located within the Beauty Shop, and the corridor door to the Beauty Shop was not equipped with a self-closing mechanism. During an interview at the time of the observation, the Director of Maintenance stated the bottom of the door was catching on the door frame, which prevented it from self-closing and latching. 3. Observation in the Basement, on 10/29/18 at 12:15 PM, revealed the door to the Folding Room would not self-close and latch into its door frame, and the room measured approximately 26 feet wide by 20 feet long and contained multiple racks of clean linen and briefs. Interview with the Administrator, at the time of the observation, revealed the linen and briefs in this room are not stored here, but are consistently delivered to the resident units. A second observation of the Folding Room on 11/2/18 at 9:55 AM revealed it contained eight wheeled racks of clean linen, four shelving units of disposable briefs and pillows, and two additional wheeled racks of disposable briefs. During an interview on 11/2/18 at 3:00 PM, the Director of Maintenance stated facility door audits are performed regularly and were last done on 7/31/18, and the doors in the Basement are affected by changes in temperature and humidity. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2, 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5

Plan of Correction: ApprovedNovember 29, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Dietary Storage Room, Materials Storage Room and Folding Room doors were repaired so that they are able to latch when closed with self closing mechanism where applicable.
2. All doors with self closing mechanisms were checked to ensure that latch to the door frame.
3. Maintenance staff was educated on ensuring that doors with self closing mechanisms latch to door frame.
4. Maintenance Director will audit all doors with self closing mechanisms weekly for 12 weeks to ensure that the deficient practice does not occur.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Maintenance Director will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/01/19.

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: Widespread
Severity: Potential to cause minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 11/2/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not include a policy and procedure for sheltering in place during an emergency. The finding is: 1. Record review of the facility's Emergency Preparedness Plan, updated 10/29/18, revealed a policy and procedure for sheltering in place during an emergency was not included, with the exception of food supplies, which was addressed in the document called Emergency Menu Plan. Further review of the Emergency Preparedness Plan revealed it contained a 23-page document called, Shelter In Place: Planning Resource Guide for Nursing Homes, and was published by the American Health Care Association and National Center for Assisted Living. Additional review of this document revealed it stated, The enclosed documents should be considered as examples, references and comparisons to what a facility has already built into their existing Emergency Management Program, and contained a planning worksheet, a list of essential functions chart, and various questions that were blank. During an interview on 11/2/18 at 12:54 PM, the Administrator stated the company is actively working on creating a new document. Additionally, the Administrator stated he found the shelter in place resource guide online and it has not been personalized to this facility. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(a)(3)

Plan of Correction: ApprovedNovember 29, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Shelter in Place policy and procedure specific to the facility will be created and reviewed by facility safety committee for approval. Upon approval Emergency Preparedness Plan will be update with these changes. This will be completed by 12/31/18.
2. Emergency Preparedness Plan was reviewed to determine if any other policies and procedures were not complete.
3. Administrator was educated to ensure Shelter in Place Policy and Procedure is in place specific to the facility. This was completed on 11/9/18.

4. Administrator will audit Emergency Preparedness Plan annually to ensure Shelter in Place Policy and Procedures are current to the facility.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/01/19.

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 minimal harm
Citation date: November 2, 2018
Corrected date: January 1, 2019

Citation Details

Based on observation, interview, and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 11/2/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Preparedness Plan did not address the provision of subsistence needs including water, pharmaceutical supplies, and alternate sources of energy. The findings are: 1. Observation in the Basement General Storage Room on 10/29/18 at 11:55 AM revealed 27 one-gallon jugs of water were in storage. Further observation revealed the manufacturer's stamp on the jugs said, use by 11/21/18. During an interview at the time of the observation, the Administrator stated this was the facility's emergency water supply. Record review of the facility's Emergency Preparedness Plan, updated 10/29/18, revealed a document called, Disruption of Water Supply/Sewage System contained a mathematical equation to compute the number of gallons that the facility should maintain on-site and the result for a 90-bed facility was 35 gallons of water. During an interview on 11/2/18 at 1:02 PM, the Administrator stated he was not aware of the mathematical equation, but he would expect the facility to maintain at least 35 gallons of water on-site and he had not considered that during an emergency, staff and visitors would increase the amount of water needed. At this same time, the Director of Maintenance stated the facility has three water holding tanks in the Basement and the water they contain is potable (safe to drink). Additionally, the Administrator stated the use of the water in the holding tanks was not included in the facility's Emergency Preparedness Plan. 2. Record review of the facility's Emergency Preparedness Plan revealed instruction about how to obtain and maintain pharmaceutical supplies during an emergency was not addressed. During an interview on 11/2/18 at 3:56 PM, the Director of Nursing stated the facility maintains an inventory of pharmaceuticals on-site, including a box for intravenous medications, locked medicine boxes on each unit, and one narcotics box. The Director of Nursing also stated this inventory would not cover each medication during an emergency, and the facility uses their own pharmacy on a regular basis, and in an emergency, the facility also has a contract with a local pharmacy. At this time, the Administrator stated to his knowledge, this information was not included in the written Emergency Preparedness Plan. 3. Record review of the facility's Emergency Preparedness Plan revealed a document called, Loss of Heat stated the facility's heating system was connected to the emergency generator, but no other details about the generator's coverage were addressed. During an interview on 11/2/18 at 1:11 PM, the Director of Maintenance stated the facility's generator provides emergency power to all of the red outlets in the building. At the same time, the Administrator stated the facility's generator covers refrigeration, emergency lighting, and the fire alarm system, but it is not stated in the written Emergency Preparedness Plan. According to State Operations Manual Appendix Z, Emergency Preparedness for All Provider and Certified Supplier Types, dated 6/9/17, 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. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(1)(ii)

Plan of Correction: ApprovedNovember 29, 2018

This facility files this Plan of Correction in compliance with regulatory requirement. It is not intended and should not be construed as an admission that the facility has violated any of the regulatory standards addressed in the survey report some or all of which the facility may choose to contest.
1. Emergency Preparedness Plan was corrected. These corrections include removal of the mathematical equation that determined amount of water needed for emergency. Facility updated plan to conclude that 1 Gallon of water per person per day. Facility will maintain enough water supply for 3 days to accommodate estimated amount of residents, staff and visitors that may be present in the event of an emergency. This plan will also include location of water supply in the facility and contact information of vendor that provides water for emergencies. Pharmaceutical supply information was updated in the Emergency Preparedness Plan to include contact information and hours of primary and backup pharmacies, location of medications in the facility. Emergency Preparedness Plan was updated to include power generator's coverage in the facility.
2. Review of the Emergency Preparedness Plan to identify other areas where provision of subsistence needs to be specified.
3. Administrator, Maintenance Director, Director of Nursing and Inservice Coordinator was educated on the requirements of the Emergency Preparedness Plan to include provision of subsistence.
4. Administrator will Audit the Emergency Preparedness Plan annually to ensure the provisions of subsistence is in place.
All Results will be reported to the Quality Assurance Committee in which progress will be reviewed. Determinations for ongoing monitoring will be determined at that time.
5. The facility Administrator will be responsible to ensure the completion of the corrective action. The plan will be completed by 1/01/19.