Avon Nursing Home, LLC
December 1, 2017 Certification Survey

Standard Health Citations

FF11 483.60(g):ASSISTIVE DEVICES - EATING EQUIPMENT/UTENSILS

REGULATION: §483.60(g) Assistive devices The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for the use of assistive devices, the facility did not consistently provide special eating equipment and utensils for a resident who needed them. Specifically, Resident #33 was care planned for a divided or lip plate for all meals except finger foods. This is evidenced by the following: Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/8/17, revealed that the resident had severely impaired cognition and was independent with eating after set-up help. The Dietary Recommendations to Nursing Form, dated 11/6/17, included a lip or divided plate for all meals and a regular plate for finger foods. The Certified Nursing Assistant (CNA) Assignment Sheet, dated as last revised on 11/14/17, included under eating that the resident was independent after set-up, and required a lip or divided plate for meals and a regular plate for finger foods. A Nutritional Assessment, dated 11/20/17, included that the resident needs a lip plate or divided plate and/or a regular plate for finger foods per Occupational Therapy to meet the needs of the resident. During an observation on 11/29/17 at 12:30 p.m., the resident was eating lunch independently in the main dining room. The meal was turkey ala king and was served on a regular flat plate. Observations conducted on 11/30/17 included the following: a. At 8:27 a.m., the resident was eating sausage gravy on a regular plate independently. The gravy was spilling off the end of the plate onto the table. b. At 12:36 a.m., the resident had mixed vegetables and cream pie served on flat plates. In an interview on 11/30/17 at 11:39 a.m., the CNA stated that the resident eats in the dining room and she does not know if she requires anything special. Interviews conducted on 12/1/17 included the following: a. At 8:55 a.m., the Registered Nurse Manager stated that the resident needs a divided plate as she was having difficulty eating. She said she would expect the kitchen staff to use a divided plate as written in the care plan. b. At 9:19 a.m., the Occupational Therapy Assistant stated that the resident was having trouble scooping the food, and it was determined that she needed the divided plate to increase independence for all meals except finger foods. The Occupational Therapy Assistant said the divided plate should have been used for the sausage gravy, mixed vegetables, and pie. She said it should be used for anything that is not a finger food. c. At 9:25 a.m., the Dietary Supervisor stated that the resident needs plates as appropriate for the meal. The Dietary Supervisor said she would have expected staff to serve the sausage gravy and turkey ala king in a lip plate. She said she would have to re-educate the kitchen staff. (10 NYCRR 415.14(g))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident #33 was evaluated by Occupational Therapy. Resident #33?s order was clarified.
(12/1/2017)
2. All residents with assistive devices for eating were evaluated by Occupational Therapy and resident care plan clarified if needed.
(12/29/2017)
3. Facility reviewed Resident Nutrition Services Policy and Procedure. Nursing, therapy and dietary services personnel will be in-serviced and re-educated on Resident Nutrition Services Policy which includes the provision of adaptive devices if necessary
(1/19/2018)
4. Quality Assurance Audits will be conducted monthly for three months and quarterly thereafter to ensure Occupational Therapy recommendations for assistive devices are being followed. All findings will be presented at Quality Assurance Committee for action if necessary.
(1/12/2018 and ongoing)
Overall Responsibility: Director of Food Service

FF11 483.40:BEHAVIORAL HEALTH SERVICES

REGULATION: §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #17) of one resident reviewed for behavioral health services, the facility did not ensure the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The issue involved the lack of a psychiatric evaluation as ordered by the physician and an individualized person-centered approach to ensure the resident's behavioral health needs are met as identified in the comprehensive assessment. This is evidenced by the following: Review of the facility's Standards of Practice (SOP), dated (MONTH) (YEAR), directs the facility provided the SOPs to all residents unless the resident-specific care plan documented otherwise. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/20/17, revealed the resident had moderately impaired cognition, delusions and the resident's behavioral symptoms included physical behaviors towards staff. The physician orders, dated 8/15/17, included [MEDICATION NAME] (an antidepressant) and a psychiatric consultation. A Social Work (SW) Note, dated 8/15/17, documented that a psychiatric referral had been completed due to the resident's loss of control and independence. A Medical Assessment, dated 9/8/17, included a secondary [DIAGNOSES REDACTED]. A SW Note, dated 9/14/17, documented that the resident's psychiatric evaluation had not been completed. On 9/18/17, the SW documented the resident would not be seen by psychiatry as psychiatric services were unavailable at that time. The SW documented that the resident was adjusting. Progress Notes, dated 9/25/17, 9/27/17, and 10/15/17, revealed that the resident had behaviors that were suspicious of others and paranoid in nature. Review of Progress Notes, from 11/6/17 through 11/16/17, revealed three instances of paranoid behavior, including, but not limited to, stating that a friend was paying someone to kill him by (MONTH) (YEAR), battery acid is being taken from cars in the parking lot and poured on his right leg, and the boss is aware and close to catching the person. A Progress Note, dated 11/16/17, documented the resident was yelling and accusing housekeeping staff of stealing his key. He kept following the staff and was argumentative. The key was on the resident's arm. The physician had ordered a Behavior Log on 11/16/17 to be completed for seven days. The Behavior Logs, dated 11/16/17 through 11/24/17, revealed that the resident's behavior was being monitored because of increased paranoid behaviors. The documentation was incomplete 12 of 26 opportunities. The Behavior Log revealed four instances of paranoid behavior and two instances of demanding and argumentative behavior. Progress Notes, dated 11/29/17 and 11/30/17 documented episodes of paranoid behavior. A physician order, dated 11/30/17, included to discontinue psychiatric evaluation until services were available in the facility. The current Comprehensive Care Plan (CCP) included the resident's potential for psychosocial/mood problems related to recent hospitalization , decline in cognitive function and the resident was receiving an antidepressant daily. The approaches included to implement SOP. The SW SOP included monitor mood/and behaviors for patterns or triggers to effectively develop/implement interventions. The CCP does not address the resident's behaviors, delusions and person-centered approaches as identified in the Comprehensive Assessment. The current Certified Nursing Assistant (CNA) Assignment Sheet did not address a behavior management program. During intermittent observations of the resident from 11/28/17 through 12/1/17 between the hours of 8:00 a.m. and 3:00 p.m., the resident was eating his meals in the dining room sitting at a table by himself and propelling himself in his wheelchair throughout the hallways of the facility. Interviews conducted on 11/30/17 included the following: a. At 9:00 a.m., the CNA stated the resident's mood can change quickly and he becomes suspicious of others. The CNA stated the resident can be resistive to cares. She stated if that occurs she would leave and reapproach the resident later. b. At 9:48 a.m., the SW stated the facility was in the process of obtaining psychiatric services. She said nursing or administration should have informed the physician when psychiatric services were no longer available. c. At 10:30 a.m., the DON stated the physician should have been made aware that psychiatric services were unavailable. Interviews conducted on 12/1/17 included the following: a. At 9:26 a.m., the DON stated the resident had delusions, paranoia, and had difficulties delineating reality. She stated his behaviors should be addressed on the CCP. b. At 10:39 a.m., the Administrator stated psychiatric services lapsed in (MONTH) (YEAR). He stated there was a discussion with the Medical Director however, he did not recall when that occurred. The Administrator stated when the order was written in (MONTH) the physician should have been informed that psychiatric services were unavailable. He stated the SW followed the resident closely to ensure psychiatric issues were subsiding. The Administrator stated the resident's behaviors were periodic but his paranoia and accusations were not as bad. (10 NYCRR 415.12)

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident #17?s record was reviewed by Medical Director/Attending Physician. Medical Director discontinued psychiatric consult at this time due to a non-emergent need. Facility arranging for CSW to assist in the development of a behavior plan. Resident?s care plan was revised to include Resident?s behaviors.
(11/30/2017)
2. All residents were reviewed and there are no ordered psychiatric consults ordered.
(11/30/2017)
3. Facility is currently exploring psychiatric consultation services. Medical Director will notify Administrator if a psychiatric consultation is imminently necessary. At that time, arrangements will be made for outside consultations.
(2/1/2018).
4. Quality Assurance will be conducted on a monthly basis for three months and quarterly thereafter on any resident with behavioral concerns to ensure the concerns are addressed on the care plan. Concerns will be reviewed with Medical Director/ Attending Physician for orders if necessary. All findings will be presented at Quality Assurance Committee for actions if necessary.
(11/30/2017 and ongoing).
Overall Responsibility: Director of Social Work

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 3 (Residents #17, #28 and #30) of 19 residents reviewed for development of a Comprehensive Care Plan, the facility had not developed a thorough care plan based on the resident's assessment to ensure the services were provided to maintain the resident's highest practicable physical well-being. Specifically, there was no Comprehensive Care Plan for oxygen (Residents # 28 and #30) and risk for skin injury (Resident #17). This is evidenced by the following: 1. Resident #28 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/3/17, revealed the resident was mildly cognitively impaired and received oxygen therapy. The physician order, dated 10/5/17, included oxygen at 2 liters per minute via nasal cannula at bedtime for [MEDICAL CONDITION] hypertension. The Certified Nursing Assistant (CNA) Assignment Sheet, dated 11/12/17, included oxygen at 2 liters per minute at bedtime. The current Comprehensive Care Plan (CCP) did not include the resident's respiratory status or the need for continuous oxygen at bedtime. When interviewed on 12/1/17 at 12:07 p.m., the Director of Nursing (DON) stated that the resident uses oxygen and it is her expectation that the CCP included the use of oxygen. 2. Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Comprehensive MDS Assessment, dated 11/4/17, revealed the resident was moderately cognitively impaired and received oxygen therapy. The Care Area Assessment (CAA) Sheet, dated 1/13/17, documented the Activity of Daily Living (ADL)/Rehabilitation potential triggered due to the resident's fluctuating ADL needs in relation to the resident's respiratory status. The CAA Sheet, dated 11/15/17, documented the decision to proceed to care planning. The CNA Assignment Sheet, dated 11/14/17, included oxygen continuously at 2 liters per minute via nasal cannula. The current CCP did not include the resident's respiratory status or the need for continuous oxygen. During intermittent observations, from 11/28/17 through 12/1/17, the resident was receiving oxygen via nasal cannula at 2 liters per minute continuously. During an interview 11/29/17 at 2:25 p.m., the CNA stated she exchanges the resident's oxygen tanks when they are empty and regulates the liters to be delivered. When interviewed on 12/1/17 at 11:43 a.m., the DON stated she was responsible for the development of the CCP in conjunction with the Interdisciplinary Team. She stated that oxygen therapy would be addressed on the CCP if it was an issue for the resident. The DON stated the CCP should address actual and potential issues for the resident. 3. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, date 10/20/17, revealed the resident was moderately cognitively impaired and required the extensive assistance of staff for personal hygiene. The current CCP identified the resident's risk for skin breakdown and a current heel ulcer. Observations conducted on 11/28/17 at 10:50 a.m., on 11/29/17 at 11:04 a.m., and on 11/30/17 at 8:53 a.m., the resident had a small (.25 centimeter) scabbed area on the top of the tip of his nose. When interviewed on 12/1/17 at 9:26 a.m., the DON stated the resident picked and scratched his skin resulting in skin injuries. She stated the resident had a skin injury to his hand in (MONTH) (YEAR). The DON stated the resident's CCP should include the risk of skin injuries. After review of the resident's CCP, the DON said the CCP does not address the resident's risk for skin injury. (10 NYCRR 415.11 (c)(1))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident #17, Resident #28 and Resident #30 care plans were updated to include oxygen usage and risk for skin injury.
(12/28/2017)
2. All resident care plans were reviewed to ensure that oxygen use and risk for skin injuries were included when necessary/applicable.
(1/5/2018)
3. Facility Comprehensive Care Plan Policy and Procedure was reviewed. Inter Disciplinary Team members that attend Care Plan meetings will be re-educated on the Comprehensive Care Plan Policy and Procedure.
(1/3/2017)
4. Quality Assurance Audits will be conducted 2x?s a month for three months and quarterly thereafter on care planning to ensure that oxygen usage and risks for skin injuries are reflected on the care plan. All results will be presented at Quality Assurance Committee meetings for action if necessary.
Overall Responsibility: Director of Nursing

4FGA 400.10 (d):HEALTH PROVIDER NETWORK ACCESS AND REPORTING

REGULATION: The operator of a facility shall obtain from the department ' s health provider network (HPN), HPN accounts for each facility he or she operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, 24-hour, seven-day-a-week contacts for emergency communication and alerts must be designated by each facility in the HPN communications directory. A policy defining the facility's HPN coverage consistent with the facility ' s hours of operation, shall be created and reviewed by the facility no less than annually. Maintenance of each facility ' s HPN accounts shall consist of, at a minimum, the following: (d) current and complete updates of the communications directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

Based on an interview and record reviews conducted during the Emergency Preparedness Plan review in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with Emergency Preparedness requirements. Specifically, the emergency contact information in the New York State Health Commerce System (NYSHCS) database contained incorrect information and was not updated monthly. This is evidenced by the following: On 11/29/17 from 1:17 p.m. to 1:25 p.m., the Director of Environmental Services and the Administrator reviewed contact information with the surveyor as listed on the NYSHCS. The Emergency Office Roles assigned to the facility included contact information for the Office of the Administrator and the 24/7 facility contact. The contact information entered into the NYHCS showed an e-mail and cell phone number that belonged to the previous Administrator. When interviewed at that time, the current Administrator stated that he had been at the facility for about eight months. The operator of the facility shall obtain, from the Department's Health Provider Network (HPN), accounts for each facility that he or she operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, twenty-four hour, seven day a week contacts for emergency communication and alerts must be designated by each facility in the HPN Communications Directory. Current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, on a monthly basis. (10 NYCRR 400.10, 400.10(d))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Director of Environmental Services (DES) immediately updated HPN Role Assignments and verified all were current and up-to-date.
(11/29/2017)
2. HPN Role Assignments were updated by DES on 11/29/2017 immediately upon findings.
(11/27/2017)
3. Director of Environmental Service will review HPN Role Assignments on a monthly a basis. DES will verify all HPN Role Assignments are current and up to date.
(12/28/2017 and ongoing)
4. A Quality Assurance Audit will be conducted on a monthly basis by Director of Environmental Services/Designee. The findings of these Quality Assurance Audits will be reviewed and discussed at Quality Assurance Committee for actions as necessary.
(12/28/2017 and ongoing)
Overall Responsibility: Director of Environmental Services

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: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey it was determined that for one (Resident #17) of two residents reviewed for non-pressure related skin conditions, the facility did not investigate a skin injury to rule out abuse, neglect or mistreatment. The issue involved the lack of an investigation of an injury of unknown origin. This is evidenced by the following: The facility Standards of Practice, dated (MONTH) (YEAR), included to observe skin with cares and report changes. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/20/17, revealed the resident had moderately impaired cognition and required the extensive assistance of staff for personal hygiene. The Certified Nursing Assistant Assignment Sheet, dated 11/30/17, documented that the resident required minimum assistance with upper body cares and extensive assistance with lower body cares. The Assignment Sheet for grooming assistance was incomplete. The Nursing Measures Record, dated (MONTH) (YEAR), instructed to complete a full skin check once weekly on shower day (Friday). The entry was not signed as completed on 11/10/17, 11/17/17 and 11/24/17. Review of the Incident/Accident Reports, from 7/1/17 through 11/30/17, revealed no reports of an injury to the resident's nose. Review of Nursing Progress Notes, from 11/1/17 through 11/30/17, revealed no documentation of a skin injury to the resident's nose. During observations conducted on 11/28/17 at 10:50 a.m., on 11/29/17 at 11:04 a.m. and on 11/30/17 at 8:53 a.m., the resident had a small (.25 centimeter) scabbed area on the top of the tip of his nose. Interviews conducted on 11/30/17 included the following: a. At 8:53 a.m., the resident stated that he broke his nose years ago and he had a bump. The resident stated when he shaved he hit the area. He said staff had not shaved him yet that day. b. At 1:40 p.m., the Director of Nursing (DON) stated nursing staff observe the resident's skin every day with cares. She stated if a skin injury was observed staff would report the issue to a nurse. The DON stated that if it was a non-pressure related skin injury an Incident/Accident Report and investigation would be completed. The DON stated if a resident had a new skin issue, there would be documentation in the Progress Notes. c. At 1:42 p.m., the Licensed Practical Nurse (LPN) stated the resident had a skin issue on his shin. The LPN said she did not recall any other skin issues. She stated an Incident/Accident Report should be completed as soon as an issue/injury is reported. The LPN stated she was not aware of the scabbed area on the resident's nose. At that time, the Registered Nurse Manager stated she was not aware of the scabbed area on the end of the resident's nose. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. An Incident and Accident report was immediately initiated by Licensed Practical Nurse upon Surveyors findings on scab of Resident #17?s nose.
(11/30/17)
2. All residents received skin checks, ensuring all non-pressure related skin conditions were investigated and had proper incident and accident reports completed.
(12/29/2017)
3. Accident and Incident Reporting Form was reviewed. All nursing personnel will be in-serviced on Accident and Incident Reporting Form Completion Procedure.
(1/5/2018)
4. A Quality Assurance audit on Incident and Accident reports will be conducted weekly x?s 4, bi-weekly x?s 4, monthly x?s 3 and quarterly thereafter. Quality Assurance Audit results will be presented to the Quality Assurance Committee for actions as necessary.
Overall Responsibility: Director of Nursing

FF11 483.21(b)(3)(ii):QUALIFIED PERSONS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 of 18 residents reviewed for care plan implementation, the facility did not provide services in accordance with the written plan of care. Specifically, Resident #18 was observed scratching herself and was not wearing gloves as per plan of care. This is evidenced by the following: Resident #18 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/21/17, included that the resident had severely impaired cognition and required extensive assist of staff for dressing. The most recent Physician Medical Assessment, dated 11/3/17, included that the resident was still picking at her skin and to add an [MEDICATION NAME] to her medications. Review of the current Comprehensive Care Plan and Certified Nursing Assistant (CNA) Assignment/Accountability Sheet revealed that the resident has a potential for alteration in skin integrity and scratches self often. Special instructions included that the resident may wear white gloves as needed if she is picking at her face. Multiple observations of the resident included the following: a. On 11/28/17 at 11:09 a.m., the resident was in the living room area watching television (tv). She was continuously picking at her face and had multiple small scabs all over her face. b. On 11/29/17 at 8:29 a.m., at 10:52 a.m., and again 3:45 p.m., the resident was observed in the hallway or living room area and was picking at her face and head. c. On 11/30/17 at 11:58 a.m., the resident was sitting in the living room area watching tv and picking at her face. The resident was not wearing gloves for any of the above observations. When interviewed on 11/30/17 at 1:07 p.m., the CNA stated that the resident has scabs on her face because she picks at it and scratches herself. She said that sometimes they use mitts here but she did not know if the resident had any. In an interview on 12/1/17 at 10:19 a.m., the Registered Nurse Manager (RNM) stated that the resident has gloves that she wears but sometimes takes them off. The RNM said that she would expect staff to try and put them on the resident if she was scratching. She said if the resident refuses to wear the gloves then staff should inform her. When observed on 12/1/17 at 10:36 a.m., the resident was watching TV and wearing white gloves and was not seen attempting to remove them. The resident currently has at least ten small scabbed areas scattered around her face. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident #18?s gloves were immediately applied to assist with Resident #18?s picking.
(11/30/2017)
2. Any resident with a documented history of self-inflicted injury was reviewed for care planning and implementation.
(1/5/2018)
3. Nurse Aide Assignment and Accountability Record Resident Specific Policy and Procedure was reviewed by the Director of Nursing. Nursing personnel will be re-educated on the Nurse Aide Assignment and Accountability Record Resident Specific Policy and Procedure and the importance of following the instructions on the assignment sheet
(1/12/2018)
4. QA audit will be conducted 2x?s a month for three months and quarterly thereafter on ensuring care plan compliance for residents with a history of self-inflicted injuries. Quality Assurance Audit results will be discussed at quarterly Quality Assurance Committee for actions as necessary.
Overall Responsibility: Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: December 1, 2017
Corrected date: N/A

Citation Details

On 11/28/17, from approximately 2:00 p.m. to 2:30 p.m., the employee records related to the CHRC were reviewed for a prospective maintenance staff worker. The records showed that the facility submitted a CHRC request for that person and a pending denial letter was issued on 3/8/17, with a final denial of employment on 7/19/17. Further record review showed the Termination Notice (DOH-105e) was submitted to the CHRC by the facility on 10/16/17. In an interview at that time, the Director of Environmental Services (one of the CHRC authorized persons) stated that they were not sure why it did not get submitted earlier and that the person in question never began work at the facility because they were waiting for him to clear the CHRC. (10 NYCRR: 402.3(j), 402.9(b), 402.9(b)(1))

Plan of Correction: ApprovedDecember 29, 2017

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #1) of 18 residents reviewed for professional standards, the facility did not provide services consistent with professional standards of quality. The issue involved the improper application of Ace wraps. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/17/17, revealed the resident was severely cognitively impaired. The physician orders, dated 10/19/17, included to apply Ace wraps to both lower extremities every morning for [MEDICAL CONDITION] and remove at bedtime. The Certified Nursing Assistant Assignment Sheet, dated 11/14/17, included Ace wraps to both lower extremities, applied in the morning and removed at bedtime. During an observation on 11/28/17 at 2:20 p.m., the resident was sitting in a wheelchair in the hallway, and she had Ace wraps on both lower extremities ending mid-calf. There was slight swelling between the Ace wraps and the knees. The resident's legs were not elevated. Review of the Nursing Progress Notes and the Comprehensive Care Plan revealed there was no documentation related to the resident's refusal or preferences related to the application of the Ace wraps. During an observation of care on 11/30/17 at 9:26 a.m., the Licensed Practical Nurse (LPN) applied an Ace wrap to the resident's lower extremities, wrapping the foot and ankle of each extremity. The resident was cooperative and non-verbal throughout the procedure. At that time, the LPN stated staff just wrap the resident's feet because if you go up any further the resident becomes upset. The LPN stated the resident developed fluid in her feet and the Ace wraps assist in keeping the fluid down. The LPN stated the Director of Nursing (DON) instructed her on the application of Ace wraps. During an interview on 11/30/17 at 9:58 a.m., the DON stated she had provided education and competency evaluations on Ace wraps for the nursing staff. She stated Ace wraps are applied from the toes to the knees or the resident's preference. She stated the purpose of Ace wraps was to increase circulation and decrease [MEDICAL CONDITION]. (10 NYCRR 415.11 (C)(3)(i))

Plan of Correction: ApprovedDecember 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Application of Resident #1?s ace wraps were immediately corrected by Director of Nursing.
(11/30/2017)
2. All Residents with ace wrap physician orders [REDACTED].
(12/29/2017)
3. Director of Nursing and Physical Therapist reviewed guidelines for ace wrap application. Nursing personnel will be re-educated on facility Guidelines of Ace Wrap Application. If resident unable to tolerate ordered applications physician would be notified.
(1/5/2017)
4. Quality Assurance Audits will be conducted 2x?s a month for three months and quarterly thereafter on application of ace wraps. All results will be presented at Quality Assurance Committee for action if necessary.
Overall Responsibility: Director of Nursing

FF11 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- §483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #18) of five residents reviewed for vision and hearing, the facility did not provide assistive devices to maintain vision ability. The issue involved the lack of follow-up to replace missing eye glasses for a resident. This is evidenced by the following: Resident #18 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) Assessment, dated 10/21/17, and the most recent Comprehensive MDS Assessment, dated 1/25/17, included that the resident had severe impairment of cognitive function, has ability to see adequately (able to see fine details such as regular print in newspaper/books), had corrective lenses and required extensive assist of staff for dressing. The Comprehensive MDS Assessment also included that it was very important to the resident to have books, magazines and newspapers to read. Review of the last two optometry evaluations, dated 10/14/16 and 11/2/17, revealed that the resident's vision was moderately impaired and that she wears reading glasses. The current Comprehensive Nursing Care Plan and the Certified Nursing Assistant (CNA) Assignment Sheet revealed that the resident had a potential for alteration in communication related to mild hearing deficit, cognitive deficit and memory loss. The care plans include that the resident did not wear hearing aids but neither care plan mentioned eye glasses. Multiple observations over several days included, but was not limited to, the following: a. On 11/28/17 at 9:39 a.m., the resident was sitting at a table with a magazine and a newspaper. When asked what she was reading she stated she could not see it. The resident said that she used to have glasses but did not know where they were. b. On 11/29/17 at 10:52 a.m., the resident was in a group activity and watching but not participating with the group. She was not wearing any eye glasses. c. On 11/29/17 at 3:45 p.m., the resident was again sitting at a table in the living room area with a newspaper in front of her attempting to read with her face bent over close to the newspaper. She was not wearing eye glasses. When interviewed on 11/29/17 at 2:22 p.m., the Activity Director stated that the resident likes to read and was always picking up magazines and newspapers. She said the resident complained about not being able to see and that her eyes were bothering her. The Activity Director said that staff give the resident large print bingo cards that she can use, but she really cannot see the news print. Interviews conducted on 11/30/17 included the following: a. At 1:07 p.m., the CNA stated that the resident had glasses but she does not wear them. When asked if she offered them to the resident that day, she stated no. The room was searched at that time and no eye glasses were found. b. At 1:24 p.m., the Licensed Practical Nurse stated that she thought the resident's representative may have taken the eye glasses home. c. At 1:23 p.m., and again on 12/1/17 at 10:19 a.m., the Registered Nurse Manager (RNM) said that she was not aware that the resident's representative took the eye glasses home. She said that she has seen the eye glasses on the resident but she was not sure of how long ago she saw them. After calling the representative, the RNM later stated she was told they were not taken home and she would see about getting the resident some reading glasses. (10 NYCRR 415.12(3)(b))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident #18 will be seen by Sight-Rite (Facility Optometry) to replace missing glasses.
(1/4/2018)
2. All residents with visual impairments will be reviewed to ensure that all residents with eyeglasses have the glasses present. This will be reviewed by Director of Social Work.
(1/4/2018)
3. Facility Standards of Practice was reviewed. All nursing home personnel will be re-in-serviced on Facility Standard of Practice, which includes and ensures the usage of eye glasses as necessary.
(1/12/2018)
4. Quality Assurance audits will be conducted on ensuring that all residents have proper eye wear 2x?s a month for three months and quarterly thereafter. All findings will be presented at Quality Assurance Committee for action if necessary.
Overall Responsibility: Director of Social Work

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #9) of one resident reviewed for pressure ulcers, the facility did not provide the necessary services to prevent the development of, or promote healing of, a pressure sore. The issues involved the lack of ordered treatments administered for a pressure sore. This is evidenced by the following: Resident #9 was admitted to the facility on [DATE] and has current [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/26/17, included that the resident has severe impairment of cognitive function, requires limited assist of staff for personal hygiene and no pressure ulcers. The current facility policy, Pressure Injury Prevention Points, directed to inspect the skin at least daily for signs of pressure injury especially nonblanchable [DIAGNOSES REDACTED] (redness), to ensure that the heels are free from the bed, and to use heel offloading devices on individuals at high risk for heel ulcers. A Braden Skin Assessment (formal scale for determining pressure sore risk of residents), dated 9/29/17, revealed that the resident was a high risk for pressure ulcers. The Comprehensive Care Plan, dated 11/23/17, and the current Certified Nursing Assistant (CNA) Assignment Sheet revealed that the resident had a red and mushy left heel (indicative of pressure injury) and approaches included, but were not limited to, a 'pillow boot' while in bed to the left foot. Review of Wound Care Flow Sheets, dated 11/27/17, revealed that the resident had a Stage I pressure injury (a persistent red area of intact skin indicative of pressure related alteration in skin integrity) on the left heel and a Stage II (a partial thickness of loss of skin or open area) pressure injury of the buttocks. Physician orders, dated 11/9/17, included knee high TED (compression stockings) to both lower extremities every morning and remove at bedtime for [MEDICAL CONDITION]. Physician orders, dated 11/24/17, included to apply Skin Prep (a protective liquid barrier applied to skin for protection) to the left heel every shift. The (MONTH) (YEAR) Treatment Administration Record (TAR) includes TED stockings to both lower extremities every morning and was signed off as applied on both 11/29/17 and 11/30/17 at 8:00 a.m. The TAR also included that the skin prep was applied to the left heel on 11/30/17 day shift, but was not signed off as applied on the previous night shift on 11/30/17. Observations of the resident included the following: a. On 11/29/17 at 11:00 a.m., the resident was sitting in his wheelchair in the living room dressed for the day. He was wearing white socks and sneakers but no TED stockings. b. On 11/30/17 at 7:48 a.m. and again at 9:47 a.m., the resident was in bed sleeping. The resident was not dressed and was not wearing a pillow boot at either observation. The resident's feet were not elevated and were laying on a bare mattress as the sheet had come undone. The resident's left heel had an approximately 4 centimeter area of slightly redden skin that appeared mushy and he had trace to +1 [MEDICAL CONDITION] to both feet. When touched by the CNA during care, the resident winced and when asked if his heel hurt, he stated yes. Morning care was completed by the CNA and the resident was dressed in clothes, socks and sneakers, then transferred to the living room for an activity. At no time was the skin prep applied to the heel or TED stockings applied. When interviewed at that time, the CNA stated that the resident does not get anything special to his heels. The CNA said she was not aware of a boot and that the resident wears socks and shoes. Interviews conducted on 11/30/17 included the following: a. At 11:30 a.m., the Registered Nurse Manager stated that staff should not sign off for treatments prior to administering them. b. At 2:27 p.m., the Registered Nurse/Treatment Nurse stated that she did not apply the Skin Prep to the resident's heel and she should not have signed it off on the Treatment Sheet. She said that the resident's TEDS stockings should be applied by the CNA. After surveyor intervention, the RN applied the Skin Prep and stated that the resident's heel looked mushy. When asked if it was a suspected deep tissue injury, she stated yes. c. At 2:29 p.m. and again on 12/1/17 at 10:07 a.m., the Director of Nursing (DON) stated that she gave staff the pillow boot last week and expected it to be applied every night. Review of the resident's room at that time revealed no pillow boot in the room. The DON said that the TED stockings should be on the resident as they were signed off as applied on the Treatment Sheet. In a Wound Care Flow Sheet, dated 12/1/17, the DON documented that the left heel ulcer is a suspected deep tissue injury that appears mushy and interventions are to continue the Skin Prep and pillow bootie. (10 NYCRR 415.12(c)(2))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident #9?s ordered treatment was immediately administered by nurse.
(11/30/2017)
2. The RN responsible for Resident #9?s treatment on 11/30/17 was counseled on the Treatment Administration policy which specifies to complete treatment before signing the Treatment Administration Record.
(1/12/2018)
3. Treatment Administration Policy and Procedure was reviewed by the Director of Nursing with licensed Nursing Staff. All nurses will be re-educated on Treatment Administration Policy.
(1/19/2018)
4. Quality Assurance Audits will be conducted on weekly basis for one month, bi-monthly for two months, monthly for three months and quarterly thereafter on ensuring of proper implementation and signing of treatment orders.
(1/12/2018 and ongoing)
Overall Responsibility: Director of Nursing

Standard Life Safety Code Citations

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

Based on an interview and record reviews conducted during the Emergency Preparedness Plan review in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with Emergency Preparedness requirements. Specifically, information in the facility communicatons plan did not comply with state requirements. This is evidenced by the following: On 11/29/17 from 1:17 p.m. to 1:25 p.m., the Director of Environmental Services and the Administrator reviewed contact information with the surveyor as listed on the New York State Health Commerce System (NYHCS). The Emergency Office Roles assigned to the facility included contact information for the Office of the Administrator and the 24/7 facility contact. The contact information entered into the NYHCS showed an e-mail and cell phone number that belonged to the previous Administrator. When interviewed at that time, the current Administrator stated that he had been at the facility for about eight months. (42 CFR 483.73 - Emergency Preparedness; 42 CFR 483.73(c))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Director of Environmental Services (DES) immediately updated HPN Role Assignments and verified all were current and up-to-date.
(11/29/2017)
2. HPN Role Assignments were updated by DES on 11/29/2017 immediately upon findings.
(11/27/2017)
3. Director of Environmental Service will review HPN Role Assignments on a monthly a basis. DES will verify all HPN Role Assignments are current and up to date.
(12/28/2017 and ongoing)
4. A Quality Assurance Audit will be conducted on a monthly basis by Director of Environmental Services/Designee. The findings of these Quality Assurance Audits will be reviewed and discussed at Quality Assurance Committee for actions as necessary.
(12/28/2017 and ongoing)
Overall Responsibility: Director of Environmental Services

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain and test patient care related electrical equipment. Specifically, there was no maintenance manual for an alternating pressure pump, and inspections for oxygen concentrators were overdue. This is evidenced by the following: 1. Observations on 11/28/17 at approximately 9:05 a.m. revealed a Select Air Alternating Pressure Pump attached to the Bed A in Resident room [ROOM NUMBER] with a sticker that was dated (MONTH) (YEAR) and initialed. In an interview at that time, the Director of Environmental Services stated that the device was a rental and was inspected for electrical safety when it first came in. He said they do not have a maintenance manual for the pressure pump. Further review of pages 14 and 15 of a maintenance manual sent by the vendor shows a requirement for a monthly cleaning and inspection of the filter. There was no documentation to show that this was being done. 2. Observations on 11/28/17 at approximately 1:25 p.m. revealed a Devilbiss Brand Oxygen Concentrator next to the Bed B in Resident room [ROOM NUMBER]. The plastic tubing connected to the concentrator was marked with a date of 10/24. A review of the maintenance manual for the oxygen concentrator revealed the humidifier bottle is supposed to be cleaned daily and the air filter weekly. There was no documentation to show that this was being done. In an interview at that time, the Director of Environmental Services revealed both maintenance and nursing share the responsibility for maintaining the oxygen concentrators and it is documented in a monthly log. The 2012 edition of NFPA 99, Standard for Health Care Facilities, directed facilities to establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. Policies shall be established for the control of appliances not supplied by the facility. Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. A permanent file of instruction and maintenance manuals shall be maintained and be accessible. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99:10.5.2.1.1, 10.5.3.1.2, 10.5.6.1.1)

Plan of Correction: ApprovedDecember 29, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Resident in room [ROOM NUMBER]?s mattress was replaced with a facility owned perimeter mattress.
(11/30/2017)
Resident in room [ROOM NUMBER]?s oxygen tubing was immediately replaced and dated. The humidifier bottle was replaced and the air filter was cleaned.
(11/30/2017)
2. All residents with rental mattresses were replaced with the new rental mattresses, in which had maintenance manuals and were being followed.
(12/8/2017)
All residents with oxygen concentrator tubing were reviewed to ensure that all dates were replaced within the facility procedure.
(12/8/2017)
3. All previous rental mattresses have been removed from the facility and new rental mattresses have replaced the previous mattresses. All current rental mattresses now have the maintenance manual and is being followed accordingly.
(12/8/2017)
A sign off sheet will be implemented on dating of oxygen tubing, humidifier cleaning daily and filter cleaning weekly.
(1/19/2018)
4. Quality Assurance Audits will be conducted on a monthly basis for three months and quarterly thereafter on ensuring all bed mattress rentals have readily available maintenance manuals and are being followed according to manufacturer recommendations. All Quality Assurance Findings will be presented a Quality Assurance Committee for actions as necessary.
Quality Assurance Audits will be conducted on the replacement and dating of oxygen tubing, cleaning of humidifier bottles daily and cleaning of filters weekly. All Quality Assurance findings will be presented at Quality Assurance Committee for actions as necessary.
Overall Responsibility: Director of Nursing

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for one of one emergency generator, the facility did not properly maintain the emergency power system. Specifically, there was no remote annunciator for the emergency power source (generator). This is evidenced by the following: Observations on 11/29/17 at 9:05 a.m. revealed a Generac brand natural gas-powered emergency generator located outside on the East side the facility. A panel on the generator had indicators for: fuel, coolant, oil level, louvres, spark plugs, leakage, and vibration. Further observations throughout the facility revealed there was no annunciator panel for the generator. When interviewed at that time, the Director of Environmental Services revealed there was a system in place to notify him via e-mail and text when the generator was running or there were problems, but there was no actual audible/visual indicator panel at the nurse's station. The 1999 edition of NFPA 99, Health Care Facilities Code directed that a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99:6.4.1.1.17, 6.5.1)

Plan of Correction: ApprovedJanuary 5, 2018

Avon Nursing Home will be submitting an application for a Waiver by 1/15/2018.
Overall Responsibility: Director of Environmental Services
Contingency Plan:
Avon Nursing Home currently has a contract with an outside generator company. This generator company monitors all aspects of facility generator. Monitoring system sends all alerts and notifications directly to the Director of Environmental Services and secondary contact via cell phone and email 24/7 on any actions and errors that may occur with generator.

EMERGENCY OFFICIALS CONTACT INFORMATION

REGULATION: [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 1, 2017
Corrected date: February 1, 2018

Citation Details

Based on an interview and record reviews conducted during the Emergency Preparedness Plan review in conjunction with the Life Safety Code Survey, it was determined that the facility did not comply with Emergency Preparedness requirements. Specifically, the emergency officials contact information did not include the Office of the State Ombudsman. This is evidenced by the following: On 11/29/17 from 9:30 a.m. to 3:00 p.m., the facility's Emergency Preparedness Plan was provided for review. There was no contact information for the Office of the State Ombudsman contained within the plan. When interviewed at that time, the Director of Environmental Services and the Administrator revealed a guide that they were using to develop the Emergency Preparedness Plan which contained the contact information that was going to be in the plan. The facility must develop and maintain an Emergency Preparedness Communication Plan that complies with federal, state and local laws and must be reviewed and updated at least annually. The communication plan must include contact information for the Office of the State Long-Term Care Ombudsman. (42 CFR 483.73 - Emergency Preparedness; 42 CFR 483.73(c)(2)(iii))

Plan of Correction: ApprovedDecember 29, 2017

Preparation and execution of this plan of correction does not constitute admission or agreement by the facility of the facts alleged or conclusion set forth in the statement of deficiencies. This plan of Correction is prepared and executed solely because it is required by the provisions of
State law.
1. Director of Environmental Services (DES) immediately revised Facility Emergency Preparedness Plan. DES placed The Office of the State Ombudsman contact information in Facility?s Emergency Preparedness Manual.
(11/29/2017)
2. The Office of the State Ombudsman contact information was placed in Facility?s Emergency Preparedness Manual and was corrected on 11/29/17, immediately upon findings.
(11/29/2017)
3. Facility Emergency Preparedness Plan will be reviewed and revised on an annual basis, ensuring that all requirements are met and are readily accessible in Emergency Preparedness Plan.
(12/1/2017 and ongoing)
4. Emergency Preparedness Plan will be reviewed and revised on an annual basis. If any changes are made it will be reviewed and discussed at Quality Assurance Committee Meetings.
(12/1/2017 and ongoing)
Overall Responsibility: Director of Environmental Services