Elderwood at Ticonderoga
July 28, 2017 Certification Survey

Standard Health Citations

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Riley, Barbara A. Based on record review and interviews conducted during a recertification survey, the facility did not ensure that it developed a comprehensive care plan (CCP) for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 5 (five) (Resident #'s 4, 5, 55, 57 and #81) of 16 (sixteen) residents reviewed. Specifically: For Resident #4, the facility did not ensure a CCP was developed for suicidal ideation; For Resident #81, the facility did not ensure a CCP was developed for [MEDICAL CONDITION] medications and; For Resident #57, the facility did not ensure a CCP was developed for anti-anxiety medications. This is evidenced by: Resident # 4: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The (MDS) of 7/20/17, assessed the resident understands, was understood and had a Brief Interview of Mental Status of 12/15 or moderately impaired cognitive ability. A Nursing Progress Note dated 12/9/16, documented: The resdient's daughter came to visit the resident. She came to the desk and said he refused his laboratory tests and said he could refuse medications, to eat and there is nothing she could do. He hates this place. She said her dad said he was going to commit suicide. She decided to leave because he stopped talking to her. The Nurse went down to talk to the resident. He said he hated it here, that he was going to commit suicide, and that he didn't want to live. The Nurse spoke to the DON (Director of Nurses), the resident was placed on 15 minute checks, his suspenders, belt, electric shaver and gait belt were removed. The MD was notified. A physician progress notes [REDACTED]. He does not want to go to Plattsburg to have a psychiatric doctor take care of him. Promised to work with him in a week or so to make him more comfortable, he settled down and agreed to come out of his room and have some dinner and watch a movie. Review of the medical record did not include documented evidence of a Comprehensive Care Plan (CCP) to address the resident's suicidal ideation. During interview on 7/28/17 at 11:09 am, the Registered Nurse Manager (RNM) was asked if there was a CCP for the resident's suicidal ideation back in December. She stated she may have thought the social worker did one. The RNM said someone would normally initiate a CCP for suicidal ideation. She looked in the computer and said she could not find a CCP addressing suicidal ideation. During interview on 7/28/17 at 11:21 am, the Social Worker (SW) was asked about the resident's suicidal ideation on 12/9/16. She looked in the computer and said there were no SW notes around that time. She stated the first SW note was on 12/15/16, when the resdient asked for a room change. She stated she did not remember the incident, she did not know if she was made aware. The SW stated that if she was made aware she would have documented something. She stated that when suicidal ideation occurs it would be put into a care plan. She stated SW did not have anything in a CCP. Resident #57: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) of 12 indicating a moderate cognitive impairment. The resident is assessed to be usually understood by others and others usually understand the resident. Physician orders [REDACTED].) Give 1 tablet by mouth at bedtime for anxiety. The electronic Medication Administration Record [REDACTED]. by mouth at bedtime for anxiety, 0.25 mg. total dose. Review of the Comprehensive Care Plans (CCP) did not include documented evidence of a CCP for anti-anxiety medications to include potential side effects and nursing considerations for the medication [MEDICATION NAME]. During interview on 7/28/17 at 9:55 am, the Registered Nurse Manager (RNM) stated there needs to be a CCP for anti-anxiety medications. The former CCP for anti-anxiety mediations may have been deactivated because of medication changes for the resident. Resident #81: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severely impaired for cognition, was able to understand others and sometimes was understood. Policy and Procedure for Care Planning revised 4/2017, documented it is the policy of the facility to use an interdisciplinary process to develop and maintain an individualized person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, nutritional, therapy, activity and psychosocial needs. The services that are to be furnished must help to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan is designed to address identified problem areas, assess risk/benefit factors, reflect treatment goals and objectives that are realistic and have measurable outcomes. Progress notes dated 1/06/17 at 3:11 pm, documented the resident was admitted to the facility from the hospital. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The electronic Medication Administration Record [REDACTED]. The electronic Medication Administration Record [REDACTED]. Progress notes dated 2/09/17 at 9:20 am, documented the resident was discharged to home. Progress notes dated 2/23/17 at 12:30 pm, documented the resident was admitted to the facility from the hospital. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The eMAR for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] 0.25 mg at bedtime for agitation from 2/23/17 to 3/03/17. The eMAR for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] (an anti-anxiety medication) 1 mg every 2 hours PRN for anxiety/distress on 2/23/17 at 10:56 pm. The eMAR for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] 2 mg every 2 hours PRN for anxiety/distress on 2/28/17 at 10:30 pm. During an interview on 7/21/17 at 9:35 am, Registered Nurse Manager (RNM) #1 stated the resident was admitted to the facility for rehab on three occasions. Each time, the resident was admitted to the facility with an order for [REDACTED]. The RNM stated the [MEDICATION NAME] was not effective in treating the resident's agitation as he would do better when not on it. The RNM reviewed resident's careplans and was not able to locate a [MEDICAL CONDITION] careplan. She stated there should have been a careplan for the anti-psychotic as well as for the other [MEDICAL CONDITION] medications the resident was taking. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedAugust 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Facility shall comply with 483.20(d);483.21(b)(1) DEVELOP COMPREHENSIVE CARE PLANS
Corrective action(s) accomplished for resident(s) that have been affected by the deficient practice:
For residents #4, 5, 55, and 57:
Resident's #4, 5, 55, and 57's comprehensive care plans were reviewed and updated to include the use of [MEDICAL CONDITION] medications.
For resident #4:
Resident #4's comprehensive care plan was updated to include suicidal ideation.
For resident #81:
Resident #81 was discharged from the facility.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
1)All resident's orders were audited for the use of [MEDICAL CONDITION] medication and then audited to ensure that they had a care plan for [MEDICAL CONDITION] medications.
2)Any residents with known history of having had suicidal ideation were identified and their care plans reviewed and updated.
Measures put in place to ensure that the deficient practice does not recur:
1)Education regarding the need for comprehensive care plans to be completed for [MEDICAL CONDITION] medications and suicidal ideation to be completed for the nursing and social work departments.
2)Policy regarding response to suicidal ideation reviewed and updated. Nursing and Social Services educated on the policy.
Corrective actions will be monitored to ensure the deficient practice will not recur:
1)All new/changed orders for [MEDICAL CONDITION] medications will be audited and a care plan will be initiated or updated for [MEDICAL CONDITION] medications. The audits will be performed daily times one month, then weekly times 4 weeks, then monthly times 3 months. Results will be reported to the QAPI committee who will determine continued need for monitoring and frequency.
2)24 hour shift report will be reviewed by Nurse Manager/Social Services daily (Monday through Friday) to ensure that any resident identified as having suicidal ideation is followed up on according to policy. This monitoring will occur daily times one month, weekly times 4 weeks, monthly times 3 months. Results will be reported to the QAPI committee who will determine continued need for monitoring and frequency.
The Director of Nursing is responsible for this Plan of Correction.

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Food Code, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that equipment and surfaces shall be kept clean and food workers are to wear hair restraint. Specifically, various food contact surfaces in the kitchen were not clean and not all food workers practiced effective hair restraint while working with food. Also on the Lake Placid Lodge Unit, the microwave in the Dining Room had a large amount of dry liquid food spillage and the refrigerator/freezer contained food that had expired or was not labeled and dated and a couple of strands of hair adhered to the outside of a food container. This is evidenced as follows. Finding #1: Main Kitchen The main kitchen was inspected on 07/26/2017 at 2:30 pm. The slicer and fire extinguisher were soiled with food particles or dust. The nourishment kitchen on the Patriot Unit was inspected on 07/25/2017 at 11:10 am and again on 07/28/2017 at 10:00 am. The interior of the microwave oven was soiled with food particles. The Chef Manager stated in an interview conducted on 07/26/2017 at 2:30 pm, that he will ensure the slicer is cleaned more thoroughly and will have maintenance clean the fire extinguisher. Finding #2: Main Dining Room On 7/25/17 at 4:10 pm, a male food service worker (FSW) brought food on a rolling cart to the main dining room. He did not have hair restraint on his head and beard. He left the Dining room and came back with a hair net on his head. There was no beard covering. He served food to the residents in the dining room and made room trays for the other residents not in the dining room without his beard covered. The Chef was asked about the lack of a beard restraint for the FSW. He stated it was not necessary if the beard was neat and trimmed. He said he was going by restaurant guidelines. 483.35(i)(2); 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110
Finding #3 Dining Room on the Lake Placid Lodge Unit The facility did not ensure that the microwave and refrigerator/freezer in the Dining Room of the Lake Placid Lodge Unit was clean and free of food spillage and the refrigerator/freezer contained only food that was labeled and dated and had not expired. This was evidenced by the following observations: 7/25/17 at 11:15 am, the inside of the microwave was observed to have a large amount of dry brown colored liquid spillage. 7/25/17 at 11:15 am, the inside of the refrigerator was observed to have 2 strands of brown hair adhered to the outside of a small Styrofoam bowl containing approximately 6 individually wrapped single serving pats of butter. There was also a plastic bag containing a jar of mayonnaise and cheese not labeled or dated, a large insulated tote bag with small plastic containers of food which was not labeled or dated , and an opened squeezable container of mayonnaise with an expiration date of 7/17/17 which was 8 days beyond the expiration date. 7/25/17 at 11:15 am, the inside of the freezer section of the refrigerator was observed to contain 2 opened half empty containers of Stewart's ice cream which were not dated or labeled, and 1 pint size container of gelato which was opened and not dated or labeled. The facility Policy Titled Refrigerator Checks/Cleaning effective 7/2017 documented the following: POLICY: Separate refrigerators are located on each units of the nursing home for the storage of resident and staff food. Procedure : Dietary Department will clean up any spills found in the refrigerators and/or freezers as needed. Nursing Home Staff will check refrigerators and freezers daily to ensure compliance with policy: Any food/beverage items must be stored in original container,sealed and labeled with the resident's name and date. no food/ beverage can be left for more than 3 days. Discard any outdated items. Clean up any spills. Housekeeping staff will: Perform deep clean of all refrigerators every other week and document on form provided. During an observation and interview with the Nurse Manager (NM) of the Lake Placid Lodge Unit on 7/27/17 at approximately 4:30 pm , the NM observed the spillage in the microwave, the hair adhered to the outside of the Styrofoam bowl containing the individually wrapped pats of butter, the expired squeezable container of mayonnaise in the refrigerator, and the opened containers of ice cream and gelato which were not labeled or dated. The large insulated tote and the plastic bag with food in plastic containers which were not labeled or dated had been removed . The NM stated that she thought that the refrigerator/freezer was cleaned a few days ago and that staff are well aware that they are not to store any of their food in this refrigerator and any resident's food that is placed in the refrigerator and freezer has to be labeled with the resident's name and the date that it was placed in the refrigerator or freezer. The NM also stated that nursing does not keep a sign off list with dates that the nursing staff has checked the refrigerators and freezers and was not aware if the Housekeeping Department kept a list of who and when the microwave , refrigerator and freezer were last cleaned.

Plan of Correction: ApprovedAugust 25, 2017

The Facility shall comply with 483.60(i)(1)-(3) FOOD PR(NAME)URE, STORE/PREPARE/SERVE - SANITARY
Corrective action(s) accomplished for deficient practice is as follows:
1)All surfaces identified as not meeting the standard were cleaned (specifically refrigerators, microwaves, slicer, fire extinguisher).
2)Staff member not wearing beard net was immediately re-educated and put on beard net.
The Facility will identify other areas having the potential to be affected by the same deficient practice:
1)Facility identified locations of all refrigerators and microwaves not identified in statement of deficiency and ensured all were cleaned properly.
The facility shall put in place the following procedures so that the deficient practice does not recur:
1)The refrigerator checks/cleaning policy was reviewed and updated to include microwaves. Staff were educated on policy which includes checks from dietary, nursing and deep cleaning from housekeeping staff.
2)The dietary staff were re-educated on the policy regarding hair nets and beard guards.
3)signs were placed by the microwaves to inform staff to clean up any spills immediately after use.
4)A cover was ordered and received for the slicer.
Corrective actions will be monitored to ensure the deficient practice will not recur:
1)Inspections of refrigerator and microwaves will be done daily from nursing and dietary and a deep clean will be completed every other week by housekeeping. This will be documented on log sheets. The logs will be audited daily times one month, weekly times 4 weeks, and monthly times 3 months. Results will be reported at QAPI committee who will determine continued need for monitoring and frequency.
2)Three forms in the dietary department have been revised:
a)Opening Manager/Supervisor Checklist; (added slicer cleaned and covered (daily); spot checks for hair restraints/beard guards (daily) and completion of sanitation audit (weekly)).
b)Closing Manager/Supervisor Checklist (added slicer cleaned and covered (daily), refrigerators cleaned (daily); and
c)Weekly Sanitation Audit (added fans/vents/fire extinguishers, and slicer (weekly)).
3)Dietary will audit these forms daily times one month, weekly times 4 weeks, then monthly times 3 months. Results will be reported at QAPI committee who will determine continued need for monitoring and frequency.
4)The refrigerators, microwaves, slicer and fans/vents/fire extinguishers, will be added to the Environmental Rounds which will take place 3x/week for 4 weeks, then monthly for 3 months. The results will be reported at QAPI committee who will determine the need for continued monitoring and frequency.
The Director of Dietary is responsible for this Plan of Correction.

FF10 483.25(b)(2)(f)(g)(5)(h)(i)(j):TREATMENT/CARE FOR SPECIAL NEEDS

REGULATION: (b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident?s medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments (f) Colostomy, ureterostomy, or ileostomy care. The facility must ensure that residents who require colostomy, ureterostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident?s goals and preferences. (g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to ? prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (h) Parenteral Fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident?s goals and preferences. (i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents? goals and preferences, and 483.65 of this subpart. (j) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents? goals and preferences, to wear and be able to use the prosthetic device.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure a resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive care plan (CCP) for one (Resident #43) of four resident's reviewed who needed oxygen therapy during the recertification survey. Specifically: For Resident #4: the facility did not ensure the resident received oxygen at the physician ordered flow rate, did not ensure the CCP was consistent with the physician order; did not ensure education was provided and documented in regards to the potential negative effects of the resident's manipulation with the flow rate of oxygen; and did not ensure the resident's physician was notified of the resident's manipulation with the flow rate of oxygen. This is evidenced by: Resident #43: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 7/7/17, assessed the resident understands, was understood, and had a Brief Interview of Mental Status (BIMS) of 15/15 or no cognitive impairment. It documented the resident received oxygen therapy. A current physician order, undated but currently in use, documented: Oxygen 2 liters continuous via nasal canula. The Treatment Administration Record (TAR) for (MONTH) (YEAR), documented under Unscheduled Other Orders: Oxygen 2 liters continuous via nasal canula. The resident's CCP for [MEDICAL CONDITION], initiated 9/1/16, documented an intervention to give oxygen/Nebulizer therapy as ordered by the physician. The resident at this time is continuous on 3 liters. During interview of a group of residents on 7/25/17 at 2:00 pm, the resident stated there was a night he ran out of oxygen and it took staff a long time to come to help him. On 7/25/17 at 4:54 pm, the resident was observed in the Dining Room sitting at a table. His oxygen was on via nasal canula. The tank meter was in the red, but not empty. The flow rate was at 3 liters. On 7/26/17 at 7:34 am, the resident was in the dining room at his table. His oxygen was running at 4 liters and the tank was half full. At 12:30 pm, the resident was in the dining room with his oxygen running at 4 liters. At 12:57 pm, the resident was in his room in bed with the oxygen running via concentrator at 3 liters. On 7/27/17 at 8:21 am, the resident was in the dining room eating breakfast. His oxygen was running at 3 liters. On 7/28/17 at 8:27 am, the resident was in the dining room eating breakfast. His oxygen was running at 4 liters. During interview on 7/28/17 at 8:30 am, the Registered Nurse (RNMN) Medication Nurse, stated the resiient was on oxygen at 2 liters per minute when she looked in the computer. She said she was not the usual medication nurse. The nurse went to the resident's room and said the concentrator was running at 3 liters. She said the resdient sets the flow rate himself. She stated that when the resident was on the tank of oxygen it should be at 2 liters. She was told the resident was in the dining room on 4 liters now and she stated the resident did that himself. She stated that she had set his oxygen at two liters when he was changed to the tank this morning. The RNMN stated that she heard that the resident changes the flow rate himself. During interview on 7/28/17 at 9:58 am, the Licensed Practical Nurse (LPN), stated the resident is supposed to be at 2 liters per minute for oxygen. She stated the resident likes to turn the oxygen up when he is moving around, i.e. walking to the bathroom. She stated that the morning is the worst time for the resident, he is up and moving around and gets short of breath (SOB). She stated the resident has end stage [MEDICAL CONDITION] and has good days and bad days. She was asked if he had ever run out of oxygen. She stated that there was a time when the tank was in the red, but not empty. She stated that when she is in the dining room she will periodically check his tank, but it is not on the Medication Administration Record [REDACTED]. She stated she believed the MD (Medical Doctor) was aware the resident changes the flow rate. The LPN said that she had told the Registered Nurse Manager (RNM) he changes the rate. She stated she had never educated the resident that it was not good to change the flow rate. She stated she turns the oxygen down when she sees it is wrong. During interview on 7/28/17 at 10:11 am, the RNM stated that if the resident is SOB, he will get very anxious. She stated there was no incident when he had actually run out of oxygen. She stated that he dials his own flow rate at times. She stated that she had spoken to him that he should not change the flow rate. She stated that she had noticed the CCP said 3 liters and the order was for 2 liters when she looked this morning. She thought the physician had ordered 2-3 liters of oxygen. She said the resident should have enhanced monitoring of oxygen in the CCP and she had added it that morning, it wasn't there previously. The RNM stated the physician was aware the resident changes his flow rate and had talked with him about it. She did not know if the physician had documented it. Approximately an hour later, the RNM stated that there was no documentation the physician was made aware the resident changes his oxygen flow rate or had gone to see the resdient about that. She said there were no physician notes by any physician that they were made aware the resident changes his flow rate. The RNM also stated there was no order for 3 liters of oxygen. During interview on 7/28/17 at 10:23 am, a facility physician was asked if a physician would be made aware a resident was changing his own oxygen flow rate. He stated that the physician should probably be notified. He also stated that too high a flow rate could be harmful to a resident. Changing a liter or so probably was not harmful, but he would not want the resident to keep raising the flow rate. During interview on 7/28/17 at 12:10 pm, the resident's physician stated he could not remember if he was notified the resident changes his oxygen flow rate. He stated if he was made aware he would want to determine if oxygen levels dropped when the resident exerted himself, i.e. make the trip to the dining room. If it dropped, then the resident would need a higher flow rate. He did not remember if this was done, he presumed there would have been documentation someplace if done. During interview on 7/28/17 at 12:57 pm, the RNM stated the physician never officially ordered to do the above mentioned trial. It had not been done. 10NYCRR415.12(k)(6)

Plan of Correction: ApprovedAugust 21, 2017

The Facility shall comply with 483.25(b)(2)(f)(g)(5)(h)(i)(j) TREATMENT/CARE FOR SPECIAL NEEDS.
Corrective action(s) accomplished for resident that has been affected by the deficient practice:
For resident #43:
1) Resident # 43: physician was notified of resident's manipulation of O2 and was seen by the physician on 8/16/17, a progress note was written, and orders clarified for 2 Liters of O2.
2)Education was provided to resident regarding the potential negative effects of the resident's manipulation with the flow rate of oxygen.
3)Comprehensive Care Plan was updated to reflect physician ordered liter flow of 2 Liters as well as resident's self manipulation of oxygen.
4)Orders were added in the EMAR to check for appropriate liter flow 2X each shift.
Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken:
1) All residents who use O2 were reviewed to identify any residents at risk for self manipulation of O2.
2)Any residents identified as being capable of manipulation of O2 will be educated on the potential negative effects of the resident's manipulation with the flow rate of oxygen.
Measures put in place to ensure that the deficient practice does not recur:
1)all new admissions admitted with O2 orders and any existing residents with new orders for O2 will be assessed for risk of manipulation of O2.
2)Those identified as at risk will be educated on the potential negative effects of the resident's manipulation with the flow rate of oxygen. The physician will be notified and a care plan will be initiated.
Corrective actions will be monitored to ensure the deficient practice will not recur:
1)All new admissions/new orders for O2 will be audited to ensure that those residents are assessed and identified. Audits will be completed daily times one month, weekly times 4 weeks, and monthly times 3 months. Results will be reported at QAPI committee who will determine continued need for monitoring and frequency.
The Director of Nursing is responsible for this Plan of Correction.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, corridor doors were not free of impediments to closing the doors in the event of a fire emergency. NFPA 101 Life Safety Code 2012 Edition section 19.3.6.3.10 requires that corridor doors shall not be held open by devices other than those that release when the door is pushed or pulled. Specifically, on 1 of 2 resident units, corridor doors would latch closed when shut. This is evidenced as follows. The Adirondack Unit corridor doors were inspected on 07/27/2017 at 9:00 am. When checked, one of the double leaf doors each to the Library and Main Dining Room would require opening the other leaf to close the door. The Plant Engineer stated in an interview conducted on 07/27/2017 at 9:00 am, that he would adjust these doors to close properly. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.6.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.6.3

Plan of Correction: ApprovedAugust 21, 2017

The Facility shall comply with NFPA 101 Life Safety Code 2012 Edition section 19.3.6.3.10 requires that corridor doors shall not be held open by devices other than those that release when the door is pushed or pulled.
The Plan of Correction for this deficient practice is as follows:
1) The double leaf doors to the Library and Main Dining Room were adjusted to properly close according to the Life Safety Code. Completed 8/11/17.
The Facility will identify other areas having the potential to be affected by the same deficient practice by:
1) All doors were inspected to ensure that they release when the door is pushed or pulled. Completed 8/18/17.
The Facility will monitor its corrective actions to ensure that the deficient practice will not recur:
1) There will be an annual review of all doors to ensure proper functioning according to NFPA 101 Life Safety Code 2012 Edition section 19.3.6.3.10.
The Director of Plant Operations is responsible for this Plan of Correction.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. Specifically, non-compliant power strips were used to power patient care-related equipment and non-patient care electrical devices in patient care areas on 2 of 2 units. This is evidenced as follows. The facility was assessed for use of power strips on 07/27/2017 at 2:10 pm. A non-compliant power strip was used to power the medical care mattress and window air conditioner in resident room [ROOM NUMBER]. A non-compliant power strip was used to power the medical vacuum pump in resident room [ROOM NUMBER]. A non-compliant power strips were used to power personal electronics and window air conditioning units in resident room [ROOM NUMBER], the Adirondack Unit dining room, and the Restorative Nursing exercise room. The Plant Engineer stated in an interview conducted on 07/27/2017 at 2:10 pm, that the building will be checked for power strips and only compliant power strips will be used. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedAugust 21, 2017

The Facility shall comply with NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment.
The Plan of Correction for this deficient practice is as follows:
1)The Facility has ordered all new power strips that meet the standard (Quote date 8/2/17).
The Facility will identify other areas having the potential to be affected by the same deficient practice by:
1)The Facility has removed all non-compliant power strips. Completed 7/28/17.
The Facility shall put in place the following procedures so that the deficient practice does not recur:
1) All power strips coming into the building will be inspected by maintenance and only put in to service if compliant.
2)The formulary for purchasing power strips was updated to ensure that only compliant power strips are purchased.
The facility will monitor it's corrective action to ensure the deficient practice does not recur:
1) Maintenance will do a quarterly audit of all power strips to ensure all meet the standards and are in compliance.
2)A report of the audit will be submitted to QAPI quarterly and the QAPI committee will make recommendations for continued monitoring.
The Director of Plant Operations is responsible for this Plan Of Correction.

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

REGULATION: Fundamentals - Building System Categories Building systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

Based on staff interview during the recertification survey, the facility did not conduct a building systems risk assessment as required by adopted regulation. NFPA 99 Standard for Health Care Facilities 2012 Edition section 4.2 requires that building systems, such as electrical systems and heating, air conditioning, and ventilation systems, are to undergo a formal and documented risk assessment by qualified personnel. Specifically, the required building systems risk assessments were not conducted. This is evidenced as follows. The Plant Manager stated in an interview conducted on 07/27/2017 at 10:55 am, that the facility building systems have not undergone a risk assessment and been assigned risk categories. 42 CFR 483.70 (a) (1); 2012 NFPA 99 4.2

Plan of Correction: ApprovedAugust 21, 2017

The Facility shall comply with NFPA 99 Standard for Health Care Facilities 2012 Edition section 4.2 requires that building systems, such as electrical systems and heating, air conditioning, and ventilation systems, are to undergo a formal and documented risk assessment by qualified personnel.
The Plan of Correction for this deficient Practice is as follows:
1)A Risk Assessment of the building systems was completed by qualified personnel on 8/3/17.
The Facility will monitor it's corrective action to ensure that this deficient practice will not recur:
1)The facility will ensure that all inspections and preventive maintenance is completed on building systems.
2)The Director of Plant Operations or designee will submit report to QAPI any issues related to the risk assessment requiring action for inspection, preventive maintenance or repair/replacement.
The Director of Plant Operations is responsible for this Plan of Correction.

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, staff were not handling medical oxygen cylinders safely and the facility did not provide continuing education associated with the handling medical oxygen cylinders. This is evidenced as follows. On 07/26/2017 at 11:00 am, an oxygen cylinder was found free standing and not in a cylinder cart in the Restorative Nursing exercise room. The Director of Nursing stated in an interview conducted on 07/27/2017 at 9:10 am, that the facility has not provided the pertinent staff with training on the risks and use of oxygen cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedAugust 21, 2017

The Facility shall comply with NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use.
The Plan of Correction for this deficient practice is as follows:
1) The oxygen cylinder was immediately removed and properly stored.
2)The Restorative Nursing Aide was educated regarding proper use of/storage of oxygen completed 7/27/17.
The Facility will identify other areas having the potential to be affected by the same deficient practice:
1) Facility wide education for staff was initiated 7/27/17 regarding the risks and use of oxygen cylinders.
The facility will put into place the following procedures so that the deficient practice does not recur:
1) Education associated with the risks and use of handling oxygen cylinders has been added to the orientation for new employees and will be added to annual orientation.
The Director of Plant Operations is responsible for this Plan of Correction.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust, and section 5.3.3.1 requires that alarming devices servicing sprinkler systems shall be tested quarterly. Specifically, on 2 of 2 resident units, sprinkler heads were found with a coating of dust, and 1 of the past 4 required sprinkler system flow alarm device tests was not conducted. This is evidenced as follows. An assessment of the sprinkler system was conducted on 07/27/2017 at 2:10 pm. Sprinkler heads were found with a coating of dust in resident rooms [ROOM NUMBERS], C-Bathing room, Adirondack Unit common area, and the Courtyard entrance on the Patriot Unit. The Plant Engineer stated in an interview conducted on 07/27/2017 at 2:10 pm, that he will have the dusty sprinkler heads cleaned. The sprinkler system test reports were reviewed on 07/27/2017. These records show that the sprinkler system flow alarms were not tested during the second quarter of (YEAR). 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1, 5.3.3.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8, 5-3.3.1

Plan of Correction: ApprovedAugust 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Facility shall comply with the NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust, and section 5.3.3.1 requires that alarming devices servicing sprinkler systems shall be tested quarterly.
The Plan of Correction for this deficient practice is as follows:
1) The sprinkler heads in resident rooms [ROOM NUMBERS], C-Bathing room, Adirondack Unit common area, and the Courtyard entrance on the Patriot Unit were cleaned. Completed by 8/3/17.
The Facility will identify other areas having the potential to be affected by the same deficient practice by:
1) All sprinkler heads were assessed and cleaned immediately upon inspection of needed. Completed by 8/3/17.
The facility shall put in place the following procedure so that this deficient practice does not recur:
1)A Policy entitled Weekly Sprinkler Head Cleaning was created and maintenance staff educated on the new policy.
2) A Sprinkler Head Check List for preventive maintenance has been created and will be performed weekly.
3) All sprinkler heads found to be out of compliance will be immediately cleaned.
The Facility will monitor its corrective actions to ensure the deficient practice does not recur:
1) The Sprinkler Head Check List will be audited to ensure compliance and will be reported to the monthly QAPI Committee for 3 months. The QAPI Committee will review for further recommendations regarding reporting.
The Director of Plant Operations is responsible for this Plan of Correction.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.5 requires that smoke barriers shall be continuous from floor to the underside of the roof and through all concealed spaces, and penetrations and miscellaneous openings be sealed with materials capable of maintaining the fire rating of the smoke barrier wall. Specifically, 1 of 1 smoke barriers observed was not continuous and the fire rating was not maintained. This is evidenced as follows. The Adirondack/Common Core smoke barrier wall (wall) was inspected on 07/27/2017 at 9:40 am. In resident room 201, 22-foot length of 6-inch by 4-inch through-holes were the wall meets the underside of the roof were not sealed. In the corridor, an 8-foot by 16-inch metal beam was not fire-protected and did not have a fire-resistance rating. The Plant Engineer stated in an interview conducted on 07/27/2017 at 9:40 am, that he will enclose the meal beam and all penetrations found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedSeptember 5, 2017

The Facility shall comply with NFPA 101 Life Safety Code 2012 edition section 8.5 requires that smoke barriers shall be continuous from floor to the underside of the roof and through all concealed spaces, and penetrations and miscellaneous openings be sealed with materials capable of maintaining the fire rating of the smoke barrier wall.
The Plan of Correction for this deficient practice is as follows:
1)Resident room 201, where the wall meets the underside of the roof was sealed; Completed 8/3/17; and the metal beam was fire protected with a fire-resistant rating; Completed 8/4/17.
The Facility will identify other areas having the potential to be affected by the same deficient practice by:
1) Random audits of 6 walls per quarter will be inspected and any spaces found to be out of compliance will be rectified.
The Facility will monitor it's corrective action to ensure that the deficient practice will not recur:
1)Results of the audits will be brought to the QAPI Committee quarterly. The QAPI Committee will make recommendations for the need for continued monitoring.

The Director of Plant Operations is responsible for this Plan of Correction.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Specifically, the walls of 1 of 1 stairwells observed did not maintain a 1-hour fire resistance rating. This is evidenced as follows. The Adirondack stairwell was inspected on 07/27/2017 at 10:20 am. An 8-foot length of metal I-beam and the 6-inch by 4-inch spaces above the I-beam were covered and packed loosely with mineral wool insulation and did not maintain the fire resistance rating of the stairwell walls. The Plant Engineer stated in an interview conducted on 07/27/2017 at 10:20 am that he will properly enclose the metal beam and spaces found in the stairwell wall. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedAugust 21, 2017

The facility shall comply with the with the NFPA 101 Life Safety Code 2012 edition section 8.6.2: Vertical Openings - Enclosure, specifically that stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour.
The Plan of Correction for this deficient practice is as follows:
1)The I-beam was inspected and work was completed to enclose according to the NFPA 101 Life Safety Code to maintain the 1 hour fire resistance rating. Completed 8/4/2017.
The Facility will identify other areas having the potential to be affected by the same deficient practice by:
1) The Plant Operations Director/designee will complete an audit to ensure that vertical openings, such as stairwells are inspected to ensure they meet the requirements of the Life Safety Code section 8.6.2.
2)Areas found to not be in compliance will be fixed according to Life Safety Code.
The Facility will monitor it's corrective actions to ensure that the deficient practice will not recur as follows:
1)The Director of Plant Operations/designee will submit a report of the audit to the QAPI Committee monthly for three months then quarterly at the discretion of the QAPI Committee.

The Director of Plant Operations is responsible for this Plan of Correction.