Bedford Center for Nursing and Rehabilitation
February 6, 2017 Certification Survey

Standard Health Citations

E3BP 402.6(b):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (b) A provider requesting a criminal history record check pursuant to this Part shall do so by completing and submitting a form developed and provided by the Department after consultation with the Division and transmitting two sets of fingerprints to the Department. An authorized person, and only an authorized person, shall complete such form and shall submit the original with the authorized person signature (not a facsimile signature) and two sets of fingerprints to the Department not more than ten days (excluding Saturdays, Sundays and legal holidays) after taking the fingerprints of the prospective employee. The Department shall maintain such form, in the form and format prescribed by the Department, which: (1) identifies the name of each person for whom the provider requests a criminal record check, and attests that each such person is a prospective employee of the provider, and, as such, the person is a subject individual, as defined in this Part; (2) identifies the specific duties of the subject individual which qualify the provider to request a check of the subject individual's criminal history information; (3) attests that the results of the criminal history record check will be used by the provider solely for the purposes authorized by law; and (4) attests that the provider, its agents, and employees are aware of and will abide by the confidentiality requirements and all other provisions of Public Health Law Article 28-E and Executive Law section 845-b, as they may from time to time be amended.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: April 1, 2017

Citation Details

Based on interview and record review, the facility did not ensure that timely submission for Criminal History Record Check (CHRC) was conducted for 1 of 5 prospective employees. (Employee #4). The finding is: Review of the personnel file for Employee #4 revealed the employee was hired on 12/19/16 as the Director of Admissions. There was no documented evidence that the employee was submitted for CHRC review. On 02/02/2017 at 11:43AM, the facility Authorized Person was interviewed and stated that she submits all unlicensed staff for CHRC and must have missed submitting this employee. She further stated that the employee was employed at a sister facility in the past and she did not think she needed to submit her again. On 02/03/2017 at 10:54AM, an interview was conducted with the Director of Admissions who stated that she was hired in (MONTH) (YEAR). She further stated that she is involved in the admission process which entails preparing charts and delivering them to the units and providing family members with tours on the unit when required. She also that her last position was outside of this organization and that she has had prior submission to CHRC when she worked at other facilities. Review of the facility policy entitled Criminal History Background Check dated 5/2015 documents that the facility requires that a DOH CHRC criminal history record check be performed on any non-licensed individuals to be employed.

Plan of Correction: ApprovedMarch 2, 2017

I. Corrective Actions for Residents Identified
? Employee #4 ? Request for CHRC was submitted on 2/2/17 and determination letter was received on 2/2/17.
II. Residents at Risk
? All residents have the potential to be affected by this practice.
? All files of non-licensed personnel hired within the last 6 months were audited for compliance with CHRC submission.
III. Systemic Changes
? Facility Authorized CHRC person was re-educated on CHRC Policy and Procedure
? CHRC log was developed and being implemented for potential/new hired employees, which includes CHRC submission with date.
IV. Monitoring of Corrective Actions
? Facility Authorized CHRC person will maintain log of all potential employees and submit to Administrator weekly for 3 months.
? On a weekly basis for 3 months, Administrator or designee will review random files for a proof of CHRC submission.
? On a quarterly basis, Administrator or designee, will report results to QA Committee.
? QA Committee to determine if further action is required.

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: April 1, 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 that a resident's drug regimen was free from unnecessary drugs. Specifically: 1) Insulin was administered to a resident when the blood glucose level was below the ordered parameters (Resident #44) and; 2) [MEDICAL CONDITION] medication was re-ordered for a resident with a [DIAGNOSES REDACTED]. This was evident for 2 of 5 residents reviewed for Unnecessary Medication Use. (Resident # 44 and #148). The findings are: 1) Resident #44 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/31/17 at 11:00 am during the initial tour of the unit, the resident was observed in the day room, alert and wake. The resident was sitting with other residents at a table and easily engaged in conversation with the SA (State Agency). The Admission MDS (Minimum Data Set) 3.0 assessment dated [DATE] documented intact cognition and limited assistance for activities of daily living. The Comprehensive Care Plan (CCP) for Endocrine/Diabetes dated 9/17/16 and revised 12/16/16 documented the following interventions: Administer med's (medications) as ordered by MD (Medical Doctor), monitor for effectiveness of medications, monitor blood glucose level as ordered, monitor glucose level three times daily. Goals included: resident will be free of signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION] and resident will maintain blood glucose level within acceptable ranges. Physician orders dated 9/16/16 documented: Humalog Subcutaneous Solution 100 Unit/ML Insulin [MEDICATION NAME] (Human) 14 unit(s) subcutaneous 3 times daily before meals. Medical condition: Type 2 Diabetes Mellitus If blood sugar < ( less than) 70 then call MD (Medical Doctor) If blood sugar > ( greater than) 400 then call MD [MEDICATION NAME] Subcutaneous Solution 100 Unit/ML (Insulin) 40 unit(s) subcutaneous bedtime The Medication Administration Records (MAR) dated 9/2016 to 2/2017 were reviewed and documented that on 1/14/17 at 11:30 am, the fingerstick reading was 68 mg/dl (milligrams/deciliter). The documented dosage of Insulin that was administered was 14 units of Humalog Insulin. On the same day 1/14/17, the LPN documented in the comment section of the MAR indicated [REDACTED]. The note further documented that 14 units of Insulin was administered per the resident's request. There was no documented evidence that the Physician was contacted in accordance with the order for contacting the doctor if the blood sugar was below 70. On 2/2/17 at 1:31 PM, an interview was conducted with the LPN (Licensed Practical Nurse) who administered the insulin on 1/14/17. The LPN acknowledged that the Physician order documents that the Physician is to be called if the blood sugar is less than 70 mg/dl and greater than 400 mg/dl. The LPN further stated that she administered the Insulin because the resident insisted that the Insulin be administered after her blood sugar was rechecked. The nurse was unable to explain why the physician was not contacted. On 2/3/17 at 12:45 PM, an interview was conducted with the resident who stated that she has been diabetic for many years and receives insulin three times a day. The resident further stated that sometimes she does not have an appetite and when they give her the insulin her blood sugar drops. The resident also stated many times they have to give me some orange juices and I will begin to shake or have blurred vision. 0n 2/3/17 at 1:00 PM, an interview was conducted with the unit RN (Registered Nurse) Nurse Manager who stated that the resident is on a standing scale order for Humalog insulin. The RN further stated that she does had not directly observe the LPN's administering Insulin but believed they were following the doctors orders. The facility policy for Guidelines for Safe Administration of Insulin dated 6/2016 documented the following: the nurses must check the physician order. Confirm the blood glucose result as ordered, recheck the amount of insulin drawn before injection, document the amount of insulin administered. 2) Resident #148 is an [AGE] year old admitted to facility 1/12/16 from an acute hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented severe cognitive impairment with no mood impairment or behavioral symptoms. The MDS further documented extensive assistance for activities of daily living and always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 1/12/16 documented interventions that included observe for side effects, psych consult as needed, monitor for changes in mood, behavior, mental status, approach res in calm, gentle manner The evaluation section of the CCP for [MEDICAL CONDITION] drug Use dated 7/28/16 documented that the resident continues on [MEDICATION NAME] 2.5 mg (milligrams) po (by mouth) q hs (every hour of sleep). Psych (Psychiatry) f/u (follow up) as needed. The Medication Regimen Review completed on 9/17/16 documented currently receiving [MEDICATION NAME] 2.5 mg QD for behaviors associated with Dementia. No recent behavior problems apparent on review of documentation in clinical record. Please evaluate, consider trial discontinue if appropriate. Physician's response- was documented as agree, will do. Physician's orders dated 9/20/16 documented [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg (milligrams) by mouth at bedtime was discontinued. Physician's Orders dated 1/20/17 documented [MEDICATION NAME] 2.5 mg by mouth was re-ordered. Review of the Medication Administration Record [REDACTED]. Review of the Mood and Behavior Flow Record from (MONTH) (YEAR) to (MONTH) (YEAR) documented that no behavior was exhibited. Review of nursing progress and Nurse Practitioner notes from 9/26/16 to 1/20/17 document no behavioral issues. Psychiatry Consult dated 1/19/17 documented patient appears confused and psychotic-dressed up with her coat on, had a bag with her clothes ready to go home. She is unable to state where exactly she wants to go. The consult further documented restart [MEDICATION NAME] 2.5 mg HS for [MEDICAL CONDITION]. There was no documented evidence in the medical record of specific behaviors or rationale to support the reordering of the antipsychotic medication on 1/19/17. On 02/02/2017 at 2:21 PM, an interview was conducted with the Certified Nursing Assistant assigned to the resident in (MONTH) (YEAR). The CNA stated that the resident is confused and needs reminders and prompts to complete her ADL's (Activities of Daily Living). She also stated that the resident is monitored for holding onto garbage and hiding it in her pockets and bed. She stated that the resident can refuse care on occasion but responds to redirection and calms down when she is spoken to about her son who is involved in her care. On 02/06/2017 at 11:28 AM, the Registered Nurse Supervisor was interviewed and stated that the resident has been stable and has not been exhibiting any behaviors and is unsure of why the [MEDICATION NAME] was restarted. She also stated that there is no behavior flow sheet for (MONTH) (YEAR) because the resident had not exhibited behaviors for the past three months which would have necessitated daily monitoring. She further stated communication about medication changes occurs between the physician and the Nurse Practitioner and that she is not consulted. On 02/06/2017 11:36:48 AM, the Nurse Practitioner was interviewed and stated that she has been providing care for the since (MONTH) (YEAR) and that the resident is very demented. She also stated that the resident had no behavioral issues and a gradual dose reduction was done for the resident in (MONTH) (YEAR). She further stated that [MEDICATION NAME] and [MEDICATION NAME] were added and adjusted to better manage the resident's Dementia. She also stated that the behavior documented as [MEDICAL CONDITION] is the resident's usual behavior and not an indication for ordering of antipsychotic medication and she would re-evaluate the need for the medication with the psychiatrist. A telephone interview was conducted with the Psychiatrist on 02/06/2017 at 11:46 AM who stated that she is at the facility once a week and conducts evaluations every other month or as requested. She also stated that the resident has a history of [MEDICAL CONDITION] and she prescribed the medication based on what she observed during her evaluation of the resident. She further stated that even if the staff did not document resident behaviors in the medical record, she cannot be held responsible when prescribing the medication. Review of the facility policy Antipsychotic Medication Use dated (MONTH) 1, (YEAR) documents residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective nursing staff will document in detail an individual's target symptom(s). 415.12(l)(1)

Plan of Correction: ApprovedMarch 3, 2017

I. Corrective Actions for Residents Identified
? Resident #44 no longer resides at the facility
? Resident #148?s antipsychotic medication was discontinued on 2/23/17.
II. Residents At Risk
? All residents receiving Insulin injections have the potential to be affected by this practice.
? An audit of Medication Administration Record [REDACTED].
? All residents receiving antipsychotic medications have the potential to be affected by this practice.
? An audit of medical records of resident receiving antipsychotic medications was conducted
III. Systemic Changes
? All nurses are being in-service on:
- ?Guidelines for Safe Administration of Insulin? policy.
- Timely notification of Physician and documentation of such notification when blood sugar level is below/above order parameters.
- ?Antipsychotic Medications Use? policy.
- Facility Psychiatrist was changed.
- New procedure is being implemented to ensure antipsychotic medication not prescribed to a resident without specific conditions for which is indicated and effective.
IV. Monitoring of Corrective Actions
? On a weekly basis, DNS or designee, will audit 10 eMARs of residents receiving Insulin for compliance with facility policy for 3 months.
? On a monthly basis, DNS or designee, will audit charts of residents with new order for antipsychotic medications.
? On a monthly basis, DNS or designee, will report the findings to Administrator and QA Committee.
? On a quarterly basis, DNS or designee, will report results to Administrator and QA Committee.
? QA Committee to determine if further action is required.

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: February 6, 2017
Corrected date: April 1, 2017

Citation Details

Based on observations and interviews, the facility did not ensure food was prepared and served under sanitary conditions to prevent food borne illness. Specifically: 1) A food service worker was observed preparing and serving food without proper hair coverings and; 2) The Recreation Therapist (RT) was observed holding a peice of bread with no barrier between the bread and her bare hand and was also observed touching her hair without washing her hands in between the feeding of two residents. This was evident for observations conducted during the Kitchen and Food Service and Dining Observations (Kitchen and 5th Floor). The finding is: 1) On 1/31/17 from 9:26 AM to 9:30 AM, a food service worker was observed wrapping plates of fruit and cookies with plastic wrap without wearing hair covering. On 2/1/17 from 11:25 AM to 11:33 AM, another observation was conducted of the same food service worker standing over the steam table without a hair covering during the lunch tray line. On 2/2/17 at 11:38 AM, the food service worker was interviewed and stated that he always wears his Kippah (religious head covering) without a hairnet and he was not told that he had to wear a hairnet. On 2/6/17 at 10:26 AM, the Food Service Director stated all food service staff are expected to wear a hairnet or a cap when entering and handling food in the kitchen. Daily reminders are verbally given to the staff in the morning to discuss sanitation practices including wearing hair coverings. The facility policy and procedure Infection Control- Dietary Department (dated (YEAR)) documented the following. .Kitchen employees must wear hats .serving food to the patient . 2) On 1/31/17 from 12:15 PM to 12:25 PM, during a lunch time dining observation conducted on the of the 5th floor, Recreational Therapist (RT) was observed holding a peice of bread with her left bare hand without a barrier. She was then observed touching her hair multiple times and then touching the bread with her left bare hand. The RT was not observed washing her hands between the feeding of residents. On 1/31/17 at 12:39 PM, the RT was interviewed and stated that she recieves annual in-services regarding when to perform hand washing which included before and in between feeding residents and touching her face and hair. She further stated that she was aware that there should have been a barrier between her hand and resident's bread. On 2/6/17 at 10:41 AM, the Assistant Director of Nursing (ADON) was interviewed and stated that she is responsible for providing in-services to all departments including infection control and hand washing. She stated staff are expected to wash hands before the meal service, when hands get soiled, in between feeding residents, and when touching face and hair. There also needs to be a barrier between food and the staff's bare hands. On 2/6/17 at 1:05pm, an interview was conducted with the Infection Control Nurse who stated that he conducts random observation of staff to monitor hand hygiene and that food should not be touched with bare hands. He also stated that this information was not included in his in-services on infection control and he will emphasize it moving forward. The undated facility policy and procedure entitled Hand Hygiene/Infection Control documented the following: .Hand hygiene indications .Before and after eating or handling food (hand washing with soap and water) .Before and after assisting a resident with meals (hand washing with soap and water) .After performing your personal hygiene (hand washing with soap and water) 415.14(h)

Plan of Correction: ApprovedMarch 2, 2017

I. Corrective Actions for Residents Identified
? Food Service employee was re-educated on proper hair coverage during preparation and serving of food.
? Recreational Therapist (RT) was re-educated on proper hand hygiene and proper food handling while assisting residents with meals.
II. Residents At Risk
? All residents have the potential to be affected by this practice.
III. Systemic Changes
? All food service employees were in-serviced on ?Infection Control-Dietary Department? policy and procedure.
? ?Hand Hygiene/Infection Control? Policy and Procedure was revised.
? All Recreation Department Employees were in-serviced on hand hygiene/infection control revised policy.
IV. Monitoring of Corrective Actions
? On a daily basis, Food Service Supervisor will observe department employees for compliance with Infection Control policy.
? On a weekly basis, Infection Control Coordinator or designee, will perform random audit of Food Service employees during preparation and serving of food for 3 months.
? On a monthly basis, Infection Control Coordinator or designee, will report the findings to Administrator.
? On a quarterly basis, Infection Control Coordinator will report results to Administrator and QA Committee.
? QA Committee to determine if further action is required.

FF10 483.70(i)(1)(5):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident?s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician?s, nurse?s, and other licensed professional?s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: April 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that the medical record was accurately documented. Specifically, the Medication Administration Record documented multiple discrepancies in the administered dosages of Insulin administered by the unit nurses. This was evident for 1 of 5 resident reviewed for Unnecessary Medication Use. (Resident # 44) The findings are: 1) Resident #44 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/31/17 at 11:00 am during the initial tour of the unit, the resident was observed in the day room, alert and wake. The resident was sitting with other residents at a table and easily engaged in conversation with the SA (State Agency). The Admission MDS (Minimum Data Set) 3.0 assessment dated [DATE] documented intact cognition and limited assistance for activities of daily living. The Comprehensive Care Plan (CCP) for Endocrine/Diabetes dated 9/17/16 and revised 12/16/16 documented the following interventions: Administer med's (medications) as ordered by MD (Medical Doctor), monitor for effectiveness of medications, monitor blood glucose level as ordered, monitor glucose level three times daily. Goals included: resident will be free of signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION] and resident will maintain blood glucose level within acceptable ranges. Physician orders [REDACTED]. Medical condition: Type 2 Diabetes Mellitus If blood sugar < ( less than) 70 then call MD (Medical Doctor) If blood sugar between (201 and 250) then dose 2 units If blood sugar between (251-300) then dose 4 units If blood sugar between (301-350) then dose 6 units If blood sugar between (351-400) then dose 8 units If blood sugar > ( greater than) 400 then call MD A review of Medication Administration Records (MAR) dated 10/11/16 to 2/2/2017 documented the following blood sugar results and dosages of Insulin administered: 10/11/16 at 11:30 AM, blood glucose - 156 mg/dl-0 unit of Humalog 10/11/16 at 4:30 PM, blood glucose -100 mg/dl-0 unit of Humalog 10/19/16 at 4:30 PM, blood glucose -125 mg/dl-67 units of Humalog 11/7/16 at 4:30 PM, blood glucose -204 mg/dl, 15 units of Humalog 11/21/16 at 11:30 AM, blood glucose-168 mg/dl-15 units of Humalog 11/29/16 at 4:30 PM, the blood glucose-150 mg/dl- 15 units of Humalog 12/9/16 to 12/11/16, blood glucose ranges 169 mg/dl to 266 mg/dl- 4 units of Humalog 1/3/17 at 11:30 AM, blood glucose-139 mg/dl-79 units of Humalog The MAR further documented that on 11/22/16 to 1/30/17, on various shifts, the blood sugar ranges were 100 to 250 mg/dl and 0 units of Humalog were administered. There was no documented evidence in the medical record to explain the multiple discrepancies between the ordered and administered Insulin doses. On 2/3/17 at 10:34 AM, an interview conducted with a Licensed Practical Nurse (LPN) who stated she could not explain the discrepancies in the ordered and administered Insulin doses documented on the MAR. On 2/3/17 at 10:55 AM, an interview was conducted with LPN who documented 0 on the MAR on multiple occasions. The LPN stated that he did not document the actual dose of Insulin administered, instead documented zero, clicked save believed that this was sufficient documentation The facility policy for Guidelines for Safe Administration of Insulin dated 6/2016 documented the following: The Nurses must check the physician order. Confirm the blood glucose result as ordered, recheck the amount of insulin drawn before injection, document the amount of insulin administered. 415.22(a)(1-4)

Plan of Correction: ApprovedMarch 2, 2017

I. Corrective Actions for Residents Identified
? Resident #44 no longer resides at facility.
II. Residents at Risk
? All residents receiving Insulin injections have the potential to be affected by this practice.
? An audit of Medication Administration Record [REDACTED].
III. Systemic Changes
? All nurses are being in-service on:
- ?Guidelines for Safe Administration of Insulin? policy.
- Timely notification of Physician and documentation of such notification when blood sugar level is below/above order parameters.
- Proper transcription of Insulin order into EMR.
IV. Monitoring of Corrective Actions
? On a weekly basis, DNS or designee, will audit 10 eMARS of residents receiving Insulin for compliance with facility policy for 3 months.
? On a monthly basis, DNS or designee, will report the findings to Administrator and QA Committee.
? On a quarterly basis, DNS or designee, will report results to Administrator and QA Committee
? QA Committee to determine if further action is required.

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 more than minimal harm
Citation date: February 6, 2017
Corrected date: April 1, 2017

Citation Details

Based on record review and staff interview, the facility did not submit the DOH (Department of Health) 105 Termination form for an employee who was not hired by the facility within the required 30 day time period. This was evident for 1 of 5 employees reviewed for CHRC with Negative Determination letters. (Employee #3). The findings are: The facility received a Pending Denial letter for employee #4 dated 9/26/16. The employee was not hired at the facility. The Termination Form (#105) dated 12/18/16, was not submitted within the 30 calendar day time period. On 02/02/2017 at 11:43AM, the facility Authorized Person was interviewed and stated that she usually does all her terminations when she receives the letter that the employee is not cleared and cannot be hired. She further stated that she was going through her records in (MONTH) and noticed that this one had not been done so did it then. A review of the facility policy entitled Criminal History Background Check dated 5/2015 revealed no documented guidelines for the management of prospective employees who receive a negative determination letters.

Plan of Correction: ApprovedMarch 2, 2017

I. Corrective Actions for Residents Identified
? Facility Authorized CHRC person was re-educated on the importance of timely submission of DOH 105 Termination Form.
II. Residents at Risk
? All residents have the potential to be affected by this practice.
? All files of non-licensed personnel not hired or terminated within the last 6 months were audited for compliance with 105 Form completion.
III. Systemic Changes
? Facility CHRC Policy and Procedure was revise to include guidelines for the management of prospective employees who received a negative determination letters.
? CHRC log was developed and being implemented which includes date determination letter was received and date 105 Form was completed.
IV. Monitoring of Corrective Actions
? Facility Authorized CHRC person will maintain log of all not hired/terminated personnel and submit to Administrator weekly for 3 months.
? On a weekly basis for 3 months, Administrator or designee will review random files for a proof of DOH 105 Form Completion.
? On a quarterly basis, Administrator or designee, will report results to QA Committee.
? QA Committee to determine if further action is required.

Standard Life Safety Code Citations

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: March 29, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that doors to hazardous areas were either kept in the closed position or held open by releasing devices that will automatically close the door upon activation of the facility fire alarm systems, as per 7.2.1.8.2. Reference is made to the door to the boiler room in the basement, that was tied in the open position by means of a wire. The findings are: On (MONTH) 31,2017 between 9:30 AM to 3:00 PM, it was observed that, although the door to the boiler room was made self-closing, the door was kept in the closed position. The door was held open by means of a wire tied behind the door and anchored to the wall. This is not an approved device of holding the door open that will automatically release the door upon activation of the facility fire alarm systems and loss of power, as per 7.2.1.8.2. On (MONTH) 31, (YEAR) at approximately 12:00 PM, the facility's Director of Maintenance stated that the wire was removed and either the facility will keep the boiler room closed or install an approved held open device in accordance with section 7.2.1.8.2. 711.2(a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 24, 2017

I. Immediate Corrective Action:
? The door to the Boiler Room was immediately closed and the wire removed.
? All Maintenance Staff were in-serviced that hazardous area enclosures and stairways must be closed.
? All doors to hazardous areas in the building were inspected by the Maintenance Director to be self-closing.
? Person responsible ? Director of Maintenance
II. Identification of other Residents:
?The facility respectfully states that all residents could have been potentially affected by this.

III. Systemic Changes:
? The Director of Maintenance will ensure that all hazardous area enclosures are self-closing and kept in closed position.
Rounds will be made weekly for a month and afterwards monthly to ensure compliance
? Responsible person ? Director of Maintenance

IV. QA Monitoring:
? The Director of Maintenance will conduct weekly rounds to ensure compliance with K223.
? Audit with negative findings will be immediately corrected and reported to Administrator.
? Audit Reports will be reported at the quarterly QA meetings.
? Responsible person ? Director of Maintenance
? QA meeting will be on 3/29/17

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: March 29, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the delayed-egress locking systems of egress doors was in accordance with 7.2.1.6.1. Reference is made to the doors to exit stair West, that were equipped with the delayed-egress locking system but lacked the instructional signs to how to open the door, as per 7.2.1.6.1. The findings are: On (MONTH) 31, (YEAR) between 9:30 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the exit stair West doors were equipped with the listed delayed-egress locking system. Although the delayed-egress locks were in accordance with the criteria stated under 7.2.1.6.1, the doors lacked the instructional signs for opening the doors. All doors equipped with the delayed-egress locking arrangement must in addition to the conditions described under 7.2.1.6.1, have signs posted adjacent to the door releasing device stating: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS as per 7.2.1.6.1(4) On (MONTH) 31, (YEAR) at approximately 11:15 AM, the facility's Director of Maintenance stated that all doors to the exit stairways that are equipped with the delayed-egress locking system will be provided with the door opening instructional signs, as per 7.2.1.6.1(4). 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 24, 2017

I. Immediate Corrective Action:
? Administrator made an inspection of all doors with delayed egress locking arrangements to ensure proper sinage on each door with instructional language.
Facility ordered permanent appropriate signage

II. Identification of other Residents:
? The facility respectfully states that all residents had the potential to be affected by this.
? The Administrator and the Director of Maintenance toured the building and found no other issues.

III. Systemic Changes:
? All doors with delayed egress locking devices were provided with proper signage with instructional language on how to open the door.
? Responsible person- Director of Maintenance
Completed (MONTH) 20 '17
IV. QA Monitoring:
? The Director of Maintenance will conduct monthly rounds to ensure sinage is on necessary doors to comply with all K222 rules.
? Audits with negative findings will be immediately corrected and submitted to the Administrator.
? Audit finding will be reported at quarterly QA meetings to evaluate and to follow up.
? Responsible person ? Director of Maintenance
? QA meeting will be on 3/29/17

K307 NFPA 101:ELEVATORS

REGULATION: Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: March 29, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the elevator compled with the firefighter's service requirements of ASMF/ANSI A 17.3. Reference is made to the lack of an elevator lobby smoke detector off of the physical therapy area that was designed to automatically recall the elevator upon activation, as per section 9.4. The findings are: On (MONTH) 31, (YEAR) between 9:30 AM to 3:00 PM, it was observed that the facility elevators were equipped for the firefighter's phase I and phase Ii service requirements. The elevator lobby off of the physical therapy area, however, lacked a smoke detector as required for firefighter's service recall phase II. On (MONTH) 31, (YEAR) at approximately 12:15 PM, the facility's Director of Maintenance stated that the elevator company will be contacted to install a smoke detector in the elevator lobby off the physical therapy area in accordance with the firefighter's service elevator recall phase II, as per section 9.4. 711.2(a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 24, 2017

I. Immediate Corrective Action:
? Alburtan Electric was notified to install smoke detector system in requirements of ASMF/ANSI-A-17.3 outside of the elevator in the physical therapy area designed to automatically recall elevator upon activation. Installed on Friday, 2/17/17.

II. Identification of other Residents:
? The facility respectfully states that all residents could be potentially affected by this deficient practice.
? The Administrator and the Director of Maintenance toured the building and no other issues identified
? Responsible person ? Director of Maintenance

III. Systemic Changes:
? The Director of maintenance will ensure that all elevators are equipped with smoke detectors that will automatically recall elevator upon activation.
? Responsible person- Director of Maintenance

IV. QA Monitoring:
? The Director of Maintenance will conduct monthly rounds to ensure that all elevators have the proper smoke alarm systems.
? All findings will be reported at quarterly QA meetings.
? Responsible person ? Director of Maintenance
? QA meeting will be on 3/29/17

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2017
Corrected date: March 29, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the lack of sprinkler coverage for a number of areas in the building, including the main electrical panel room, a section of the area under the hood in the kitchen, and the large metal overhang adjacent to the laundry area. The findings are: On (MONTH) 31, (YEAR) between 9:30 AM to 3:00 PM during the recertification survey, it was observed that a number of areas in the building, including but not limited to the following areas, lacked sprinklers and did not meet the exception rules, or the sprinklers were obstructed so as not to provide coverage for the entire protected areas: (1) The main electrical room in the basement lacked sprinklers. The room did not meet the exception rules as a section of the electrical panels was being used as a coat closet for the empoyees; a stack of building plans were hanging behind the room door; an aproximately 5 inche in diameter annular hole was present around the penetrating conduits through the room enclosure wall; and the door to the room was not a 1-1/2 hour rated door. (2) A section of the area under the exhaust hood in the kitchen,containing the Blodgett and Cleveland upright pressure cooking equipment, lacked sprinkler coverage. The existing pendent type srpinkler was obstructed by the hood construction so as not to provide coverage for the section of the area containing the cooking equipment. (3) In the basement, the large (approximately 20 ft x 12 ft) metal overhang connected to the building structure adjacent to the laundry area, lacked sprinklers. The area under the overhang was being used for storage of motorized snow blowing equipment and other miscellaneous items. (4) At least three central sprinkler control valves, drain valves or the testing valves in the pump room lacked the required identifying signs, as per NFPA 13. All central, drain, test connection valves are to be identified with metal or rigid plastic identification signs. On (MONTH) 31, (YEAR) at approximately 11:30 AM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to evaluate the conditions, and either provide sprinklers for the identified areas or comply with the exception rules as stated in NFPA 13. 711.2(a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedFebruary 24, 2017

I. Immediate Corrective Action:
? The main electric room was cleaned of all material that does not belong.(ex) coat closet
? Holes in the Electric Room were closed.
? Our Sprinkler Company was called to add additional sprinkler coverage for the ?Blodgett? and ?Cleveland?.
? The area adjacent to the Laundry area covered by the metal overhang was cleaned, and will not be used for storage; therefore, sprinklers will not be needed.
? Automatic Sprinkler Company was called to make us metal signs on all control, drain, and/or testing valves.

II. Identification of other Residents:
? The facility respectfully states that all residents could be potentially affected by this deficient practice.
? The Administrator and the Director of Maintenance toured the building and no other issues were identified
? Responsible person ? Director of Maintenance

III. Systemic Changes:
? The Director of Maintenance will make sure that all electrical rooms are not used as storage; therefore, not needing sprinkler coverage.
signage were posted in electrical room restricting storage at all times to comply with NFPA exemption code
. Door being replaced with a UL listed 90 minute door
Door installed (MONTH) 22 '17
? Rounds will be done weekly for a month and then monthly to ensure compliance.
? All ceiling holes and holes in the walls will be closed with fire stop material and will be inspected on a regular bases.
? Rounds will be done weekly for a month and then monthly to ensure compliance.
? The area under the exhaust hood where the ?Blodgett? and ?Cleveland? area will have sprinkler coverage added to it.
? The area under the overhang adjacent to the laundry area will be kept clear from storage and/or equipment.
? Rounds will be done weekly for a month and then monthly to ensure compliance
? All sprinkler control valves, drain valves and/or testing valves will have metal or rigid plastic signs identifying them.
Completed (MONTH) 22 '17
? Responsible person- Director of Maintenance
The director of Maintenance will monitor all areas that it be made to comply with the exception rules
IV. QA Monitoring:
? The Director of Maintenance will weekly conduct weekly rounds to insure continued compliance with K351.
? A QA tool will be created.
? Audits with negative findings will be immediately corrected and submitted to the Administrator.
? Audit finding will be reported at quarterly QA committee meetings to evaluate and to follow-up.
? Responsible person ? Director of Maintenance
? QA meeting will be on 3/29/17