Troy Center for Rehabilitation and Nursing
October 24, 2017 Certification Survey

Standard Health Citations

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: October 24, 2017
Corrected date: November 30, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that food preparation and serving areas and equipment are to be kept clean. Specifically, equipment and sections of the floor in the main kitchen and areas in two (2) of two (2) unit kitchenettes were not clean. This is evidenced as follows. Observations of the main kitchen on 10/19/2017 at 8:10 am, revealed that the slicer, can opener, and table mixer were soiled with food particles. The floor under the automatic dishwashing machine was soiled next to the wall. Observations of the North and South Unit kitchenettes revealed that the bottoms of the refrigerators and the cabinets under the sinks were soiled with food particles and/or liquid stains. The Food Service Director stated in an interview conducted on 10/19/2017 at 10:00 am, that he will follow up with staff on the routine cleaning schedule routine and will discuss cleaning the kitchenettes with the housekeeping department. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.95, 14-1.170

Plan of Correction: ApprovedNovember 17, 2017

F0371-STORE/PREPARE/DISTRIBUTE FOOD - SANITARY
How the corrective action will be accomplished for any resident affected by deficient practice:

Equipment and sections of floor in Main kitchen and areas in two (2) or two (2) unit kitchenettes were cleaned and sanitized 10/19/2017
The slicer, can opener, and table mixer were cleaned and sanitized The floor under the automatic dishwashing machine was swept and mopped 10/19/2017.
North and South Unit kitchenettes: the refrigerator bottoms and the cabinets under the sinks were thoroughly washed 10/19/2017.
All dietary staff in house on 10/19/2017 were educated on cleaning and sanitization of equipment, washing of floors near dish machine area.
All housekeeping staff in house on 10/19/2017 were educated on the cleaning of refrigerator bottoms and cabinets under the sink in the kitchenettes.
How we identified other residents/areas that could potentially be affected:
All resident at risk for deficient practice.
All kitchen areas and unit kitchenettes were inspected and there were no additional findings.
Measures to ensure were/will be put into place to assist this area of concern:
The policy of sanitation conditions was reviewed and revised on 11/1/2017.
All dietary staff were educated on cleaning and sanitization of equipment, washing of floors near dish machine area.
A Daily Cleaning Schedule was implemented to add the areas of concern such as the slicer, mixer, and under the automatic dish machine.
Housekeeping has been educated on the policy for sanitation of the kitchenettes which will be validated weekly to maintain compliance
A Daily Cleaning Schedule was implemented to ensure the cleanliness of the refrigerator bottoms and cabinets under the sinks in the kitchenettes
The food service director or designee will inspect these areas utilizing a cleaning list that was devised to ensure compliance.
How the concern will be monitored and title of person responsible for monitoring:
QA audit tool was devised to:
Ensure equipment and sections of floor in Main kitchen including the dishwashing area and areas of unit kitchenettes, the slicer, can opener, and table mixer
are cleaned and sanitized.
Audit tool was devised to ensure kitchenette refrigerators, cabinets under the sink are clean and free of food spillage and debris.
Audits will be conducted weekly x4 weeks, then monthly x 3mths
Findings will be reported to the QA team for input.
Responsible party: Director of Food Services

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: October 24, 2017
Corrected date: November 30, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the corridor carpeting was soiled on two (2) of two (2) resident units and the walls and bath tubs in one (1) of two (2) Tub Rooms were not in good repair. This is evidenced as follows. Observations on 10/19/2017 at 10:00 am, revealed that the corridor carpeting throughout the north resident unit and south resident units was heavily soiled with dark staining and was not clean, and wall coving tiles in the South Unit Tub Room were cracked and had black grout stains. The faucet on the whirlpool bathtub in the South Unit Tub Room was leaking causing water staining inside the tub. The Regional Maintenance Director stated in an interview conducted on 10/19/2017 at 10:45 am, that the carpeting will be replaced, but a date has not yet been set, and he will look into the issues in the South Unit tub Room. 483.10(i)(2)

Plan of Correction: ApprovedNovember 17, 2017

F0253-HOUSEKEEPING AND MAINTENANCE SERVICES
How the corrective action will be accomplished for any resident affected by deficient practice:
The facility corridor carpeting on the two nursing units was shampooed and extracted on 10/21/2017 and 10/22/2017.
The parts to complete the repair of the faucet on the whirlpool bathtub in the South Unit Tub Room were ordered and the faucet was repaired.
The water staining in the South Unit Tub was cleaned on 10/20/2017.
The wall coving tiles in the South Unit Tub Room were repaired and cleaned to remove the black grout stains on 10/23/17.
All housekeeping/maintenance staff caring for those area have been educated on cleaning carpets, bath tubs and wall coving tiles.
How we identified other residents/areas that could potentially be affected:
All residents have the potential to be affected by the deficient practice.
All facility corridor carpets were inspected for soiling and all areas of soiled carpet were cleaned and extracted.
All facility tub walls and faucets were inspected and there were no additional findings.
Measures to ensure were/will be put into place to assist this area of concern:
The carpet cleaning policy was reviewed and revised as necessary on 11/1/2017.

All housekeeping staff will be educated on the proper method to ensure the carpets remain clean.
Environmental rounds will be conducted on a weekly basis to maintain compliance.
How the concern will be monitored and title of person responsible for monitoring:
Audits will be conducted to validate that carpets are clean weekly x 4, monthly x 3.

Observation audits to validate that tub rooms are kept in good repair and free of black grout stains weekly x 4, monthly x 3.
Findings will be reported to the QAPI committee for input.
Responsible party: Director of Maintenance and Administrator



FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 24, 2017
Corrected date: November 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection determined for 2 of 2 dressing changes observed. Specifically, for Resident #'s 34 and #69, the facility did not ensure standard precautions and infection control practices were maintained during dressing changes. This is evidenced by: Policy and Procedure for Standard Precautions for Infection Control dated 4/15/10, documented hands are to be washed after touching blood, body fluids, secretions, excretions, and contaminated items. Resident #34: The resident was admitted to the facility initially on 3/24/15 and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The MDS also documented that the resident requires the moderate assisitance of 2 persons to transfer in bed and the extensive assistance of 2 to transfer out of bed. The resident does not ambulate and uses a wheelchair for locomation. During observsation of the wound care to the resident's deep tissue injury pressure ulcer on his left heel on 10/23/17 at 10:35 am, the LPN had set up her field but had only partially opened the gauze packets. After washing her hands and putiing on a pair of gloves the LPN picked up the gauze packet, touching the outside of the gauze packet with her gloved hands, took the gauze out of the packet, opened the bottle of saline and poured the saline on the gauze. Without washing her hands and changing her gloves, the LPN picked up the gauze she had moistened with saline and cleansed the pressure ulcer on the resident's left heel . During an interview with the LPN on 10/23/17 at 10: 55am , prior to the LPN proceeding to do wound care with a dressing change on the resident's stage 2 pressure ulcer on the calf of his left leg, the surveyor asked the LPN to reiterate how she had done the wound care to see if she would recognize if she had not followed standard and infection control practices. When the surveyor cued her about washing her hands and changing gloves she realized that she did not wash her hands and change her gloves after touching the outside of the gauze packet and picking up the small saline bottle. She stated that she should have set up her dressing field by opening the gauze packet all the way so she could moisten the gauze with saline and then wash her hands and put on a new pair of gloves. During an interview with the DON on 10/23/17 at 4:30 pm , the DON stated that clean dressings and not sterile dressings are done in the facility but that standard precautionary measures are to be maintained during wound care to prevent contamination. Resident #69: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was readmitted to the facility from the hospital on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment and was able to understand others and was able to be understood. Physician's Progress Note dated 8/10/17, documented the ulcer to the resident's right buttock seemed to be getting worse. The wound had an odor and pus was oozing out of the wound. The skin around the wound was swollen and red. An antibiotic was ordered to treat the infected stage 4 ulcer. Progress Note dated 8/10/17 at 6:39 pm, documented the resident had been admitted to the hospital with [REDACTED]. Progress Note dated 9/18/17 at 2:36 pm, documented the resident returned to the facility. At the hospital the resident was transfused with 2 units of red blood cells related to anemia caused by multiple wound debridements (removal of dead or contaminated tissue) of the stage 4 decubitus to her left ischium. Wound Round notes dated 9/20/17, documented the pressure ulcer to the left ishium measured 4.5 centimeter (cm) x 3.0 cm. Tunneling measured 9.0 cm. Healthy pink granulation tissue was noted throughout. No necrosis (dead tissue) or slough (dead skin that separated from the wound) was noted. The amount or color of drainage could not be determined because the resident had been incontinent of stool into the dressing. Air mattress was in place and the resident was to be put back to bed after meals for pressure relief. A physician's orders [REDACTED]. Pack left ischium wound after irrigation with normal saline, then cover with foam dressing. During an observation of a dressing change on 10/20/17 at 1:45 pm, standard precautions were not followed: -package of cotton tipped swabs was touching the foam dressing on the barrier. -LPN #2 picked up the opened package containing cotton tipped swabs and laid it on the bed near the resident. Without washing her hands or changing gloves, she used the swabs to pack the wound with alginate rope. During an interview on 10/20/17 at 2:00 pm, LPN #2 stated she did not realize she should have washed her hands and changed gloves after touching the outside of the package containing the cotton tipped swabs before she packed the wound. During an interview on 10/23/17 at 2:20 pm, the Director of Nursing (DON) stated she would expect the supplies to be opened and prepared prior to the dressing change. DON stated during the dressing change, the inside only of the package containing dressing supplies may be touched without the nurse having to wash hands and change gloves. If the nurses do touch the outside of dressing supply packages, the nurse should wash hands and change gloves. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedNovember 17, 2017

F0441-FACILITY ESTABLISHES INFECTION CONTROL PROGRAM
How the corrective action will be accomplished for any resident affected by deficient practice:
Resident # 34 had no negative outcomes related to the findings.
Resident #69 had no negative outcomes related to the findings.
LPN #1 and LPN # 2 have been educated on the policy for Pressure Injury and Non-Pressure Injury Treatment.
LPN #1 and LPN # 2 have been educated on the policy for Hand Washing.
LPN #1 and LPN # 2 have demonstrated competency and understanding regarding wound/treatment dressing changes, hand washing and infection control techniques.
How we identified other residents/areas that could potentially be affected:
All residents have potential to be affected by deficient practice.
All nurses licensed nursing staff will be in-serviced on Hand washing/Hand Hygiene and practices to maintain standard precautions and Infection Control related to Wound Care/Dressing change.
All licensed nurses will have wound care treatment and hand washing competencies completed with 100% compliance
Measures to ensure were/will be put into place to assist this area of concern:
IDT reviewed and adopted the policy Pressure Injury and Non-Pressure Injury Treatment.

IDT reviewed and adopted the policy for Hand washing/Hand Hygiene
All nurses licensed nursing staff will be in-serviced on Hand washing/Hand Hygiene and practices to maintain standard precautions and Infection Control related to Wound Care/Dressing change.

All licensed nurses will have wound care treatment and hand washing competencies completed with 100% compliance.
How the concern will be monitored and title of person responsible for monitoring:
Weekly audits will be randomly conducted for hand washing and maintaining infection control practices during dressing changes via competency on licensed nursing staff. Audit to be conducted each shift weekly x 6, monthly x 2.

Results of audit will be reported to QAPI committee monthly.
DON will be responsible for correction of this deficiency


FF10 483.25(b)(1):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 24, 2017
Corrected date: November 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, for one (Resident #69) of eight residents reviewed for pressure sores. Specifically, for Resident #69, the facility did not ensure ongoing monitoring of the decubitus ulcer was performed on a weekly basis, and that evaluations of the pressure ulcer was documented correctly and completely. This is evidenced by: Resident #69: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was readmitted to the facility from the hospital on [DATE], with a [DIAGNOSES REDACTED]. At the hospital, the wound was debrided (removal of dead or contaminated tissue) several times which caused acute blood loss [MEDICAL CONDITION]. The resident received 2 units of a blood transfusion to treat the [MEDICAL CONDITION]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment, was able to understand others and was able to be understood. Facility's Skin Care Protocol documented all pressure ulcers will be staged according to National Pressure Ulcer Advisory Panel (NPUAP) and Resident Assessment Instrument (RA) Manual guidelines. Dermal Tracker Sheet and Wound Rounds were documented as follows: -Dermal Tracker Sheet and Wound rounds dated 5/13/17, documented Stage II pressure ulcer over the left ischial tuberosity of the buttocks measured 5 centimeter (cm) x 1.5 cm and 0.1 cm. -Dermal Tracker Sheet dated 5/16/17, documented Stage II pressure ulcer of the left ischium measuring 4.8 x 1.4. Wound Rounds created on 5/18/17, documented Stage II pressure ulcer of the left ischium measuring 4.8 x 1.4. There was no documented date to indicate when assessment took place. -Dermal Tracker Sheet and Wound rounds dated 5/23/17 documented Stage II pressure ulcer over the left ischium measuring 3.2 x 1.8 -Dermal Tracker Sheet and Wound Rounds dated 5/30/17, documented a Stage II pressure ulcer over the left ischium measuring 1.0 x 1.6. There was no staging of the pressure ulcer on Wound Rounds documentation. -Progress note dated 6/20/17 at 7:53 pm, documented the left ischium pressure sore appeared to be a Stage III with a necrotic area in the center. Dermal Tracker Sheet dated 6/20/17, documented left ischium pressure sore was a Stage II, 3.0 cm x 1.5 cm with necrotic area in the center. Wound Rounds dated 6/20/17, documented the left ischium pressure sore was 3.0 cm x 1.5 cm and had improved as it decreased in size and necrotic tissue. The wound had 90% of yellow slough to the wound bed. There was no documented staging of the wound. -Dermal Tracker Sheet dated 6/27/17, documented left ishial wound was a stage II, measuring 2.5 cm x 3.0 cm with odor. Wound Rounds dated 6/27/17, documented left ischium wound was worse, measuring 2.5 cm x 3.0 cm, slough with tunneling noted. Thick, foul smelling drainage. There was no documented staging of the wound, measurement to indicate depth of the wound or location of the tunneling. -Dermal Tracker Sheet dated 7/03/17, documented left ischium wound was a stage II, measuring 3.0 x 4.0 with scant slough at base of wound with odor. Wound Rounds dated 7/03/17, documented left ischium wound had increased in size and depth measuring 3.0 x 4.0 with no necrotic tissue noted. Some yellow slough at base. Significant decrease in drainage. There was no documented staging or measurements to indicate depth of the wound. There was documentation to indicate tunneling. -Dermal Tracker Sheet dated 7/11/17, documented left ischium wound was a stage II, measuring 2.8 x 3.0 x 2.0 with yellow slough at the base. Wound Rounds dated 7/13/17, documented physician evaluated left ishium wound with change in orders for dressing change. There was no documented staging, measurements or description of the wound. -Dermal Tracker Sheet dated 7/18/17, documented N/A. There was no documentation to indicate Wounds Rounds were done on 7/18/17. -Dermal Tracker Sheet dated 7/25/17, documented left ischium wound was a stage II, measuring 2.0 x 3.0 x 2.0 with odor. Wound Rounds dated 7/25/17 documented left ischium wound improved 2.0 x 3.0 x 2.0 deep. There was no documented staging of the wound. -Dermal Tracker Sheet dated 8/1/17, documented left ischium wound was a stage II, measuring 2.0 x 3.0 with no odor. Wound Rounds dated 8/1/17, documented left ischium wound measured 2.0 x 3.0. There was no documented staging or measurement indicating depth of the wound. -Dermal Tracker Sheet dated 8/8/17, documented left ischium wound was a stage II, measuring 2.0 x 3.0 x 6.0. Copius foul odor. Wounds Rounds dated 8/08/17, documented left ischium wound was worse, measuring 2.0 x 3.0 x 6.0 deep. Copius foul smelling brown drainage. There was no documented staging of the wound. A Physician's Progress Note dated 8/10/17, documented the Stage IV ulcer to the resident's right buttock had developed an odor and was oozing pus. Surrounding skin was swollen and red with an antibiotic being ordered. Progress Note dated 8/10/17 at 6:39 pm, documented the resident had been admitted to the hospital with [REDACTED]. Progress Note dated 9/18/17 at 2:36 pm, documented the resident returned to the facility. At the hospital, the resident was transfused with 2 units of red blood cells related to [MEDICAL CONDITION] caused by multiple wound debridements of the stage 4 decubitus to her left ischium. -Tissue Trauma Discover Form dated 9/18/17 documented the left ischium pressure ulcer was a Stage IV, measuring 4.5 cm x 3.0 cm with tunneling 12 o'clock measuring 9.0 cm and tunneling at 2 o'clock measuring 7.0 cm. Dermal Tracker Sheet dated 9/18/17, documented left ischium wound was a Stage IV, measuring 4.5 x 3.0 x 9.0 tunneling. Wound rounds created 9/20/17, documented the pressure ulcer left ischium wound measured 4.5 x 3.0. Tunneling measured 9.0 cm. There was no documentation to indicate the date of the wound assessment and there was no documented staging of the wound. No necrosis (dead tissue) or slough (dead skin that separated from the wound) was noted. The amount or color of drainage could not be determined because the resident had been incontinent of stool into the dressing. Air mattress was in place and the resident was to be put back to bed after meals for pressure relief. -Dermal Tracker Sheet dated 9/26/17, documented left ischium wound was a Stage IV, measuring 2.0 x 4.0 x 8.0. Documentation indicated the tunnels had merged. Wound rounds dated 9/26/17, documented left ischium wound has improved, decreased size and depth, measuring 2.0 x 4.0 x 8.0 deep. There was no drainage or odor to the wound. There was no documented staging of the wound. -There was no Dermal Tracker sheet or Wound Rounds documentation dated 10/17/17. During an interview on 10/24/17 at 11:15 am, the Assistant Director of Nursing (ADON) stated wound rounds were not done for the resident on 10/17/17 because they were held up on North Unit. The resident will be seen on 10/25/17. Dermal Tracker Sheets dated 5/13/17 to 10/10/17 were initialed by the Director of Nursing (DON) which indicated the tracker sheets had been reviewed. During an interview on 10/20/17 at 12:30 pm, LPNNM #1 stated wound rounds are done weekly with the Registered Nurse (RN). LPN #1 stated she filled out the wound tracker sheets for this resident because she had accompanied the wound team during rounds. She stated the DON signed off on the tracker sheets. The staging of the wound as a stage II got carried over in error. During an interview on 10/20/17 at 2:45 pm, the Assistant Director of Nursing (ADON) stated the tracker sheets are filled out after wound rounds by the nurse manager (NM) who is a Licensed Practical Nurse (LPN). The DON signs off on the tracker sheets. She stated it was an oversight that accidentally the wound was documented each week as a Stage II on the tracker sheets after the physician had staged it as a Stage IV. It got carried across the line. It was obviously an error. She stated she does the staging but doesn't chart it. The ADON stated when the wound worsened and was tunneling, she guesses she could have noted the wound as unstageable. She stated she does not document the stage of the wound if it does not change. The ADON stated she guessed she could chart the staging of the wound, even though it had not changed. I guess I could stage even though the description is charted. During an interview on 10/23/17 at 8:30 am, the DON stated the NM, ADON, DON and Rehabilitation go to wound rounds on a weekly basis. After assessment was entered into the computer by the ADON, the NM wrote the information onto the tracker sheet. Information contained in the tracker and wound assessments should be similar even though they are not done at the same time. She stated it was a clerical error that staging was carried over throughout. Staging of the wound was not always done as the nurses doing the wound rounds are not certified wound nurses. Description of the wound was charted. The DON stated if the wound was unstageable or was a Stage IV, maybe it should have been staged. In the careplan wound assessment, the DON stated she was more interested in the treatment and description. DON stated she signed off on the tracker sheets but did not pay attention to the top of the tracker sheet where staging was documented. She stated she looked to see if the wound had improved. She stated the tracker sheet was accurate to a certain degree. She was not signing a piece of the chart, since tracker was considered an internal document which helped with tracking. When she looked at the tracker sheet she was looking for an accurate description of the wound. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedNovember 17, 2017

F0314-PROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES:
How the corrective action will be accomplished for any resident affected by deficient practice:
Resident # 69 had no negative outcomes related to the findings
LPN #1 has watched the video ?Pressure Ulcer Staging?, was educated evaluating per the policy and procedure ?Pressure Injury and Non-Pressure Treatment?, and ongoing weekly monitoring, documenting correctly and completely on the wound tracker.

LPN NM #1 has watched the video ?Pressure Ulcer Staging?, was educated on the policy and procedure ?Pressure Injury and Non-Pressure Treatment?, and ongoing weekly monitoring, documenting correctly and completely on the wound tracker.
All licensed nursing staff educated on the policy for Pressure Injury and Non-Pressure Injury Treatment.
All licensed nursing staff educated and demonstrate accurate evaluation/assessment/staging and documentation of wounds.
How we identified other residents/areas that could potentially be affected:
All residents have potential to be affected by deficient practice.
All residents with pressure ulcers have had their wound documentation reviewed for ongoing weekly monitoring and correct and complete documentation by the wound care team.
There were no additional findings.
Measures to ensure were/will be put into place to assist this area of concern:
IDT team reviewed and adopted the policy Pressure Injury and Non-Pressure Injury Treatment
All licensed nurses will be in-serviced on documentation related to pressure ulcers and be provided a post test for pressure ulcer prevention and treatment
How the concern will be monitored and title of person responsible for monitoring:
Weekly audits will be conducted of all residents with pressure ulcers to review and validate accurate staging and weekly wound assessments completed with documentation that is accurate and consistent on all forms of documentation (weekly dermal tracker sheet, wound tracking log and progress notes). Audit to be conducted weekly x 4, monthly x 2.


Results of audit will be reported to QAPI committee monthly.
DON will be responsible for correction of this deficiency


Standard Life Safety Code Citations

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: October 24, 2017
Corrected date: November 30, 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 Health Care Facilities Code 2012 Edition section 4.2 requires that building systems, such as gas and vacuum systems; electrical systems; heating, air conditioning, and ventilation systems; electrical equipment; and gas equipment are to undergo a formal, defined, and documented risk assessment procedure by qualified personnel. Specifically, the required building systems risk assessments were not conducted. This is evidenced as follows. The Regional Director of Maintenance stated in an interview conducted on 10/19/2017 at 11:45 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: ApprovedNovember 17, 2017

K0901-FUNDAMENTALS - BUILDING SYSTEM CATEGORIES
How the corrective action will be accomplished for any resident affected by practice:
The risk assessment team has conducted a building systems risk assessment and assigned risk categories for each system.
How we identified other residents/areas that could potentially be affected:
All residents could be affected by the deficient practice.
The risk assessment team conducted a building systems risk assessment and assigned risk categories for each system.
Measures to ensure were/will be put into place to assist this area of concern:
The NFPA 99 building system risk assessment policy was developed and implemented on 11/1/2017.
All staff will be educated on the necessity to notify the Director of Maintenance or the Administrator of any changes in the condition of any of the facility systems or any equipment that are identified within the NFPA99 building risk assessment.
The risk assessment team will meet annually and as needed to maintain compliance.
How the concern will be monitored and title of person responsible for monitoring:
QA audit tool was devised to:
Identify any changes in facility systems and/or equipment.
Audits will be conducted weekly x4 weeks, then monthly x 3mths
Findings will be reported to the QAPI Committee
Responsible party: Administrator



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: October 24, 2017
Corrected date: November 30, 2017

Citation Details

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. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows. Observations of the sprinkler system on 10/19/2017 at 8:10 am, revealed that nine (9) sprinkler heads in the kitchen, two (2) sprinkler heads in the South Unit nurse station, and one (1) sprinkler head in the North Unit nurse station were found with a coating of dust. The Regional Director of Maintenance stated in an interview conducted on 10/19/2017 at 10:45 am, that the dusty sprinkler heads were overlooked for cleaning, but that they will be cleaned. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 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

Plan of Correction: ApprovedNovember 17, 2017

K0353-SPRINKLER SYSTEM-MAINTENANCE AND TESTING
How the corrective action will be accomplished for any resident affected by deficient practice:
The nine (9) sprinkler heads in the kitchen, two (2) sprinkler heads in the South Unit nurse station, and one (1) sprinkler head in the North Unit nurse station that were identified during survey were cleaned, and dust was observed to be removed on 10/20/17.
All maintenance staff has been educated and will demonstrate competency on the proper procedure to clean sprinkler heads and ensure that sprinkler heads are free of foreign materials.
The Director of Maintenance was educated on making rounds to inspect the sprinkler heads.
How we identified other residents/areas that could potentially be affected:
All residents could potentially be affected by the deficient practice.
Facility wide inspection of sprinkler heads conducted and no additional findings.
Measures to ensure were/will be put into place to assist this area of concern:
The cleaning of sprinkler head guideline was reviewed and revised on 11/1/2017.
The IDT reviewed and adopted the policy Maintenance Service.
All maintenance staff were educated on the proper procedure to clean the sprinkler heads and the Maintenance Service Policy.
All maintenance staff will demonstrate competency to properly clean sprinkler heads.

A cleaning list has been created to validate compliance.

How the concern will be monitored and title of person responsible for monitoring:
QA audit tool was devised to validate that sprinkler heads have been cleaned properly to maintain compliance.
Audits will be conducted weekly x4 weeks, then monthly x 3mths
Findings will be reported to the QAPI Committee
Responsible party: Director of Maintenance