Groton Community Health Care Center Residential Care Facility
January 31, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.80(a)(3):ANTIBIOTIC STEWARDSHIP PROGRAM

REGULATION: §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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the recertification survey, the facility did not establish an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program that promoted the appropriate use of antibiotics and included a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Specifically, the facility did not establish and implement an antibiotic stewardship program. Findings include: During review of facility Infection Control policies and procedures, there was no documented evidence the facility had an Antibiotic Stewardship Program which included development and implementation of protocols to optimize the treatment of [REDACTED]. During an interview with the Infection Control registered nurse (RN) #24 on 1/31/19 at 1:14 PM she stated she found a tracking sheet regarding active infections in the facility from 6/18-9/18 but there was no documentation since then. There was no tracking of antibiotic use and no infection control care plans for active infections. She stated, the previous infection control nurse and the previous director of nursing (DON) had reviewed the infection control plan in 9/2018 and wrote in a report that there would be an infection control policy, including antibiotic stewardship, in effect by 12/2018. She stated she has been unable to find any evidence that the policy was worked on since the review in 9/2018. During an interview on 1/31/19 at 2:43 PM, the DON stated there had been nothing done with infection surveillance or antibiotic stewardship. 10 NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedFebruary 22, 2019

Tag F881 - Antibiotic Stewardship Program
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Current resident on antibiotic will be reviewed and Infection Prevention and Control Program will include an Antibiotic Stewardship Program that also includes antibiotic use protocols and a system to monitor antibiotic use. Infection Preventionist Specialized Training (IPCO) Program certification has been completed by Infection Control Nurse.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Antibiotic Stewardship Committee will meet monthly for the first 3 months, then quarterly to review antibiotic use protocols and monitor use of antibiotic use.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
Antibiotic Stewardship Policy and Procedure were created based on the pharmacy guidelines. General staff education on antibiotic stewardship policy is complete.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The Infection Control Preventionist will audit 10% of active infections weekly for three (3) months and collate Antibiotic Stewardship data for general review at the monthly Quality Assurance Committee meeting to determine ongoing effectiveness and make adjustments as necessary.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Nursing, RN Educator/Infection Preventionist/Employee Health

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

Based on observation and interview during the recertification survey, the facility did not maintain store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the wall behind the hand wash sink was damaged; the sides of the deep fryer were unclean; and the main kitchen's three-bay sink sanitizer solution was under the minimum required quaternary ammonium sanitizer test range of 150 parts per million (ppm) to 400 ppm when tested . Findings included: 1. Food Area Damaged/Unclean During a kitchen observation on 1/27/2019 at 3:22 PM, the following was observed: - The wall behind the hand wash sink was damaged; and - Both sides of the deep fryer were unclean with debris on them. During an interview on 1/28/2019 at 3:42 PM, the Food Service Director stated: - He was not aware of the damaged wall behind the sink; - There were no work orders for the approximate 8-foot section of damaged wall; - The deep fryers were cleaned weekly; and - There was no policy on specifics of what staff cleaned, just a general policy for cleaning of the kitchen. During an observation on 01/28/19 at 3:43 PM, both sides of the deep fryer had residue on them. During an interview on 01/28/19 at 3:43 PM, dietary staff #11 stated he would clean the fryer when he did his weekly cleaning. 2. Three-Bay Sink Solution Under Minimum Concentration On 1/27/2019 at 3:45 PM the Food Service Director used a sanitizer strip and tested the sanitizing solution for the three-bay sink. As per the color scale that came with the strip, this test indicated the three-bay sink sanitizer solution was under the required quaternary ammonium sanitizer test range of 150 parts per million (ppm) to 400 ppm when tested . During an interview on 1/27/2019 at 3:45 PM, the Food Service Director stated the three-bay sink sanitizer solution was filled at approximately 2:00 PM. On 1/28/2019 at 12:26 PM the Food Service Director used a sanitizer strip and tested the sanitizing solution for the three-bay sink. As per the color scale that came with this strip, this test indicated the three-bay sink sanitizer solution was under the required quaternary ammonium sanitizer test range of 150 ppm when tested . The sanitizer sink was immediately refilled, retested and resulted in 200 ppm. During an interview on 1/28/2019 at 12:26 PM, dietary staff #9 stated she would usually check the sanitizing solution before using the three-bay sink and randomly during the course of day, but did not check when recently filling up the sink. There was no documented evidence sanitizer solution checks were made. On 1/31/2019 at 12:46 PM the Food Service Director used a sanitizer strip and tested the sanitizing solution for the three-bay sink. As per the color scale that came with this strip, this test indicated the three-bay sink sanitizer solution was under the required quaternary ammonium sanitizer test range of 150 ppm when tested . The sanitizer sink was immediately refilled, retested and resulted in less than 150 ppm. The sanitizer sink was immediately refilled, retested and resulted in 200 ppm. 10NYCRR 415.14(h)

Plan of Correction: ApprovedFebruary 22, 2019

Tag 812 - Food Procurement, Store/Prepare/Serve-Sanitary
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Work order was placed for the damaged wall behind the hand wash sink and temporary work was completed before end of survey. Maintenance has ordered appropriate building materials to finish wall/tile repair. The deep fryer was cleaned at time it was identified during the survey. The sanitizing dispenser vendor was contacted to evaluate the equipment. The vendor responded on the day of identification of issue during the survey. The new dispenser and tubing were installed by the vendor on 01/31/2019.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The maintenance department/food service coordinator will inspect the kitchen walls and complete the audit. The facility implemented policy on general kitchen cleaning and daily cleaning log audits. The general kitchen cleaning audit log will be completed daily and reviewed by the food service coordinator weekly. The sanitizer testing audit was enhanced to include step by step instructions for testing and corrective action to be taken in case of poor test results are obtained.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
Re-education for all dietary staff in spotting and recognizing damage walls. Re-education in filling out work orders for maintenance. The kitchen staff will also be re-educated on cleaning of the deep fryer. A new daily general kitchen cleaning audit log including fixed equipment and updated cleaning policy has been implemented. Also, re-education of sanitizer testing steps will also be completed.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. What quality assurance program will be put into practice?
The audit results of wall inspection will be reported to Quality Assurance Committee monthly. This will be monitored for the next six (6) months or until 100% threshold is met. After 100% threshold is obtained the audit will be done quarterly. The audit result of kitchen cleaning will be reported to the Quality Assurance committee. When a threshold of 100% are met, Quality Assurance Committee will determine if further interventions are needed. The test audit of the sanitizer log will be reported to Quality Assurance Committee Assurance Committee monthly. The Quality Assurance Committee will determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency: Date of completion: 03/29/2019 Responsible: Food Service Coordinator or designee

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey, the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 1 of 2 residents (Resident #2) reviewed for ROM. Specifically, Resident #2 was care planned for a device for a hand contracture (shortening of muscle, tendons or tissue producing deformity) and was observed throughout survey without the device in her hand. Findings include: Resident #2 was admitted to the facility 10/1/15 and had [DIAGNOSES REDACTED]. The 10/18/18 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, exhibited verbal behaviors 1 to 3 days during the assessment period, did not reject care, required extensive assistance of two staff for dressing and hygiene and had functional limitation in ROM on one side of both upper and lower extremities. An undated Kardex report (CNA instructions) documented dressing and splint care included washing and drying the left hand daily and placing a washcloth in the left hand during the day and removing at night. The resident may require verbal cues to keep the washcloth in her hand. Occupational therapy (OT) treatment notes documented: - On 1/8/19, staff were educated and instructed to let nursing or therapy know if the washcloth roll was not in the resident's left hand. - On 1/9/19, nursing caregivers were instructed on orthotic (an artificial support or brace) schedule, specifically making sure the washcloth roll was placed in the resident's hand daily. - On 1/16/19, caregiver training included washcloth management. - On 1/18/19, caregivers were educated and instructed on the importance of allowing the resident extra time and maneuvering her left hand/fingers gently when applying the washcloth roll. - On 1/22/19, day nurses were educated on washing the resident's left hand daily and applying the washcloth in her hand to prevent further contractures. The comprehensive care plan (CCP) revised 1/19/19 documented the resident had activities of living (ADL) self-care deficits related [MEDICAL CONDITION] left [MEDICAL CONDITION]. Approaches included contracture care of the left hand, provide skin care daily to keep clean and provide a washcloth. The OT discharge summary dated 1/22/19 documented recommendations including to continue to have the left hand washed and dried thoroughly before applying the washcloth roll and frequent checks to ensure the washcloth was well positioned. The resident was observed with no washcloth in her left hand, with her fingers folded down towards her palm on 1/27/19 at 5:09 PM, 1/27/19 from 5:45 PM to 6:39 PM, 1/28/19 at 9:30 AM, 1/29/19 at 9:08 AM, 1/30/19 at 8:14 AM, and 1/31/19 at 10:15 AM and 12:32 PM. During an interview on 1/31/19 at 9:50 AM, The Director of Rehabilitation Therapy stated the resident was seen in OT recently for contracture management of the left hand. Therapy recommendations included daily cleaning and a rolled washcloth in the resident's left hand during the day, and remove at night. After the resident was discharged from OT, the washcloth roll was being used daily to help with the hand contracture and it was added to the care plan on 1/19/19. CNA #1 was interviewed on 1/31/19 at 10:31 AM and stated she regularly provided care for the resident, referred to her care plan or Kardex for instructions, and there were no instructions for any devices or contracture in the care plan. She stated the nurses washed her hand and CNAs did not do anything with the resident's left hand. Care plan updates and changes were communicated verbally during shift report and she was not aware of any updates to the resident's care plan regarding the left hand contracture care. Registered nurse (RN) #2 stated during a telephone interview on 1/31/19 at 12:11 PM, the resident had a left-hand contracture, nursing staff provided the care including the washcloth. The Director of Nursing (DON) was interviewed on 1/31/19 at 1:37 PM and stated the instruction for the washcloth roll was on the Kardex and CCP. CNAs should be checking and following the Kardex daily, and the CNAs should have been applying the washcloth. If the resident refused, she expected staff to notify a nurse and would expect therapy to be notified. 10 NYCRR 415.12(e)(2)

Plan of Correction: ApprovedMarch 1, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag F688 - Increase/Prevent Decrease in ROM/Mobility
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
A chart review was completed for Resident #2 with the care plan and Kardex reviewed for accuracy. Resident #2 has a physician order [REDACTED].
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents who are identified by the therapy department to be at risk for decline in ROM/mobility will have a physician order [REDACTED]. The care plan and Kardex will then be updated.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
The adaptive equipment use policy was enhanced with specific instructions for the nursing staff to follow. A new splinting/contracture management policy was initiated to prevent further decline in mobility. Nursing staff will be re-educated on policies. All use of adaptive equipment, splinting, or contracture management will require a physician order. After the physician order [REDACTED]. The care plan and Kardex will then be updated.
All CNAs will be re-educated regarding checking the Kardex before providing care to residents.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
A monthly meeting with nursing and therapy will occur to review adaptive equipment, assistive devices, and/or contracture management. The MAR/TAR will be reviewed to ensure physician orders [REDACTED]. A weekly audit on adaptive equipment/contracture management/assistive device will be completed on residents on each unit for 3 months and then quarterly after audit threshold of 100% is attained and reported to the Quality Assurance Committee. The Quality Assurance Committee will determine if further intervention is needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Nursing or designee

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

Based on observations, 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. Specifically, 1 of 10 employees reviewed for influenza vaccination did not have proof of receiving or declining the (YEAR)-2019 influenza vaccination; and the facility policy did not include identification of those areas where unvaccinated personnel must wear a mask during the time when influenza is declared prevelant in New York State. Findings include: The facility policy, Influenza Vaccination for Staff, effective 8/2017, documented record of vaccine administration /refusal would be kept on file in the employee health record. The policy did not address the requirement of unvaccinated staff to wear a mask in areas they could come in contact with residents. The employee health records for 10 employees were reviewed for influenza vaccination status. There was no documentation registered nurse (RN) #15 had proof of influenza vaccination or declined the influenza vaccination. RN #15 was not present in the facility during the recertification survey. During the recertification survey from 1/27-1/31/19 no staff were observed wearing masks in resident care areas. During an interview on 1/31/19 at 1:23 PM, the Infection Control RN #24 stated she kept the records of staff vaccination status in a binder in her office. She stated she thought there were a few staff members that declined the vaccination and she thought they wore stickers. She stated the Human Resources (HR) Director would know more about the employee flu records and she did not have access to them. She was unaware of any revisions to the infection control policies. The HR Director was not available for interview during the recertification survey. During an interview on 1/31/19 at 2:43 PM, the DON stated she was not aware of a list of staff who were vaccinated or who had declined the flu vaccine. She stated her expectations were they were vaccinated and if not they would wear a mask during flu season. 10 NYCRR 415.19(a)(1)

Plan of Correction: ApprovedFebruary 22, 2019

Tag I210 - Infection Control
1) What corrective action(s) will be accomplished for those staff/residents found to have been affected by the deficient practice?
RN #15 gave proof of influenza vaccination on (MONTH) 18, 2019. RN #15 had flu vaccination administered by Kinney?s Pharmacy on (MONTH) 23, (YEAR).
2) How you will identify other staff/residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Current staff medical files have been reviewed to verify proof of influenza vaccination or declination. Staff education completed on Influenza Policy and Procedures. Staff Education also complete on requirements and monitoring of staff who sign a declination for the influenza vaccination.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
Policy and Procedure reviewed and enhanced to meet current NYSDOH standards. Staff has been educated on policy revisions.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The RN Educator/Infection Preventionist/Employee Health will audit new employee medical files weekly for 3 months or until 100% compliance is achieved and collate data for general review at the Quality Assurance Committee meeting and make adjustments as necessary.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Nursing, RN Educator/Infection Preventionist/Employee Health

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 1 of 1 residents (Resident #57) reviewed for pressure ulcers. Specifically, hand hygiene was not performed during a dressing change observation. Findings include: The facility policy Hand Hygiene effective 7/2012 documented nursing facility personnel shall wash their hands to prevent the spread of infection before donning and after removing gloves. Resident #57 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 1/22/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, had an unstageable (unable to see wound bed) pressure ulcer and received application of nonsurgical dressings. The 1/2019 treatment administration record (TAR) documented to cleanse right upper buttock wound with normal saline, pat dry, apply [MEDICATION NAME] (a wound care product) to wound bed, and cover with Allevyn (a wound dressing) two times a day. On 1/29/19 at 11:30 AM LPN #7 was observed performing a wound dressing change on Resident #57. During the treatment, LPN #7 removed her soiled gloves after removing the old dressing, then immediately donned another pair of gloves without performing hand hygiene. There was no visible hand sanitizing gel near the treatment supplies. After applying the new dressing, LPN #7 then went to the bathroom sink and performed hand hygiene. Before she obtained a paper towel to dry her hands, she wiped her right hand on her pant leg. She then donned a pair of gloves to remove the dirty supplies. When interviewed on 1/30/19 at 10:40 AM, LPN #7 stated she should have performed hand hygiene between glove changes. She stated she usually had alcohol based hand sanitizer gel when she did dressing changes, and was not aware she did not have it during the dressing change. She stated she was not aware of touching her pant leg after washing her hands, and she should have washed her hands again prior to donning gloves. During an interview on 1/31/19 at 1:23 PM the infection control nurse stated she expected staff to perform hand hygiene after removing and before replacing gloves when completing a dressing change. 10NYCRR (b) (2,4), (a) (1,3)

Plan of Correction: ApprovedFebruary 22, 2019

Tag F880 - Infection Prevention & Control
1)What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident #57 did not exhibit any signs or symptoms of an infection. New treatment orders for wound care received from the physician for Resident #57. Resident was also referred to the Wound Clinic.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Wound care with respect to infection control procedure education complete. RN Educator/Infection Preventionist/Employee Health will audit 10% of wound care treatments weekly for 3 months to assure compliance with completed staff education
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
Employee #7 had completed Infection Control Education with handwashing and PPE competencies on (MONTH) 21, 2019. Post survey, Employee #7 has been officially counseled and re-educated on Infection Control Policy and Procedures and education on wound care with respect to infection control procedure.
Infection Control Policy and Procedure reviewed and revised to meet national standards. General staff education on infection control policy is complete. Annual review of Infection Control Policy and Procedure will be completed yearly by the Interdisciplinary Team.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The RN Educator/Infection Preventionist/Employee Health will audit 10% of wound care treatments weekly for 3 months and collate wound care treatment data for general review at the monthly Quality Assurance Committee meeting to determine ongoing wound care management and make adjustments as necessary.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Nursing & RN Educator/Infection Preventionist/Employee Health

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the recertification survey, the facility did not ensure all allegations of abuse, neglect, or mistreatment were thoroughly investigated for 1 of 2 residents (Resident #25) reviewed for abuse. Specifically, Resident #25 sustained a leg fracture of unknown origin and a thorough investigation was not completed to rule out abuse, neglect, or mistreatment. Findings include: The facility's Accident/Incident Reports and Investigation policy effective 9/15/14 documented: - A thorough investigation is conducted to determine the possible cause of the accident/incident. - It is the policy to complete an accident/incident report promptly. - All incidents will be reviewed with the interdisciplinary team. - Nurse manager, supervisor, or charge nurse will initiate an investigation immediately of all accidents/incidents. - Investigations will include: resident statement, witness statements from employees who discovered injury and employees assigned to care for the resident 24 hours prior to identifying the area. Resident #25 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 6/11/18 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of 2 with transfers and was not on a scheduled pain medication regime and did not receive prn (as needed) pain medication and had no signs of pain. The 9/19/18 MDS documented the resident had severe cognitive impairment, was totally dependent on 2 staff for transfers, was not on a scheduled pain medication regime, received prn pain medication and had vocal complaints of pain 1-2 days during the assessment period. An undated Kardex report (CNA instructions) documented the resident transferred with stand-pivot with 2 assistance or a Hoyer (mechanical lift). A licensed practical nurse (LPN) progress note dated 7/20/18 at 2:40 AM documented the resident reported she banged her knee on the bed during a transfer and no redness or swelling was noted. The resident also told one (unidentified in progress note) certified nurse aide (CNA) she bumped it and told the other (unidentified in progress note) CNA she had fallen on it. The note was entered by a licensed practical nurse (LPN) who was no longer employed by the facility at the time of survey. A nursing progress note entered by LPN #3 dated 7/20/18 at 10:28 AM documented the resident continued to complain of pain and was administered [MEDICATION NAME] at 8:20 AM and she would continue to be monitored. The 24-hour nursing report dated 7/19/18 to 7/20/18 documented the resident reported she banged her knee on the bed during a transfer and had told one CNA she bumped it and told another CNA she had fallen. The resident was given [MEDICATION NAME] for pain. A nursing progress note entered by registered nurse (RN) #2 dated 7/20/18 at 9:48 PM documented the resident stated she twisted her knee during a transfer, her right knee was swollen, and an ice pack was applied. The 24-hour nursing report dated 7/20/18-7/21/18 documented the resident stated she twisted her knee during a transfer and her right knee was swollen and an ice pack was applied. On 7/21/2018-7/22/18 documented the resident displayed signs and symptoms of pain every shift and her knee was painful with movement. There was no documentation on the 7/23/18-7/24/18 report regarding the resident's right knee. There was no documented evidence an investigation was initiated to determine the cause of the resident's right knee injury. There were no nursing progress notes addressing the resident's right leg, including X-ray orders and results of X-rays from 7/21-7/25/18. The physician order [REDACTED]. There were no documented results of the X-ray or physician progress notes [REDACTED]. Nursing progress notes dated 7/25/18 and 7/31/18 documented pain treatment for [REDACTED]. There was no further documentation regarding the resident's knee injury from 8/1/18 through 8/31/18. The physical therapy (PT) evaluation and plan of treatment dated 7/27/18 documented the resident had a bad transfer per nursing; the X-ray showed a fracture, the resident was not a candidate for surgery, PT was not indicated, and a knee immobolizer was recommended for protection and healing. The orthopedic surgeon consultation form dated 8/29/18 documented right knee pain from injury approximately one month prior. The resident was diagnosed with [REDACTED]. During an interview with the resident on 1/28/19 at 9:30 AM, she stated she had knee pain and she fell a while ago. When interviewed on 1/30/19 at 12:25 PM, LPN #3 stated she recalled the resident's knee was injured and she was not working the day it was thought to have happened during a transfer. Any injuries of unknown origin should be investigated. LPNs were able to initiate investigations and a nursing supervisor would complete it. When interviewed on 1/30/19 12:46 PM, CNA #4 stated she regularly provided care to the resident. She thought the resident's knee was injured during a transfer in the shower sometime in the summer. She was not with the resident when it happened and was not asked to provide a statement for an investigation. When interviewed on 1/30/19 at 1:20 PM, CNA #5 stated she regularly provided care to the resident. She recalled seeing the resident's knee after the injury in 7/2018. The knee was red and swollen. She was not with the resident when the injury occurred and did not know when it happened. The resident had previously transferred with stand and pivot, and the CNA had to use the Hoyer lift due to the resident's knee pain. She was not asked to provide any statements for an incident report and stated she heard from other staff the injury occurred during a transfer. During a telephone interview on 1/31/19 at 12:11 PM, RN #2 stated she recalled the resident's knee pain and heard it was injured on the day shift during a transfer. She had written a progress note on 7/20/18 documenting the resident had told her she twisted her knee during a transfer. She did not initiate an investigation and did not have a role in completing one. She stated the nurse who first learned of the injury should have initiated an investigation if it was unclear how the resident was injured. During an interview with the Director of Nursing on 1/31/19 at 1:37 PM, she stated she was unable to locate an incident report or investigation for the resident's knee fracture. She stated she was unable to address the reason the former DON did not investigate the incident. She stated any injury of unknown origin should be investigated to rule out abuse or neglect. She reviewed the 7/20/18 nursing progress notes and stated based on the documentation, it was unclear how the resident sustained [REDACTED]. 10 NYCRR 415.4(b)(3)

Plan of Correction: ApprovedMarch 1, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag F610 - Investigate/Prevent/Correct Alleged Violation
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
A chart review was completed for Resident #25 with the care plan and Kardex reviewed for accuracy. Resident #25 has a healed bicondylar [MEDICAL CONDITION] tibia and is on physical therapy at current time. Resident #25 now has scheduled pain medication for complaints of right knee pain.
An investigation was completed to determine the probable cause of Resident #25 fracture. During the investigation the staff reported that resident #25 stated that She (Resident #25) banged her knee on the bed during a transfer. Resident #25 also reported it to staff that She (Resident #25) bumped it . She (Resident #25) had fallen on it. Resident #25 requires extensive assistance of two for stand pivot transfers. It is also reported that Resident #25 twists her right leg during transfer which can potentially cause injury. The Resident #25 care plan to be updated to sit to stand lift with assistance of two for safety to prevent twisting of the right leg.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All Accident/Incident (A/I) reports are initiated by the charge nurse/nurse manager/nurse supervisor. These A/I reports are kept in binders on the unit and collected by the Director of Nursing. Once reviewed for accuracy or for any resident injury, the A/I report is taken to morning meeting and discussed with the inter-disciplinary team (IDT) team. A thorough investigation is then completed by the Director of Nursing. Once the investigation is completed an IDT note is written in the resident?s chart. Any follow- up recommendations are reported to the IDT team for completeness. Referrals requested or physician services needed are reported to the medical providers and physician orders [REDACTED]. The resident?s care plan and Kardex are then updated with any changes that are made.
The facility will implement a daily audit to track resident injuries from PointClickCare 24-hour report to ensure an investigation is initiated.
The facility will also implement a weekly audit to determine if Accident/Incident (A/I) are completed when there are resident injuries.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
The Accident/Incident Reports Investigation policy was enhanced. Nursing staff to be educated on A/I reports including the different types of A/I that could occur and what types of A/I that must be reported to the Director of Nursing immediately. The IDT team now discuss A/I reports during morning meeting. A thorough investigation of all A/I reports are completed by the Director of Nursing nursing including documentation for the incident, and witness statements. The A/I report will be reported to the Department of Health (DOH) if it meets their criteria. The Director of Nursing or designee will report the A/I report to the DOH if necessary.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
All Accident/Incident reports will be logged and filed in a binder by month of occurrence. A/I reports including results of daily audit to track resident injuries from PointClickCare 24-hour report to ensure an investigation is initiated and the weekly audit to determine if Accident/Incident (A/I) are completed when there are resident injuries will be reported to the Quality Assurance Committee at least on a quarterly basis for three (3) months or until 100% threshold is achieved. The Quality Assurance Committee will determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Nursing or designee

FF11 483.65(a)(1)(2):PROVIDE/OBTAIN SPECIALIZED REHAB SERVICES

REGULATION: §483.65 Specialized rehabilitative services. §483.65(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident's comprehensive plan of care, the facility must- §483.65(a)(1) Provide the required services; or §483.65(a)(2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: April 11, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the recertification survey, the facility did not ensure each resident received specialized rehabilitative services to assist them to attain, maintain , or restore their highest practicable level of physical and functional well being for 1 of 2 residents (Resident #25) reviewed for range of motion (ROM). Specifically, Resident #25 had orders from her orthopedic specialist to resume physical therapy and a referral was not submitted for the resident to receive services. Findings include: Resident #25 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 6/11/18 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive assistance of 2 with transfers. The 12/4/18 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment was totally dependent with assistance of 2 for transfers and had lower body impairment on one side. The resident had no occupational or physical therapy (OT/PT) recorded. The physician order [REDACTED]. The orthopedic surgeon consult form dated 1/7/19 documented the resident was seen for follow up for a displaced [MEDICAL CONDITION] condyle of right side tibia (leg bone) and closed [MEDICAL CONDITION] end of tibia. The orthopedic surgeon documented to start PT with no restrictions. The resident's attending physician and licensed practical nurse (LPN) #7 signed the form. Nursing progress notes from 1/7/19-1/31/19 had no documentation regarding the resident's orthopedic appointment, instructions following her return, or of a referral to PT. The comprehensive care plan (CCP) updated 1/20/19 documented the resident had ADL self-care performance deficits related to fatigue and impaired balance. Interventions included transfers with stand-pivot with assistance of 2 staff, a Hoyer (mechanical lift) could be used, and PT/OT evaluation and treatment as per physician orders. The physician's progress note dated 1/22/19 did not contain any documentation regarding the resident's knee or orthopedic recommendations for PT. On 1/27/19 at 3:41 PM, the resident was in bed, her right leg was elevated on a pillow and she complained of leg pain and weakness. At 6:03 PM, the resident was in her wheelchair with a Hoyer lift pad under her. During an interview with the resident on 1/28/19 at 9:30 AM, she stated she had knee pain, she used to be able to stand and pivot for transfers, and now had to have a (mechanical) lift. She stated she thought she was supposed to have therapy to help her knee, she had not started it yet, and was unaware of the reason. When interviewed on 1/30/19 at 1:20 PM, CNA #5 stated the resident had a prior knee injury and no longer used a brace. She used to stand and pivot for transfers and used the Hoyer lift now due to weakness and difficulty supporting herself on both legs. During an interview on 1/31/19 at 8:50 AM, the resident's attending physician stated it was his signature on the 1/7/19 orthopedic surgeon consult form. After he signed the form, he expected nursing to follow up with the recommended PT services by making the arrangements for PT. He stated if the orthopedic surgeon recommended PT, the resident should have started PT. He had standing orders for the resident for all skilled therapy services (PT/OT/SLP) and there should not have been any delays related to waiting for an order for [REDACTED]. During an interview on 1/31/19 at 9:50 AM, the Director of Rehabilitation Therapy stated nursing staff communicated referrals verbally in morning report directly to her, or a message was left on her voicemail. She had not received any referrals for PT for the resident's right knee since 1/7/19 and the last time the resident was seen in PT for her knee was 11/28/18. LPN #7 stated in an interview on 1/31/19 at 12:25 PM when residents returned from appointments, nursing reviewed the consult forms for instructions, signed the form, and placed it in a file for the physician to review and sign. She reviewed the 1/7/19 consult form and confirmed her signature. She stated she called PT per the instructions on the form and she could not recall who she spoke to. She stated she should have documented in a progress note and there was no other means to track the referral. During an interview on 1/31/19 01:37 PM, the Director of Nursing (DON) stated the nurse who signed the form should have called PT and documented it, and the resident should have begun PT by now. 10 NYCRR 415.16(a)

Plan of Correction: ApprovedMarch 1, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Tag F825 - Provide/Obtain Specialized Rehab Services
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
A chart review of resident #25 was completed with the care plan and Kardex reviewed for accuracy. Physical Therapy (PT) is currently working with resident #25 as of 2/1/19. PT is addressing active ROM of right knee, flexion to 110 degrees to assist with transfers. PT is also addressing active ROM to right hip, abduction to 20 degrees to facilitate comfort, re-positioning, and weight distribution. The long term goal is for this resident to safely self propel in wheelchair 100 feet with supervision.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A pink therapy screen/consult binder will be initiated and placed on each unit. These binders will include a therapy request form which can be completed by any staff member who is concerned regarding a resident?s ADLs. Therapy will then take the request form and complete a therapy recommendation form and return this back to nursing which will then notify the medical providers if physician orders [REDACTED]. Once a physician order [REDACTED]. A copy of all consults will also be placed in the pink therapy screen/consult binder. After the physician reviews the therapy recommendations and/or consults these will be scanned into the resident?s chart.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
A copy of all therapy recommendations and consults will be given to the Director of Rehabilitation and the Director of Nursing. A list of residents receiving therapy services will be given to the nurse manager/nurse supervisor/charge nurse and Director of Nursing weekly. The interdisciplinary (IDT) team will meet weekly and review the therapy recommendations and consults for the week to ensure each discipline is updated. The IDT team will also discuss the residents who are on therapy services at current time.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
Charge nurses/nurse supervisors/nurse managers are required to review the pink therapy request/consult binder daily. The IDT team will meet weekly to discuss therapy requests, therapy recommendations/consults/residents currently receiving therapy services. An audit will be completed weekly for the next 3 months then monthly for 3 months then quarterly or until 100% threshold is attained. This will be tracked and reported quarterly for Quality Assurance Committee. The Committee will determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Nursing or designee

Standard Life Safety Code Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not follow manufacturer's inspection recommendations for all testing and repairs of all patient care related electrical equipment in accordance with National Fire Protection Agency (NFPA) 99 for an otoscope (medical device used to look into ears). Specifically, the facility did not follow the preventative maintenance guidelines set forth by the manufacturer for an otoscope. Finding include: On 1/28/2019 at 2:40 PM, an otoscope located in the first-floor nursing office was observed in a charging station without an inspection tag. During an interview on 1/30/2019, between 3:50 PM and 4:27 PM, the Director of Environmental Services stated that the otoscope observed in the first-floor nursing office was not being maintained by the maintenance staff. 2012 NFPA 99: 10.5.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 22, 2019

Tag K921 - NFPA 101 Electrical Equipment - Testing and Maintenance
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
It is the policy of this facility to remain compliant with NFPA 101 standards for electrical equipment testing and maintenance. More specifically all patient care related electrical equipment (PCREE) is to be logged with the manufactures maintenance recommendations and inspected on a monthly basis. The otoscope has been inspected and added to the PCREE log book to be completed on an ongoing basis.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility will conduct a thorough audit to capture any and all undocumented electrical equipment on the inspection schedule to ensure compliance with the NFPA 101 standards.
3. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
The log book will be updated to reflect a monthly audit of the facility to ensure any and all missed items are captured on a regular basis. The Maintenance staff will be re-educated on the PCREE log update and importance of capturing all PCREE with the monthly inspection.

4. How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. What quality assurance program will be put into practice?
The audit results will be tracked and submitted to the Quality Assurance Committee on a monthly basis for three (3) months or until 100% threshold has been met and periodically thereafter as determined by the committee to ensure proper preparedness and compliance with NFPA 101 standards. Any positive findings will have a root cause analysis to determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Maintenance Director or designee

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 31, 2019

Citation Details

Based on observation, record review and interview during the Life Safety Code survey, the facility did not ensure the testing of 1 of 1 generator (building generator) was maintained; and the facility did not ensure the proper number of automatic transfer switches (ATS) were installed for 1 of 1 generator (building generator) in accordance with National Fire Protection Association (NFPA) 99 - Health Care Facilities Code section 6.5.2.2.1.3, which states: One transfer switch shall be permitted to serve one or more branches in a facility with a continuous load on the switch of 150 kVA (120 kW) or less. In addition, NFPA 70 - National Electric Code section 517.41(b), states The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the essential electrical system shall be served by one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA. Specifically; the facility was not documenting load during monthly load tests and the annual load bank test was not competed, the annual diesel fuel test for the building generator was not being completed; the building generator 4-hour continuous exercise test in the last three years was not completed; and there was only one ATS for the 350-kW building generator. Findings include: 1. Total Load Not Documented During Load Test/Annual Load Bank Test Not Completed Review on 1/30/2019 of monthly generator test reports for the building generator, revealed from 10/30/2017 to 12/21/2018 the facility did not include the amperes (amp) drawn or the total load drawn during the test. The surveyor could not determine the load percent for the generator. The facility had a 350 kilowatt (kW), 3 phase generator. On 1/30/2019 at 1:30 PM, the surveyor was told that a generator load test was in progress. The surveyor observed the panel on the generator and the highest amperage value observed was 237 amperes (amp). After converting the amp value to total KW, the total load for this test was 85 kW. This value was 24% of the total generator capacity. On 1/30/2019 at 1:37 PM, maintenance worker #8 stated he did the monthly load tests and there was no spot on the form to document the amp values. On 1/30/2019 at 2:31 PM, the Director of Environmental Services stated he figured the facility form had been used for several years and it was compliant. He knew that amp values were needed to calculate load during a monthly load test. He was not aware that an annual load bank test was required if the monthly load test was less than 30% of total generator capacity. 2. Annual Fuel Test The facility could not provide documentation that the annual fuel test for the diesel generator was completed. On 1/30/2019, between 10:50 AM and 11:25 AM, the Director of Environmental Services stated the annual fuel test was an additional service to the current contract and had not been completed. 3. Four Hour Continuous Exercise Test Not Completed The facility could not provide evidence that the building generator 4-hour continuous exercise test was completed in the last three years. The load for this test must be at least 30% of the generator capacity. On 1/30/2019, between 10:50 AM and 11:25 AM, the Director of Environmental Services stated he had no documented evidence that a 4-hour continuous exercise test was completed. 4. Only One Transfer Switch on Generator Review on 1/30/2019 of monthly generator test reports for the building generator, revealed the facility had a 350 kW generator. When interviewed on 1/30/2019 at 2:40 PM, the Maintenance Supervisor stated the building is not 100% on generator, and included only the critical and life safety components. He also stated the monthly load test was under the required 120 kW requirement and the facility was not required to have two transfer switches. The facility was unable to provide documentation to prove the maximum demand on the generator was less then 120 kW. 2012 NFPA 99: 6.4.4.1.1.3, 6.5.2.2.1.3 2010 NFPA 110: 8.3.8, 8.4.2.3, 8.4.9 2012 NFPA 70: 517.41(b) 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 6, 2019

Tag K918 - NFPA 101 Electrical Systems - Essential Electric System
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
It is the policy of the facility to perform maintenance and testing of the generator and transfer switch in compliance with NFPA 110. The Generator test log will be enhanced to include the amp draw on the generator as well as the 36 month 4 hour run test. Also a generator contractor has been contacted to conduct the annual fuel test on the generator as well as determining the maximum demand on the essential electrical system to determine if the facility needs either another automatic transfer switch or an annual load bank test as determined by NFPA 70 517.41(b). The facility will comply with the appropriate corrective action identified by the test on the essential electrical system to comply with the previously stated NFPA regulation.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility will conduct audits to ensure that the required tests/inspections and logs are conducted
sufficiently for the generator backup electrical system to comply with the NFPA 110 regulation.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
The annual fuel test will be added to the generator vendor's current contract so that it will be completed on an annual basis moving forward as well as the annual load bank test if it is found to be required. Maintenance staff will be re-educated on the new log which will include amp draw as well as a four (4) hour test every 36 months and the importance of testing requirements.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The audit results will be tracked and submitted to the Quality Assurance Committee on a monthly basis for three (3) months or until 100% threshold has been met and periodically thereafter as determined by the committee to ensure proper preparedness and compliance with NFPA 110 standards. Any positive findings will have a root cause analysis to determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 05/23/2019 Responsible: Maintenance Director or designee

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

Based on record review and interview during the Life Safety Code survey, the facility's fire alarm system was not tested in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, the semi-annual visual maintenance requirements for all initiating devices of the fire alarm system were not completed. Findings include: Review on 1/27/2019 of the facility's fire alarm system inspection report dated 4/25/2018, indicated there was no documented evidence of semi-annual visual inspections for all fire alarm initiating devices. During an interview on 1/28/2018 at 1:27 PM, the Director of Environmental Services stated the required NFPA 72 semi-annual visual maintenance requirements for the facility's initiating devices were not completed. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 22, 2019

Tag K345 - NFPA 101 Fire Alarm System - Testing and Maintenance
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
It is the policy of this facility to ensure that the fire alarm system shall be tested and maintained in compliance with NFPA 72. The facility policy will be enhanced to reflect semi-annual visual inspections for all fire alarm initiating devices. The facility will conduct a semi-annual visual inspection for all fire alarm initiating devices in compliance with NFPA 72 14.3.1 regulation and will continue to complete semi-annual testing as required.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility will audit the semi-annual visual inspection for all fire alarm initiating devices. The audit threshold of 100% will be attained to ensure proper preparedness and compliance with NFPA 72 standards.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
All maintenance staff will be re-educated on the importance of a semi-annual visual inspection on all fire alarm initiating devices and the accompanying log to reflect the inspection.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The audit results, which ensures that the maintenance department conducts semi-annual inspections and that the corresponding logs are appropriately filled out, will be tracked and submitted to to Quality Assurance Committee on a semi-annual basis for 12 months and periodically thereafter as determined by the Committee to ensure proper preparedness and compliance with NFPA 72 standards. Any positive findings will have a root cause analysis to determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Maintenance Director or designee

MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 31, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Life Safety Code survey, the facility was not inspected and maintained in compliance with the National Fire Protection Association (NFPA) 80, the Standard for Fire Doors and Other Opening Protective's, for 1 of 4 one-hour fire barriers (second floor barrier near room [ROOM NUMBER]). Specifically, one of the second-floor double fire barrier doors near room [ROOM NUMBER] had damaged hardware, and one of the doors within this barrier was missing the required fire rated labeling and did not self-close. Findings include: 1. Damaged Hardware During review on 1/27/2019 of the facility's monthly fire door inspection sheets, the facility had identified a set of fire doors that were damaged on the second floor, and had ordered new doors. There were no other issues identified during the monthly inspection of fire doors. During an observation on 1/28/2019 at 2:53 PM, one of the double fire doors near room [ROOM NUMBER] had a damaged/loose actuating bar. When the bar was handled on one side of the door, the hardware on the other side of the door could be seen moving. This door was not identified during the monthly inspection of fire doors as damaged. During an interview on 1/30/2019 at 3:00 PM, the Director of Environmental Services stated he was not aware that one of the double fire doors near room [ROOM NUMBER] had a damaged/loose actuating bar, and he would fix it immediately. 2. Unlabeled Door During an observation on 1/31/2019 at 11:37 AM, the palliative care room door was part of the second floor one-hour fire barrier near room [ROOM NUMBER]. This door was missing the required fire rated labeling and the door lacked a self-closure device. During an interview on 1/31/2019 at 11:37 AM, the Director of Environmental Services stated he was not aware that the palliative care room door lacked fire rated labels, or that there was no self-closure device installed in the door. He was aware that fire doors were required to be fire rated and be self closing. 2012 NFPA 101: 19.2.1, 7.2.1.15.2 2010 NFPA 80: 4.2.1, 6.3.1.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedMarch 6, 2019

Tag K761 - Maintenance, Inspection & Testing - Doors
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
It is the policy of this facility to inspect and test fire door assemblies in accordance with NFPA 80. A fire door vendor is scheduled to recommend a proper solution for all the issues including the damaged hardware and unlabeled door. The fire door vendor will give the facility recommendations on repairing/replacing the doors to remain in compliance with NFPA 80 regulations. These recommendations will be followed to properly fix the problem areas as needed. Depending on their recommendations the facility may re-route the fire barrier which would eliminate the need for replacing the cited unlabeled door and still remain in compliance with the NFPA regulations.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility will conduct audits on the fire doors and logs that will ensure any issues are getting captured and satisfied in a timely manner to ensure proper preparedness and compliance with NFPA 80 standards.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
The fire door check sheet will be enhanced to include the criteria listed in 2010 NFPA 80 5.2.4.2. This inspection will be conducted monthly for three (3) months or until 100% compliance is reached and then the inspection will be done annually as required by 2010 NFPA 80 5.2.1. All maintenance staff will be re-educated on the enhanced inspection procedure and the importance of fire door inspections.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The audit results will be tracked and submitted to the Quality Assurance Committee on a monthly basis for three (3) months or until 100% threshold has been met and periodically thereafter as determined by the committee to ensure proper preparedness and compliance with NFPA 10 standards. Any positive findings will have a root cause analysis to determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 05/23/ 2019 Responsible: Maintenance Director or designee

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey, the facility did not ensure portable fire extinguishers were maintained for two isolated rooms (elevator machine room [ROOM NUMBER] and main mechanical room) in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Specifically, the monthly visual inspection for the only fire extinguisher in elevator machine room [ROOM NUMBER] was not completed, and the annual maintenance for the only two fire extinguishers in the main mechanical room was not completed. Findings include: 1. Monthly Visual Inspections During an observation on 1/28/2019 at 2:05 PM, the only fire extinguisher in elevator room [ROOM NUMBER] was last monthly inspected on 10/2/2018. During an interview on 1/30/2019 at 3:15 PM, the Director of Environmental Services stated he was unaware the fire extinguisher in elevator machine room [ROOM NUMBER] was not maintained as required. 2. Annual Maintenance During an observation on 1/28/2019 at 2:18 PM, the only two fire extinguishers in the main boiler room were last annually maintained in (MONTH) (YEAR). During an interview on 1/30/2019 at 3:15 PM, the Director of Environmental Services stated he was unaware the fire extinguishers in the main mechanical room were not maintained as required, and could not provide evidence that these fire extinguishers had been maintained in (YEAR). 2012 NFPA 101: 19.3.5.12, 9.7.4.1 2010 NFPA 10 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 22, 2019

Tag 355 - NFPA 101 Portable Fire Extinguishers
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
It is the policy of this facility to select, install, inspect, and maintain fire extinguishers in accordance with NFPA 10. All fire extinguishers were inspected as required. The two (2) fire extinguishers that required annual maintenance have been replaced with compliant extinguishers by the fire extinguisher vendor.
2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
An itemized monthly log will be implemented to track all fire extinguisher inspections in the facility as required by NFPA 10 7.2.1.2. This log will be created based on the criteria listed in NFPA 10 7.2.2 for fire extinguisher inspection procedures. The log will be monitored by the maintenance manager monthly to ensure completeness.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
The maintenance staff will be re-educated on fire extinguisher inspection procedures and the monthly log.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The audit results along with the log will be tracked and submitted to the Quality Assurance Committee on a monthly basis for three (3) months or until 100% threshold has been met and periodically thereafter as determined by the committee to ensure proper preparedness and compliance with NFPA 10 standards. Any positive findings will have a root cause analysis to determine if further interventions are needed
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Maintenance Director or designee

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 minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

Based on record review and interview during the Emergency Preparedness (EP) survey, the operator did not ensure the emergency preparedness requirements were met. Specifically, the EP Plan did not include 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 at an alternative care site identified by emergency management officials. Findings include: Review of the EP Plan on 1/29/2019 revealed there was no policy and procedure for 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 at an alternative care site identified by emergency management officials. When interviewed on 1/29/2019 at 9:40 AM, the Director of Environmental Services stated he could not find a policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act. 10NYCRR: 400.10(d) 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedFebruary 22, 2019

Tag E026 - Emergency Preparedness
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The Disaster and Emergency Plan will include a policy with all relevant information on the 1135 Waiver request declared by the Secretary, in accordance with the section 1135 of the Act.

2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility will audit all Disaster and Emergency Plan Manuals to ensure that they include a policy with all relevant information on the 1135 Waiver request declared by the Secretary, in accordance with the section 1135 of the Act. Audit threshold of 100% of all Disaster and Emergency Plan Manuals will be attained.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
All staff will be re-educated on the policy and all relevant information on the 1135 Waiver request declared by the Secretary, in accordance with the section 1135 of the Act.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The audit result of all Disaster and Emergency Plan Manuals will be reported to the Quality Assurance Committee. The Quality Assurance Committee will determine if further interventions are needed.
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Director of Environmental Services or designee

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure the building's automatic sprinkler system was tested in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Specifically, there was no documented evidence that a five-year internal inspection was performed, as required. Findings include: During review on 1/29/2019 of the facility's quarterly sprinkler inspection reports, all four (YEAR) quarterly sprinkler inspection reports indicated the last five-year internal inspection was done 1/10/2012 and was required to be done again. The last five-year internal inspection was not documented on the 2019 first quarter sprinkler inspection report. During an interview on 1/30/19 at 3:13 PM, the Director of Environmental Services stated the five-year internal inspection had not been done since 1/10/2012. The vendor had been trying to contact the facility via a previous staff person's email to schedule a five-year internal inspection. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedFebruary 22, 2019

Tag 353 - NFPA 101 Sprinkler System - Maintenance and Testing
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
It is the policy of this facility to ensure its automatic sprinkler system is inspected, tested , and maintained in accordance with NFPA 25. The Sprinkler system contractor has been updated on the facility contact information. The five (5) year internal inspection was completed and deficiency free on 2/20/2019.

2) How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
The facility will conduct audits on the sprinkler testing and maintenance logs that will ensure compliance with NFPA 25 standards.
3) What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur?
A check sheet will be added to the front of the sprinkler inspection report book to ensure that all recommendations from the sprinkler vendor are reviewed. The Maintenance staff will be re-educated on the new log and importance of sprinkler inspection report.
4) How the corrective actions will be monitored to ensure that the deficient practice will not recur, i.e. what quality assurance program will be put into practice?
The Sprinkler inspection audit results will be tracked and submitted to the Quality Assurance Committee on a monthly basis for 3 months or until 100% threshold has been met and periodically thereafter as determined by the committee to ensure proper preparedness and compliance with NFPA 25 standards. Any positive findings will have a root cause analysis to determine if further interventions are needed
The date for correction and the title of the person responsible for correction of each deficiency:
Date of Completion: 03/29/2019 Responsible: Maintenance Director or designee