Buffalo Center for Rehabilitation and Nursing
June 27, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.25(n)(1)-(4):BEDRAILS

REGULATION: §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during the Standard survey completed on 6/27/18 the facility did not attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements. Assess the resident for risk of entrapment from bed rails prior to installation and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Two (Resident #227 and #151) of three residents observed for side rail use had issues. Specifically, Resident #227 and #151 had bilateral assist bars on the bed in the up position, although their side rail assessments determined side rails were not indicated. The findings are: Review of a policy entitled Proper Use of Side Rails with a revised date of (MONTH) (YEAR) (identified as current by the Director of Nursing (DON)) revealed that side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. 1. Resident #151 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 5/24/18 revealed the resident was cognitively intact. During an observation on 6/20/18 at 10:08 AM, the resident was laying on her back in bed with bilateral assist bars on the bed in the up position. The resident did not answer when interviewed about the use of the bed rails to assist her with her mobility. During an observation on 6/22/18 at 9:02 AM, staff provided total assist to turn and position the resident. The resident did not make an attempt to assist with bed mobility. Review of RN (registered nurse): Side Rail Assessment dated 5/17/18 revealed that side rails were not indicated. Review of an Admission/Readmission Evaluation dated 5/17/18 revealed the resident had very limited ability to change and control body positions, makes occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently and required extensive assist of two persons for bed mobility. Review of the comprehensive care plan initiated on 6/7/18 revealed the resident required assist with Activities of Daily Living (ADL's) related to limited mobility. Additionally, the resident was totally dependent on two persons for bed mobility. Review of an undated Visual/Bedside Kardex Report (care guide used by staff to provide care) revealed the resident can not assist with rolling on or off the lift sheet and required total assist of two staff members for bed mobility. 2. Resident #227 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment, and required total assist of two persons for bed mobility. During an observation on 6/21/18 at 8:05 AM, the resident in bed laying on his back with bilateral assist bars on the bed in the up position. The resident did not answer when interviewed about the use of the bed rails to assist him with his mobility. During an observation on 6/22/18 at 11:06 AM, the staff provided total assist to turn and position the resident. The resident did not make an attempt to assist with bed mobility. Review of RN: Side Rail assessment dated [DATE] revealed that side rails were not indicated. Review of the comprehensive care plan revised on 6/14/18 revealed the resident required assist with ADL's related to limited mobility. Additionally, the resident was totally dependent and required two persons for bed mobility. Review of an undated Visual/Bedside Kardex Report revealed the resident can not assist rolling on or off the lift sheet and required total assist of two staff members for bed mobility. During an interview on 6/26/18 at 12:10 PM, Licensed Practical Nurse (LPN #3) Unit Manager stated the side rail assessments documented no side rails were indicated for these residents. The bed rails were small rails with the bed controller within it. Therefore, she did not consider them to be side rails. During an interview on 6/27/18 at 9:52 AM, the DON stated these were a newer style of bed with the bed controls within the small rail. Therefore she did not consider them to be a side rail or an assist bar. During a telephone interview on 6/27/18 at 11:00 AM, the Vice Present of Sales and Marketing from the bed manufacturer stated the small bars with the embedded controls on the beds are considered an assist bar. During further interview on 6/27/18 at 11:04 AM, the DON stated if they are considered assist bars further review would be necessary. 415.12(h)(1)

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 151 was on comfort measures and expired on [DATE].
Resident # 227 was admitted to the hospital on [DATE]. He will be re-evaluated for side rail/ assist bar use upon return and placed in the appropriate bed.
All residents have the potential to be affected.
A full house audit of beds with side rails /assist bars will be conducted by Administrative Nursing staff . The audit will ensure that residents that do not require side rails/ assist bars will not have them installed on beds. Any issues noted will be immediately addressed .
The RN Educator / designee will re-educate all licensed nursing staff regarding facility side rail/ assist bar policy including the need for side rail assessments as indicated.
The DON reviewed the ? Side rail usage ? policy with no revisions required at this time.

The Unit Managers will conduct 10 side rail/ assist bar audits weekly for 12 weeks. The audits will verify that residents using side rails/ assist bars have accurate side rail assessments as indicated and that residents not needing side rails/ assist bars do not have them on beds.
Responsibility : DON

ZT1N 415.17:DENTAL SERVICES

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/27/18, the facility did not ensure that each resident receives a complete oral examination, by a licensed and currently registered Dentist or Dental Hygienist, within 7 days following completion of the initial comprehensive assessment. One (Resident #174) of two residents reviewed for dental services did not receive an initial dental examination within 21 days after admission. The finding is: 1. Resident #174 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/7/18 revealed the resident was understood, understands and was cognitively intact. The MDS dated [DATE] documented the resident had no dental or oral cavity concerns. During an observation on 6/20/18 at 2:56 PM, the resident was edentulous (lacking teeth). During an interview on 6/20/18 at 2:56 PM, the resident stated he lost his dentures, he would like to have new dentures made, and he had not seen the dentist since his admission into the facility. Review of the comprehensive care plan dated 12/20/17, last revised 5/31/18 revealed the resident had oral/dental health problems related to missing teeth. Interventions included to coordinate arrangements for dental care, transportation as needed and as ordered. Review of the Dental Orders and Progress Notes dated 10/25/17 revealed the resident was a new admission and he was not in his room at the time of the exam. Further review of the Dental Orders and Progress Notes dated 11/8/17 revealed the resident was in therapy and will be seen upon request. Review of the Schedule of Residents to be Seen by the Dentist from 9/13/17 through 6/20/18 revealed the resident was scheduled to be seen by the dentist for a new admission exam on 10/25/17 and an evaluation on 11/8/17. During an interview on 6/25/18 at 1:28 PM, Registered Nurse (RN) Unit Manager (RN #3) stated she was unsure how often the dentist came to the facility and medical records personnel was responsible for scheduling the residents to see the dentist. During an interview on 6/25/18 at 1:38 PM, Medical Records personnel stated the dentist was scheduled weekly and the dentist is provided with a list of new admission and discharged residents. A copy of the list is sent to the units and the nursing department was responsible to ensure the residents get to the dentist. New admissions are usually scheduled twice and if they're not available then they are scheduled annually. During an interview on 6/27/18 at 11:46 AM, the Assistant Director of Nursing (ADON) stated new admissions should be seen by the dentist routinely. A resident not to be in their room was not a good reason, not to see the dentist. There should be documentation in the nurse's notes as to why the resident wasn't seen and further follow up. 415.17(c)

Plan of Correction: ApprovedJuly 23, 2018

Resident # 174 was seen by the dentist on 7/19/18.
Unit Managers will be counseled by the DON regarding importance of initial dental exams for new residents within 21 days of admission .
All residents have the potential to be affected .
A full house audit of residents admitted within the last 90 days will be conducted by the Medical Records staff. This audit will ensure that all newly admitted residents receive initial dental exams. Any issues noted will be immediately addressed.
The Medical Records clerk will notify unit managers when residents are not seen for dental exams as ordered .
Licensed nursing staff will be re-educated regarding dental visits and the need to ensure that they are completed within 21 days of admission.
The Medical Records clerk will audit all new admissions to ensure that they are seen by the dentist within 21 days of admission . Any issues noted will be immediately addressed .
Responsibility : DON

FF11 483.12(b)(1)-(3):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95,

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Standard survey completed on 6/27/18, the facility did not implement written policies and procedures that prohibit abuse, neglect, exploitation, mistreatment of [REDACTED]. Three (Dietary Aide, Assistant Maintenance Director, and Housekeeping Aide) of eight employee files reviewed for state registry checks lacked verification with the New York State Nurse Aide Registry prior to employment. The findings are: 1. Record review of a Dietary Aide's employee file on 6/21/18 revealed it contained a Nurse Aide Registry Verification Report for this employee dated 10/10/17. Further review of this employee's automated scheduling system record revealed this employee worked sixteen days at this facility between 9/18/17 and 10/9/17. Review of the Dietary Aide job description dated 7/15/97 revealed a Dietary Aide's general function is to assemble prepared foods for residents and deliver and serve meals to residents. 2. Record review of the Assistant Maintenance Director's employee file on 6/21/18 revealed it contained a Nurse Aide Registry Verification Report for this employee dated 5/2/18. Further review of this employee's automated scheduling system record revealed this employee worked six days at this facility between 4/17/18 and 5/1/18. During an interview on 6/21/18 at 9:33 AM, the Director of Human Resources stated the Assistant Maintenance Director works full-time and works on all floors of the facility. 3. Record review of a Housekeeping Aide's employee file on 6/21/18 revealed it contained a Nurse Aide Registry Verification Report for this employee dated 12/19/17. Further review of this employee's automated scheduling system record revealed this employee worked five days at this facility between 12/8/17 and 12/18/17. During an interview on 6/22/18 at 12:45 PM, the Director of Housekeeping stated this Housekeeping Aide's duties include being on the resident units and cleaning resident rooms. Review of the facility policy called, Abuse Prevention Program, revised (MONTH) (YEAR), revealed as part of resident abuse prevention, the administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has had a finding entered into the State Nurse Aide Registry. 415.4(b)(1)(ii)(a)(b)

Plan of Correction: ApprovedJuly 23, 2018

The three employees do have all necessary checks completed to date, and did have the Nurse Aide Registry checks done, when files were reviewed.
Finding #1- Dietary aide Nurse Aide Registry check was completed on 10/9/17.
Finding #2- Assistant Maintenance Director check was completed on 5/2/18.
Finding #3- Housekeeping Aide check was completed on 12/18/17.

A Review of any Resident grievances, pertaining to staff, will be done to ensure that the grievances were not a result of delayed Nurse Aide Registry checks.
Employee nurse aide registry checks were all reviewed to ensure accuracy and completion. There were no issues noted.
The facility will prevent any future residents from being affected, by a lapse in the Registry check, by completing a new hire checklist for every staff within 24 hours of the date of hire, to ensure checks are being completed in a timely manner.
The Administrator will educate the Human Resources Department on the importance of running checks prior to date of hire. All new hire files will also be audited on a weekly basis to make sure that no files were over looked.
A monthly audit will be completed by the 1st of every month, reviewing the last 30 days of Nurse Aide Registry checks.
The audits will be kept on a log, and reviewed at the monthly QAPI meetings.
Responsibility: HR Director

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed 6/27/18, the facility did not develop a comprehensive person-centered care plan for each resident, consistent with resident rights 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 for three (Residents #88, 121, 531) of 38 residents reviewed for care plan development. Specifically, the issues included the lack of care plan development to address [MEDICAL CONDITION], and the use of [MEDICAL CONDITION] medications (#88), lack of care plan development to address depression and the use of [MEDICAL CONDITION] medications (#121). Additionally, Resident #531 did not have a care plan developed to address pain management. The findings are: Review of a policy and procedure entitled Comprehensive Assessment and the Care Delivery Process dated 12/2016 revealed that comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions through identifying potential causes or contributing factors of problems and symptoms, including; medical, psychosocial, environmental and functional. The findings are: 1. Resident #88 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/20/18 revealed the resident had severe cognitive impairment, sometimes understood and sometimes understands. The MDS documented the resident received antipsychotic medications. Review of the monthly physician's orders [REDACTED]. Review of a Physician's Progress Note dated 3/15/18 revealed a history of [MEDICAL CONDITION]. Review of a Nurse Practitioner Progress Note dated 4/9/18 documented patient encountered after falling and [MEDICAL CONDITION] activity this morning. The plan included to continue [MEDICAL CONDITION] and fall precautions. Review of the current comprehensive care plan revised 6/7/18 revealed Depression was identified as a focus area with the plan to administer medications as ordered by the physician. There was no care plan was developed for the use of [MEDICAL CONDITION] medications. Additionally, there was no care plan developed with measurable goals and interventions for the [DIAGNOSES REDACTED]. During an interview on 6/25/18 at 9:42 AM, the Registered Nurse (RN #1) Unit Manager stated a care plan should have been developed for a resident with [DIAGNOSES REDACTED]. She was responsible for the development of the [MEDICAL CONDITION] care plan and the Social Worker was responsible for the development of the antipsychotic section. She had not had a chance to review the care plan because she just started working at the facility in March. During an interview on 4/26/18 at approximately 9:15 AM, the Director of Social Work stated a care plan should have been developed for the use of an antipsychotic medication. The Social Worker was responsible for this section of the care plan. 2. Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had moderately impaired cognition, received antipsychotic and antidepressant medications. Review of the Medication Administration Records (MAR) dated 12/1/16 through 3/30/18 revealed the resident received Aripiprazole ([MEDICATION NAME]-antipsychotic medication) 2 mg (milligrams) daily for depression daily from 12/6/17 through 3/28/18. The dose was decreased to 1 mg on 3/28/18. The resident also received [MEDICATION NAME] ([MEDICATION NAME]-antidepressant medication) 300 mg daily. Review of the comprehensive care plan (identified as current by facility staff) revealed there was no care plan developed that included depression, the use of [MEDICAL CONDITION] medications which included measurable goals and interventions. During an interview on 6/26/18 1:55 PM, RN #3 Unit Manager stated she thought the resident did have a care plan for depression. RN #3 reviewed the care plan in her computer, and stated it (depression focus area) was resolved. The previous social worker resolved it 11/29/17. I don't know why she did that. RN #3 said it should still be on the care plan. 3. Resident #531 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] documented the resident was cognitively intact, understands, and was understood. The MDS documented that the resident received pain medication as needed, has had pain frequently and made it hard to sleep at night. During an interview on 6/21/18 at 9:40 AM, the resident stated she doesn't receive her pain medications timely for her pain. Review of a Pain Evaluation dated 6/21/18 revealed the resident's ability to sleep, desire to participate in activities, and mobility are impacted by the pain. Review of the Physician order [REDACTED]. Review of a Physician's Progress Notes dated 6/22/18 revealed the resident currently reporting moderate discomfort of the left shoulder and reports pain related to the right below knee amputation. The physician's plan revealed the following orders: [MEDICATION NAME] 7.5 mg/325 mg two tablets every 4 hours as needed for severe pain, [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 7.5 mg / 325 mg one tablet every 4 hours as needed for pain, [MEDICATION NAME] HCL 20 mg two times a day for pain, and [MEDICATION NAME] 600 mg three times a day for [MEDICAL CONDITION] (pain, numbness or weakness of nerves). Review of the Medication Administration Record [REDACTED]. Review of the undated comprehensive care plan revealed the resident had a surgical wound of the left shoulder, and [DIAGNOSES REDACTED]. During an interview on 6/27/18 at 12:24 PM, the Assistant Director of Nursing (ADON) reviewed the resident's comprehensive interdisciplinary care plan. The resident received [MEDICATION NAME] and [MEDICATION NAME] routinely for pain and frequently received [MEDICATION NAME]/[MEDICATION NAME] upon her request to manager her pain. The ADON further stated there should be a care plan developed for the resident's pain management. 415.11(c)(1)

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Care plan for residents # 88 was revised on 6/25/18 to reflect [MEDICAL CONDITION] disorder and use of [MEDICAL CONDITION] medications.
Care plan for resident # 121 was revised on 6/26/18 to include dx of depression and use of [MEDICAL CONDITION] medications.
Care plan for resident # 531 was revised on 6/29/18 to include pain management.
Unit managers and Social workers will be counseled by the DON regarding the importance of comprehensive and timely care plan development.
All residents have the potential to be affected.
Residents with dxs of [MEDICAL CONDITION] disorder or depression or that are receiving [MEDICAL CONDITION] medications will be reviewed by the IDT team to ensure that care plans are accurately developed. Any issues noted will be immediately addressed .
The RN Educator will re-educate all members of the IDT team regarding comprehensive care plan development. This education will include the need to include [DIAGNOSES REDACTED].
The DON reviewed the policy ? Comprehensive Assessment and Care Plan Development ?with no revisions required.
The DON will conduct 10 weekly care plan audits for a period of 12 weeks. These audits will ensure that all residents have comprehensive care plans developed in a timely manner.
Any issues noted will be immediately addressed. The results of the audits will be forwarded to the QAPI Committee for review and input.

Responsibility : DON

FF11 483.25(l):DIALYSIS

REGULATION: §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint Investigation (Complaint # NY 07) completed during the Standard survey completed on 6/27/18, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #90) of one resident reviewed for [MEDICAL TREATMENT]. Specifically, the lack of a valid/correct physician's orders [REDACTED]. sound of blood flow) and thrill (a buzzing vibration felt by palpation) of the shunt. The finding is: Review of the policy and procedure entitled End Stage [MEDICAL CONDITION], Care of a Resident With dated (MONTH) 2010 revealed [MEDICAL TREATMENT] devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of the device. Nursing staff should check the patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access site. The general medical nurse should document in the resident's medical record every shift: location of catheter, condition of dressing, if [MEDICAL TREATMENT] was done during the shift, any part of report from [MEDICAL TREATMENT] nurse post [MEDICAL TREATMENT] being given, and observations post- [MEDICAL TREATMENT]. 1. Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 5/8/18 revealed the resident was understood, usually understands and was cognitively intact. The MDS also documented the resident received [MEDICAL TREATMENT]. Review of the undated comprehensive care plan revealed the resident had impaired renal function with a catheter (tube) related to end stage [MEDICAL CONDITION]. The care plan did not include the catheter type or location. Review of the physicians Order Summary Report dated 3/26/18 to 6/30/18 revealed resident had a Permcath/Central Catheter in the left chest area, monitor for bleeding and placement every shift, and if bleeding is noted apply pressure and call the physician. Review of the Medication and Treatment Administration Records (MAR and TAR) for April, (MONTH) and (MONTH) of (YEAR) revealed the resident had a permcath/central catheter in the left chest (a long flexible tube that is inserted into a vein most commonly the neck), monitor for bleeding and placement every shift, and if bleeding is noted apply pressure and call the physician. Further review of the MAR and TAR revealed there was no documented evidence the resident's left arm fistula (a tube or device surgically implanted to create an artificial connection between an artery and a vein) was observed for proper functioning, possible complications on days between [MEDICAL TREATMENT] treatments or before and after returning from [MEDICAL TREATMENT] treatment. The site was not monitored for bruit and thrill, bleeding, or signs and symptoms of infection. Review of physicians Encounter note dated 5/9/18 revealed the resident had a [DIAGNOSES REDACTED]. He was admitted to the hospital after nonstop bleeding from his left upper extremity arteriovenous fistula (AV fistula-is a connection of a vein and an artery usually in the forearm) from the [MEDICAL TREATMENT] center. He was stabilized and sent back to the skilled nursing facility. During an observation on 6/26/18 at 9:07 AM, the residents AV fistula was located in his left arm, was open to air and had no signs and symptoms of bleeding or infection. During an interview on 6/26/18 at 1:29 PM, Licensed Practical Nurse (LPN #3) Unit Manager stated she was unsure of where the resident's [MEDICAL TREATMENT] was located. After she reviewed the physician's orders [REDACTED]. Review of the Post Treatment [MEDICAL TREATMENT] report intermittently dated from 5/1/18 to 6/25/18 revealed the residents primary access site was a AV fistula in the left lower arm. During an interview on 6/27/18 at 11:43 AM, the Assistant Director of Nursing (ADON) stated if a resident has a AV fistula in the arm she would expect the nursing staff to monitor for signs and symptoms of infection and for the bruit and thrill to be checked every shift. 415.12

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The comprehensive care plan for resident # 90 was updated on 7/17/18 to include [MEDICAL TREATMENT] catheter type and location.
A clarification order was written for resident # 90 on 6/26/18. This order included the correct site of resident?s AV fistula; monitoring of site QS to include bruit/thrill , s/s bleeding or infection .
The nurses caring for resident # 90 will be counseled by the DON regarding appropriate monitoring of [MEDICAL TREATMENT] access locations.
All residents have the potential to be affected.
A full house audit of residents receiving [MEDICAL TREATMENT] will be conducted by the Administrative nursing staff. The audit will ensure that all resident with [MEDICAL TREATMENT] catheters will have QS monitoring to include bruit/ thrill, s/s bleeding or infection. In addition, all residents receiving [MEDICAL TREATMENT] will have care plan review to ensure that [MEDICAL TREATMENT] catheters are accurately care planned.
The RN Educator/ designee will educate licensed nurses regarding the facility [MEDICAL TREATMENT] polices. The need to check bruit/ thrill QS and to monitor for s/s infection or bleeding will be stressed. Residents receiving [MEDICAL TREATMENT] will have the location of catheter included in their comprehensive care plan.
The DON reviewed facility [MEDICAL TREATMENT] policies with no revisions required.
The Unit Managers will audit residents receiving [MEDICAL TREATMENT] weekly for a period of 10 weeks. Audits will ensure appropriate monitoring of [MEDICAL TREATMENT] catheter sites and inclusion in resident comprehensive care plan.
Any issues noted will be immediately addressed.
The results of the audits will be forwarded to the QAPI Committee for review and input.
Responsibility : DON


FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation, interview, and record review during the Standard survey completed on 6/27/18, the facility did not dispose of garbage and refuse properly. One of one exterior observed for proper garbage disposal was not maintained in a sanitary condition to prevent the harborage and feeding of pests and waste was not properly contained in dumpsters with lids or otherwise covered. The findings are: 1. Observation of the exterior of the building along the Administrative Wing on 6/21/18 at 2:15 PM revealed the approximately 70-foot long strip of land between the building and the sidewalk contained at least 300 cigarette butts, approximately 30 plastic cigarette/cigar filters, cigarette packaging, used vinyl gloves, and used paper towels. 2. Observation of the exterior of the building on the north side, between the building and the fence, on 6/21/18 at 2:30 PM revealed the following items were on the ground: - used single service cups and plates - food wrappers - ripped plastic wrap - two pallets of ripped 50-pound bags of rock salt - a pallet of sheets of decorative tiles - a pallet of vinyl flooring. Further observation at this location revealed there was a 55-gallon uncovered garbage receptacle approximately 1/3 full of food wrappers and debris. Continued observation revealed there was a 35-gallon uncovered garbage receptacle that contained food wrappers and debris, with approximately three inches of standing water at the bottom. In addition, there were two three-gallon totes and three toilets, each with standing water that contained insect larvae and flying insects above. During an interview at the time of the observation, the Maintenance Director stated one of the pallets of rock salt was brought out here in (MONTH) of (YEAR), but all other items have been stored here since before he began working here about two months ago. He also stated the Maintenance Department does a daily walk-through of this area, but it has not been done in three to four days. During an interview at the time of the observation, a member of the Housekeeping Department stated he has been working at this facility for five months, and these items have always been stored here. During an interview on 6/25/18 at 2:55 PM, a Maintenance Assistant stated a member of the Maintenance Department does a daily walk-through of this area and about once a month, a member of the Maintenance Department shovels up all loose debris from this area, and this was last done about one month ago. 3. Observation looking out from the Third Floor B Wing hall window on 6/21/18 at 8:23 AM revealed many pieces of garbage were on the ground between the building and the fence, including containers with standing water. One live rat was seen walking along the items. Review of exterminator's reports revealed the following: - 6/8/18 - grass needs to be cut along with weeds, mice back door and ladies room. - 6/14/18 - very overgrown back of building, needs to be cut down and cleaned. - 5/18/18 - activity in stations along fence, entire area around parking lot needs to be cleaned up, lots of debris and construction debris, garbage bins need to be completely cleaned and emptied. 4. Observation of the exterior of the building at the garbage dumpster area on 6/21/18 at 2:40 PM revealed one of two brown wheeled carts contained multiple ripped bags of garbage and at least 15 flies flying around it. The area was malodorous. 5. Observation of the garbage dumpster area on 6/21/18 at 2:41 PM revealed one of two garbage dumpsters had an open lid. A member of the Dietary Department approached it, placed a garbage bag into it, and walked away without closing the lid. Observation at the garbage dumpster area on 6/25/18 at 3:00 PM revealed one of two garbage dumpsters had an open lid and at this time it was brought to the attention of the Maintenance Director, who closed the lid. Approximately three minutes later, a member of the Dietary Department approached it, opened the lid, placed a garbage bag into it, and walked away without closing the lid. During an interview at the time of the observation, the Maintenance Director stated the garbage dumpsters must be kept closed at all times. 6. Observation behind the garbage dumpster on 6/21/18 at 2:45 PM revealed the following items on the ground: used single service cups and plates, used vinyl gloves, approximately 50 cigarette butts, and food wrappers and food containers. 415.29(i)(1)(j)(6)(i)

Plan of Correction: ApprovedJuly 23, 2018

Finding #1- Maintenance and housekeeping staff will clean up area along side of the building. Activities staff will ensure and new cigarette butts are properly disposed of.
Finding #2- Maintenance staff will move pallets of flooring, tile and rock salt.
Housekeeping, will clean and sanitize all existing garbage receptacles.
Finding #3- Maintenance staff will cut grass , clean up debris, and have an exterminator come to the facility, to follow up and make sure rodents are not in the vicinity.
Finding #4- Housekeeping department will bring in brown carts and clean.
Finding #5- dietary department will not leave trash can lids off, with new self-closing lids installed.
Finding #6- Maintenance staff will clean the area in which items were found.
All residents have the potential to be affected.
The current garbage cans will be replaced with new metal new self-closing garbage cans.
All new trash receptacles will be cleaned on a weekly basis.
The facility will prevent future residents from being effected by conducting education with the housekeeping, and dietary department on the correct way to dispose of trash.
The housekeeping department will clean and sanitize the garbage bins on a weekly basis.
All facility staff will be educated on proper disposal of cigarette butts.
A daily walk will be done each morning by a member of the maintenance department. The maintenance staff member completing the check, will sign off on the log.
Logs will be reviewed by the 15th of every month, and presented at the QAPI meeting to ensure that they are being completed.
Responsibility: Administrator




FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(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; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/27/18, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. In addition, the facility did not ensure that PRN (as needed) antipsychotic medication orders were limited to 14 days. Four (Residents #64, 88, 121, 152) of six residents reviewed for unnecessary medications had issues. Specifically, Resident #152 had a PRN (as needed) order for [MEDICATION NAME] (antipsychotic medication) that was not limited to 14 days and there was a lack of behavior monitoring to support the continued administration of the medication. Residents #88 and 121 did not receive a gradual dose reduction (GDR) for the use of [MEDICATION NAME] (antipsychotic medication) and Residents #64 and 88 did not have adequate indications and identified targeted behaviors to justify the use of an antipsychotic medication and adverse effects were not monitored. The findings include but are not limited to: Review of an undated policy and procedure entitled Tapering Medications and Gradual Drug Dose Reduction revealed within the first year after a resident is admitted on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between attempts) unless clinically contraindicated. 1.Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated 5/4/18 revealed the resident has moderately impaired cognition; receives antipsychotic and antidepressant medications; and scored a 1 on the resident mood interview (interview conducted by facility staff to assess for presence of signs of depression - maximum score is 27) Review of Medication Administration Records (MARs) dated 12/1/16 to 3/30/18 revealed the resident received Aripiprazole ([MEDICATION NAME] - antipsychotic medication) 2 mg (milligrams) daily for depression daily from 12/6/17-3/28/18. The dose was decreased to 1 mg on 3/28/18. physician progress notes [REDACTED]. Observations throughout the morning on 6/21/18 revealed the resident was sitting in her recliner chair eating breakfast and later in the morning, she was reclined in her chair and smiled at the surveyor. During an interview on 6/22/18 at 1:00 PM, the Licensed Practical Nurse (LPN #4) Unit Manager (UM) stated that the resident is on the [MEDICATION NAME] for depression; she is very sweet and cooperative with care; and she has never seen the resident cry. The LPN UM stated she's been working in the facility (approximately five months) and they reviewed everyone receiving an antipsychotic medication in (MONTH) (2010) Before then, she's not sure when they were reviewed. During an interview on 6/26/18 at 12:20 PM, the Pharmacy Consultant stated that [MEDICATION NAME] can be used as adjunct therapy for major [MEDICAL CONDITION] and it is considered an antipsychotic. The Pharmacist stated GDRs are supposed to be done twice in the first year with at least one month in between. The facility has meetings where they meet and want the team to make determinations about GDRs. The meeting is once per month and they are supposed to invite him to attend. They go through each resident, he's not sure if the DON or SW document what is discussed. The facility has asked me not to recommend GDRs on an individual basis unless I see something wacky, then I'll write something up. If for some reason a GDR isn't done, there should be documentation for the reason why. During an interview on 6/26/18 at 12:45 PM, the Director of Social Work stated she wanted an organized system to audit everyone on [MEDICAL CONDITION] medications and one of their first meetings was (MONTH) (YEAR). She attends the meetings, as well as the Pharmacy Consultant, the Director of Nursing (DON), and the Unit Managers. The Social Worker (SW) stated she runs a report from Point-Click-Care (PCC - computerized documentation program) of every resident receiving a [MEDICAL CONDITION] medication, and they discuss the residents and their behaviors. When they decide to do a gradual dose reduction for a resident, the Unit Managers are supposed to take that information to the physician to get it approved. The SW further stated they do GDRs based on regulation timeframes and the pharmacist knows the regulations. The SW reviewed an untitled medication report dated 6/12/17 that indicated that Resident #121 was on [MEDICATION NAME] and [MEDICATION NAME] (antidepressant). The [MEDICATION NAME] is circled and a handwritten note read d/c (discontinue) [MEDICATION NAME]. The SW stated, It looks like we recommended a GDR at that point but it wasn't done. During an interview on 6/27/18 at 7:30 AM, the Physician stated the facility has a GDR meeting that he doesn't attend physically but the DON is in the meeting. The Physician stated he relies on the staff to inform him of the outcomes of the meetings and let him know when a resident needs a GDR. He is aware of GDRs needing to be done but wasn't sure of specific time frames. The Physician stated that Resident #121 is stable with her behaviors 2. Resident #88 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, sometimes understood and sometimes understands. The MDS documented that the resident has no behaviors; receives an antipsychotic medication daily; and GDR was attempted. Review of physician's orders [REDACTED]. Review of MARs dated 6/2017 to 6/2018 revealed the resident received [MEDICATION NAME] 10 mg daily for depression. Review of a Pharmacy Consultant Medication Regimen Review dated 10/8/17 revealed resident is receiving [MEDICATION NAME] 10 mg daily for behavior. No recent notes listed in the medical record describing the effectiveness of the medication. Please review and update. The recommendation was noted and revealed provider updated and note to be done. The recommendation was not signed by the physician. Review of physician progress notes [REDACTED]. A Pharmacy Consultant Medication Regimen Review dated 2/3/18 documented Resident has been receiving a psychopharmacological medication ([MEDICATION NAME] 10 mg QD (daily) for behaviors) for several months. Please review if GDR could be attempted or document why the clinical rationale for any additional attempted dose reduction at the time would be likely to impair the resident's function or increase distressed behavior. Review of a Social Work [MEDICAL CONDITION] Medication Doses Form dated 3/4/18 revealed [MEDICATION NAME] 10mg for depression; Psyche to see. The Comprehensive Care Plan (CCP) revised 6/7/18 revealed a Focus area for Depression related to dementia with planned interventions to monitor for signs and symptoms of depression and report any signs to the physician and administer all medications as ordered. Review of a CNA (certified nurse aide) Documentation Survey Report Behavior Symptoms dated 12/2017 through 6/2018 revealed the resident had one episode of wandering in 12/2017, one episode of wandering in 3/2018 and one refusal of care in 5/2018. Observation on 6/22/18 at 10:47 AM revealed the resident was in the Fourth Floor Hall A sitting lounge attempting to stand up out of wheel chair and was redirected by a Licensed Practical Nurse (LPN #7). Observation on 6/25/18 at 9:26 AM revealed the resident was ambulating in the hallway with the Registered Nurse (RN #2) Inservice Coordinator. During interviews on 6/25/18 from 9:42 AM and 10:24 AM, the Registered Nurse (RN #1) Unit Manager, CNA #3 and CNA #1 stated the resident has no known behaviors. During interview on 6/25/18 at 10:17AM, the Director of Social Work stated [MEDICATION NAME] is used to treat depression and the resident has been without behaviors. The Director of Social Work stated I thought she had [MEDICAL CONDITION] and a GDR (gradual dose reduction) was not needed. The Director of Social Work then stated she was unable to locate the supporting documentation in the medical record to justify a [DIAGNOSES REDACTED]. During a telephone interview on 6/25/18 at 8:15 AM, the Pharmacy Consultant stated [MEDICATION NAME] is used as an adjunct with [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antidepressant) for depression. The Pharmacist stated at the request of the facility, he can no longer make requests for GDR's on his own, therefore he meets monthly with the interdisciplinary team and discussion is amongst the team. The Pharmacist Consultant then stated he sent a recommendation to the Physician in (MONTH) (YEAR) for a GDR of the [MEDICATION NAME] which the Physician did not address. During an interview on 6/27/18 at 7:05AM, the Physician he stated typically does not participate in the monthly [MEDICAL CONDITION] medication reviews. Pharmacy requisitions are reviewed twice weekly unless it requires immediate attention and then he would expect the nurses to email or call him for an order. The Physician stated he was unaware of the recommendation for a GDR of the [MEDICATION NAME]. A Psychologist is on board and reviews the [MEDICAL CONDITION], and he typically follows the recommendations of the Psychologist. The Physician then stated, We need to improve our communication within the facility. The Physician further stated a GDR should have been attempted and he did not recall any specific [DIAGNOSES REDACTED]. During interview on 6/27/18 at 8:50 AM, the DON stated she receives recommendations from the Pharmacist and they are distributed to the Unit Managers to address. If the recommendation requires an immediate response, then the expectation is to call the Physician or email him for an order. 3. Resident #152 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident's cognitive assessment was not complete and the resident understands and is understood. Review of a policy and procedure (P&P) entitled Antipsychotic Medication Use revised (MONTH) (YEAR) revealed antipsychotic medications are prescribed at the lowest possible dose for the shortest period when necessary to treat specific conditions which they are intended for and effective. The P&P documented that PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of the medication. [MEDICAL CONDITION] medications beyond 14 days require the practitioner to document the rationale for the extended order and the duration of the PRN order will be indicated in the order. Review of the Comprehensive Care Plan (CCP) dated 6/12/18 revealed the resident uses [MEDICAL CONDITION] drugs related to a [DIAGNOSES REDACTED]. The CCP did not identify how the resident exhibits her anxiety and there were no nonpharmacological interventions included. Review of Clinical physician's orders [REDACTED]. There was no duration written on the order and there was no specific indication identified for use. In addition, the resident had an order for [REDACTED]. Review of the MAR indicated [REDACTED]. Additional review of the 6/2018 MAR indicated [REDACTED]. Additional review revealed the resident received [MEDICATION NAME] on 6/10/18 at 12:12 AM and 6/19/18 at 8:15 AM. Review of corresponding Progress Notes revealed the following: - 6/8/18 - RN #8 documented behaviors currently exhibited. - 6/8/18 at 10:39 PM - C/O (complains of) anxiety and requests [MEDICATION NAME]. [MEDICATION NAME] given 5 mg IM, positive relief noted. - 6/10/18 - No nursing progress note was entered - 6/19/18 - There was no documentation regarding agitation or anxiety. During an interview on 6/27/18 at 7:14 AM, the Physician stated that the resident had PRN [MEDICATION NAME] for agitation; however, he could not recall the resident's target behaviors. The Physician stated that he usually prescribes [MEDICAL CONDITION] medications for the shortest possible duration and that he gave orders for use for only 14 days. The nurses complete the order entry at the facility and the prescribers electronically sign the orders after they are entered, so he does not know why a stop date was not entered. During an interview on 6/27/18 at 8:23 AM, LPN #8 stated she administered [MEDICATION NAME] to the resident on one occasion (6/23/18 at 6:47 PM) because she was very anxious and the medication did not do anything to relax her. The resident continued to ring her call bell, would not calm down and was calling her family a lot. LPN #8 stated that the resident gets nervous and depressed and usually the prescribed [MEDICATION NAME] works well to calm her down. The LPN stated she did not know why she did not administer the [MEDICATION NAME] instead of [MEDICATION NAME]. 415.12(l)(1)

Plan of Correction: ApprovedJuly 27, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The PRN [MEDICATION NAME] for resident # 152 was discontinued on 7/18/18.
Resident?s # 88's [MEDICATION NAME] was reduced on 7/18/18 . Indications for [MEDICAL CONDITION] use and targeted behaviors will be included in resident's care plan. Adverse effects of [MEDICAL CONDITION] use and reduction are being monitored.
Resident # 121?s [MEDICATION NAME] was reduced on 5/22/18.
Resident # 64 had a reduction of his [MEDICATION NAME] on 7/19/18 . Indications for [MEDICAL CONDITION] use and targeted behaviors will be included in resident's care plan. Adverse effects of [MEDICAL CONDITION] use and reduction are being monitored.
All residents have the potential to be affected.
A full house review of residents receiving [MEDICAL CONDITION] medication will be conducted. This review will ensure that PRNs are limited to 14 days and that GDRs have been attempted as indicated. The need to include targeted behaviors and justification for antipsychotic medication will also be reviewed . Any issues noted will be immediately addressed .
The DON will educate the IDT team and licensed nurses regarding [MEDICAL CONDITION] medication usage. Education will include appropriate usage , subsequent documentation and the guidelines for GDR. The need to limit PRN [MEDICAL CONDITION] medications to 14 days will also be discussed .
The DON will conduct 10 weekly [MEDICAL CONDITION] review audits for a period of 12 weeks. Audits will include documentation of target behaviors, justification for use , GDR and limitation of PRNS to 14 days. Any issues noted will be immediately addressed.
The results of the audits will be forwarded to the QAPI Committee for review and input.
Responsibility : DON


4FGA 400.10:HEALTH PROVIDER NETWORK ACCESS AND REPORTING

REGULATION: The operator of a facility shall obtain from the department ' s health provider network (HPN), HPN accounts for each facility he or she operates and ensure that sufficient, knowledgeable staff will be available to and shall maintain and keep current such accounts. At a minimum, 24-hour, seven-day-a-week contacts for emergency communication and alerts must be designated by each facility in the HPN communications directory. A policy defining the facility's HPN coverage consistent with the facility ' s hours of operation, shall be created and reviewed by the facility no less than annually.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on interview and record review conducted during the Standard survey completed 6/27/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility could not locate their eFINDS resident tracking system equipment. This has the potential to affect all residents in the facility, in the event of a disaster that would require evacuation and relocation of residents. The finding is: Record review on 6/20/18 of the facility's Emergency Preparedness Plan, last updated 3/14/18, revealed information about the use of eFINDS was included in the plan and also in the local Mutual Aid Plan, which was located within the facility's Emergency Preparedness Plan. During an interview on 6/26/18 at 10:25 AM, the Administrator stated during an emergency, the facility would use eFINDS, among other methods, to relay information to and from other health care facilities. At this time, the Administrator also stated this facility discovered that their eFINDS scanner did not work during a community-wide evacuation drill on 11/1/17. During an interview on 6/26/18 at 11:54 AM, the Assistant Administrator stated he had looked for the eFINDS scanner and wrist bands recently and could not locate them. Additionally, he stated after the community-wide evacuation drill, he and the previous Maintenance Director made several calls to inform authorities that the scanner did not function as expected, and the former Maintenance Director possibly threw out the eFINDS box that contained the eFINDS scanner and wrist bands. 10NYCRR: 400.10

Plan of Correction: ApprovedJuly 23, 2018

Order was placed for a new E-Finds Scanner on 7/19/2018 from L-Tron Corporation with 2 day shipping. In the event of a disaster or emergency while awaiting the E-Finds scanner we will communicate resident information verbally with accepting facility.
Emergency contact list will be created to identify the staff with 24-hour, seven-day-a-week, HPN access, in case of a disaster.
All residents have the potential to be effected.
Going forward, the E-Finds Scanner will be stored in the Administrators Office.
The administrator will hold a meeting with Assistant administrator, Director of Nursing, Director of maintenance to review the E-Finds scanner protocol.
E- Finds scanner location will be confirmed at every QAPI meeting, to ensure it has not been moved or misplaced.
Responsibility: Administrator


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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 27) during the Standard survey completed on 6/27/18, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Two (Residents #97, 162) of 12 residents reviewed for investigation of accidents/incidents had issues. Specifically, the lack of an investigation, including a Registered Nurse (RN) assessment for a resident who had fallen and sustained ankle injury (#97) and lack of a complete investigation after a resident had a fall (#162). The findings are: Review of the facility policy entitled Abuse/Behavior: Accident/Incident Reporting-Resident last updated (MONTH) (YEAR) revealed an Accident/Incident Form will be completed each time a resident experiences an unusual occurrence that causes or could cause injury. Unusual occurrences include but are not limited to: injury with known cause, injury with unknown cause, an observed fall, and an alleged unusual occurrence reported by the resident/family. 1.Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set-resident assessment tool) dated 1/29/18 revealed the resident is cognitively intact and transfers with extensive assistance of two people. During an interview on 6/21/18 at 10:29 AM, the resident stated that in (MONTH) a new girl transferred her, let her go, and she went down on her ankle and had an ankle fracture. Observation on 6/26/18 at 9:30 AM revealed the Certified Nurse Aide (CNA) #5 completed morning care and was putting the resident's socks on, that was noted to have a discolored brownish/yellow area on her right ankle. Licensed Practical Nurse (LPN) #7 then placed a brace on the resident's right ankle. Review of LPN Nurse's Notes revealed the following: -2/6/18 2:33 PM resident weak this shift, unable to transfer to wheelchair. -2/7/18 at 2:50 AM complaint of right ankle swelling, [MEDICAL CONDITION] noted 1+ (mild swelling) -2/8/18 at 6:58 AM revealed right ankle swollen, x-ray taken, results pending. Patient requested ice to be placed on ankle. Further review of the Nurse's Notes revealed there is no documented RN assessment of the resident's ankle. Physician note dated 2/7/18 revealed resident's chief complaint is a swollen right ankle. Patient noted right ankle swollen, twist on floor and refused pain meds. Patient was given x-ray. X-ray report dated 2/7/18 revealed the right ankle shows osteopenia (bone loss), calcaneal (heel) spurring, no fracture or dislocation. Facility 24-Hour Report dated 2/6/18 revealed the resident was weak this shift and unable to transfer to wheelchair. 2/7/18 the report includes resident on antibiotic. 2/8/18 right ankle swollen, Tylenol 1000 mg (milligrams) given, requested to stay in bed. Review of the Therapy Addendum dated 2/8/18 revealed the resident stated she was lowered to the floor the previous day during transfer into wheelchair and injured right ankle. Stated x-rays were taken but had not been sent back to facility yet and resident did not think she would be able to stand to transfer into wheelchair. Will re-assess tomorrow after receiving x-rays. Review of the Therapy Addendum dated 2/13/18 revealed the resident has been refusing to get out of bed during treatment sessions due to right ankle pain. This writer spoke to Unit Manager about ankle and x-ray was negative for fracture. Resident stated she was told she is not allowed to get out of bed or put pressure on ankle. This writer and Unit Manager approached resident and educated that x-ray was negative and she can put weight through right lower extremity. After discussion with Unit Manager, resident agreed to attempt transfers. Resident demonstrated ability to transfer with min/mod assist of 1 with standard walker. Resident demonstrated with pain during transfer but could complete the transfer. During an interview on 6/27/18 at 9:10 AM, the Physical Therapy Assistant (PTA) #1 reviewed physical therapy notes and stated that the resident was on therapy program the end of (MONTH) for a decline in her transfer status but could transfer with a minimum assist of one person as of the 2/5/18 progress report. The resident told her she was lowered to the floor, that she had a different aide on the day she fell , and the aide did not do the same things as her usual aide did. PTA #1 informed the RN Unit Manager and they spoke to the resident after they received the x-ray results. PTA #1 stated she applied ice on the resident's right ankle which was swollen and bruised. During an interview on 6/27/18 at 9:36 AM, LPN #7 (assigned to resident on day shift 2/6/18 and 2/7/18) stated, I wasn't here the day it happened, it was an agency aide, not her regular, that had lowered her into her chair. When I looked at it (right ankle), it was yellowish and swollen. I told the Unit Managers (LPN #4 and RN #3) about it, and got an x-ray ordered. The results were negative and got an order for [REDACTED]. During an interview on 6/27/18 at 9:39 AM, the LPN #4 Unit Manager stated, I didn't see the resident's ankle and an Accident/Incident Report (A&I) was not started because it wasn't a fall. During an interview on 6/27/18 at 9:55 AM, CNA #5 (assigned to the resident 2/7/18 on day shift) stated, I didn't have the resident that day, I think I was here the next day. She was a stand with a walker; when I came back she complained of right ankle pain. I asked what happened, and she said told me she got weak and went down, her legs gave out. I told the Unit Manager about the pain and they got an x-ray. CNA #5 further stated, She never fell when I took care of her, I would stand her up with her walker and hold under her arm. I never had to get her up off the floor. During an interview on 6/27/18 at 10:00 AM, RN #3 Unit Manager stated, I never heard that the resident said she was lowered to the floor. If she was lowered we would have automatically done an A&I the moment we knew it happened. You don't see a note from me because when I heard about it, the x-ray was already done. I assumed there would be an RN note from the supervisor on whatever shift the resident started saying she had the pain. During an interview on 6/27/18 at 12:15 PM, the Director of Nursing (DON) revealed she would have expected an RN to assess Resident #97's right ankle and an A&I report be completed. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revealed the resident was a Fall Risk and had a fall on 5/4/18 and 5/22/18 with plans to anticipate the resident's needs and ensure the resident wears proper footwear. Review of an A&I Report dated 5/4/18 at 11:45 AM revealed the resident's roommate called for help and staff discovered the resident on the bathroom floor. The resident was alert and oriented and stated she tried to walk to the bathroom. The resident sustained [REDACTED]. The LPN who witnessed the event completed the A&I Report and notified the Supervisor and documented the Housekeeper and a Nurse Supervisor were present. Further review of the A&I Report revealed there is no witness statement from the Housekeeper or the Nurse Supervisor. There is one statement from a CNA who was off the unit at the time of the occurrence; there are no other CNA statements. During an interview on 6/27/18 at 9:00 AM, the DON reviewed the facility staffing for 5/4/18 and stated that there were 3 or 4 other CNA's who worked on Unit 2 that should have been interviewed regarding the incident. 415.4(b)(iii)(3)

Plan of Correction: ApprovedJuly 27, 2018

Residents # 97 was seen by the physician on 2/7/18 regarding possible ankle injury . Resident remains at the facility in stable condition .
Resident # 162 was seen by the physician on 5/7/18 with no new orders. Resident remains in the facility in stable condition.
Investigations for incidents involving residents # 97 and # 162 were completed as per facility policy.
Unit Managers ( RN # 3 and LPN # 4) and nursing supervisors will be counseled by the DON regarding the need for RN assessment and the importance of thorough investigation , including obtaining of witness statements ,of all resident incidents/ injury. The need to complete accident/ incident reports for all unusual occurrences will be stressed .
All residents have the potential to be affected .
The DON/ designee will review the last 30 days of incident reports/ 24 hour report sheets to ensure that all incidents/resident occurrences are appropriately investigated and assessed. Any issues noted will be immediately addressed.
The RN Educator will educate licensed nursing staff on Investigative protocols and the facility Accident/Incident policy.
The DON reviewed the facility ?Accident/ Incident? and ?Investigation Protocols? with no revisions required.
The DON will conduct 10 weekly Incident/ Investigation audits for a period of 12 weeks. Audits will ensure that all resident incidents/injuries/unusual occurrences have thorough and complete investigation and subsequent RN assessment. Any issues noted will be immediately addressed .
The results of the audits will be forwarded to the QAPI Committee for review and input .
Responsibility : DON

FF11 483.50(a)(2)(i)(ii):LAB SRVCS PHYSICIAN ORDER/NOTIFY OF RESULTS

REGULATION: §483.50(a)(2) The facility must- (i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. (ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 6/27/18, the facility did not promptly notify the ordering physician or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification or per the ordering physician's orders [REDACTED].#88) of six residents reviewed for laboratory services. Specifically, the physician was not notified of subtherapeutic [MEDICATION NAME] acid (used to prevent [MEDICAL CONDITION]) levels in a timely manner. The finding is: Review of a policy and procedure entitled Lab and Diagnostic Test Results- Clinical Protocol dated 9/2012 revealed the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs, and a nurse will review all results. A nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. Facility staff should document information about when, how, and to whom the information was provided. 1. Resident #88 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/20/18 revealed the resident had severe cognitive impairment, sometimes understood and sometimes understands. Review of an initial Physician's History and Physical dated 6/29/17 revealed the resident was receiving [MEDICATION NAME] Capsules 250 mg (milligrams) 1 po (by mouth) every 12 hours for [MEDICAL CONDITION]. Review of a Consultant Pharmacist Medication Regimen Review dated 12/4/17 revealed the resident was receiving [MEDICATION NAME] acid ([MEDICATION NAME]) 250 mg BID (twice daily). There were no [MEDICATION NAME] acid levels noted in the chart. Recommendations included [MEDICATION NAME] acid levels to be drawn and evaluated every six months. The box was checked Agreed and noted by the Unit Manager to obtain a [MEDICATION NAME] level the next lab day, and every 6 months. The notation by the Unit Manager was dated 12/20/17. Review of a physician's orders [REDACTED]. Review of a Laboratory Services report dated 12/21/17 entitled Therapeutic Drug Monitoring revealed a low [MEDICATION NAME] acid level of 40 ug/ml (50-100 ug/ml (microgram per milliliter). Review of the medical record revealed there was no documented evidence the physician was notified of the low [MEDICATION NAME] acid level dated 12/21/17. Review of the Nursing Progress Notes dated 12/4/17 through 12/28/17 revealed there was no documentation regarding the low [MEDICATION NAME] acid level or physician notification of the low (subtherapeutic) level. Review of a facility Accident/Incident Report dated 2/11/18 revealed, at 8:00 AM the resident had [MEDICAL CONDITION] activity and was found lying on the floor sustaining a laceration to the back of her head 3 cm (centimeter) in length. The resident was sent to the emergency room (ER) for an evaluation. Review of the Hospital Discharge Summary dated 2/11/18 revealed a [DIAGNOSES REDACTED]. This was discussed with the nursing home and the medication will need to be changed to the liquid form. Review of a physician's orders [REDACTED]. Review of a Physician's Progress Notes dated 2/12/18 revealed the resident experienced [MEDICAL CONDITION] activity over the weekend. [MEDICATION NAME] acid liquid and [MEDICATION NAME] (used to treat anxiety and certain types of [MEDICAL CONDITION]) prn (as needed). Further review of a Physicians Order's dated 2/12/18 revealed an order to repeat the Depokene ([MEDICATION NAME] acid) level in two weeks. Review of the medical record from 2/12/18 through 3/23/18 revealed a [MEDICATION NAME] acid level was drawn on 3/23/18 with a result of 32 ug/ml. There was no documented evidence the physician or nurse practitioner were notified of the subtherapeutic level. Review of the Physician's Progress Notes dated 3/11/18 and 3/21/18 revealed there was no documentation regarding the subtherapeutic (less than the amount required for a therapeutic effect) [MEDICATION NAME] acid levels. Further review of a facility Accident/Incident Reports dated 4/9/18 revealed the resident was found on the floor with active tremors and [MEDICAL CONDITION] activity, sustaining a 1 cm (centimeter) by 0.5 cm laceration to her left forehead. Review of a Nurse Practitioner Progress Note dated 4/9/18 documented patient encountered after falling and [MEDICAL CONDITION] activity this morning. Per nursing, patient was not witnessed having a [MEDICAL CONDITION], but was found on the floor, grunting and lethargic and was thought to be in a postictal state (altered state of consciousness that a person enters after experiencing a [MEDICAL CONDITION]). The plan was to increase the [MEDICATION NAME] acid to 250 mg TID (three times a day), obtain a [MEDICATION NAME] acid level on 4/13/18 and to continue [MEDICAL CONDITION] and fall precautions. During an interview on 6/25/18 at 9:42 AM, the Registered Nurse (RN #1) Unit Manager stated typically labs are given to her by the Director of Nursing (DON), and she reviews the labs. She will call or email the physician with any abnormal labs, make a notation on the bottom right corner of the lab and initial that it was reviewed. If she receives new orders from the physician, she would input the order into the computer, write it on the 24-hour report sheet, and place the lab in the physician's folder for him to sign the next time he is in the facility. RN #1 stated she was not here in (MONTH) (YEAR), but was in (MONTH) (YEAR) and stated she could not recall why the abnormal [MEDICATION NAME] acid level did not get reported to the physician. During interview on 6/25/18 at 7:29 AM, the Physician stated typically he reviews the labs in his folder. He expects the nurses to notify him of subtherapeutic levels, either by calling or emailing. He was unaware of these two subtherapeutic [MEDICATION NAME] acid levels. He stated he would have monitored the patient and repeated the level more frequently. Subtherapeutic [MEDICATION NAME] acid levels certainly could have caused her [MEDICAL CONDITION]. We need better communication in this facility. During interview on 6/27/18 at 9:20 AM, the Medical Director stated when a patient is newly admitted into the facility within the year, and if unaware of history, she would expect a [MEDICATION NAME] acid level to be kept at a therapeutic level. Additionally, she would expect the [MEDICATION NAME] acid level results to be reviewed, redrawn, documented and the dose adjusted if needed. 415.20

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 88 remains at the facility in stable condition; last [MEDICATION NAME] acid level was drawn 6/12/18 and was within therapeutic range.
The Unit Manager overseeing the unit for resident # 88 during the noted time frame is no longer employed at the facility.

All residents have the potential to be affected .
Residents receiving anti-[MEDICAL CONDITION] medications will be reviewed by the Administrative nursing team. This review will ensure that physician is aware of and has addressed most recent lab values. Any issues noted will be immediately addressed.
A dedicated fax machine for lab results will be installed on the 2nd floor nursing unit. This will ensure that all incoming lab results will be available to nursing staff in a timely manner.
The RN Educator will educate licensed nursing staff regarding the timely reporting of lab results, specifically those that are not within normal range , to the practitioner. After notification to the practitioner, the nurse is to initial and date the lab noting any new orders. This notification is then to be documented in the resident record and included on 24 hour unit report.
The ADON will conduct 10 weekly laboratory results audits for a period of 12 weeks. Audits will ensure that all laboratory results are reported to the practitioner in a timely manner. Any issues noted will be immediately addressed.
The results of the audits will be forwarded to the QAPI Committee for review and input.
Responsibility : DON





















































FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/27/18, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse. One (Unit 2) of three resident units observed for the storage of controlled drugs had an issue involving the storage of multiple vials of single use injectable [MEDICATION NAME] (Schedule IV controlled substance - sedative/antianxiety medication) in a removable, locked box in an unlocked medication refrigerator. The finding is: 1. Observation on 6/26/18 at 8:30 AM revealed the Unit 2 Medication Refrigerator contained multiple vials of single use injectable [MEDICATION NAME] in a in locked box not affixed to the refrigerator. The refrigerator was not locked. During the observation on 6/26/18, the Licensed Practical Nurse (LPN #3) Unit Manger stated that was the only way she knew how to secure the medication and she did not know why the refrigerator had no lock. Review of a facility policy and procedure entitled Pharmacy Services Overview revised (MONTH) 2007 revealed a licensed pharmacist will evaluate delivery and storage systems within the facility to minimize loss of, or tampering with medication supplies. Interview with the Corporate Pharmacy Consultant on 6/27/18 at 10:26 AM revealed monthly audits are completed by corporate pharmacy auditors to ensure that medications are properly stored. During an interview on 6/26/18 at 11:30 AM, the Director of Nursing (DON) was unaware that the injectable [MEDICATION NAME] was stored in an unlocked refrigerator in a locked box which was not affixed to the refrigerator and stated she would have maintenance fix it right away. 415.18(e)(2)

Plan of Correction: ApprovedJuly 23, 2018

The lock box in refrigerator for storage of controlled substances was permanently affixed and a new lock installed on the outside of the refrigerator on 6/26/18 .
All residents have the potential to be affected .
All unit refrigerators used for controlled substance storage were checked by Maintenance on 6/25/18 with no issues noted.
The RN Educator will re-educate all licensed nurses regarding appropriate medication storage especially in regards to controlled substances.
The DON reviewed the ? Medication Storage Policy? with no revisions required at this time .
The daily refrigerator temperature log check sheet located in each medication room will be revised to include check for proper storage of controlled substances in refrigerators.

Unit Managers will conduct weekly audit of medication rooms to include check of refrigerators used to store controlled substances .Any issue noted will be immediately addressed .
The results of the audits will be forwarded to the QAPI Committee for review and input .
Responsibility : DON


FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 6/27/18, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for three (Residents #96, 152 and 531) of four residents reviewed for pharmaceutical services. Specifically, controlled substances were signed out on the control substance record, but were not accounted for and documented in the resident's medical record as administered to the residents. Additionally, there was no evidence that a pharmacist conducted periodic audits or oversight to ensure accurate record keeping and accounting of the controlled substances. The findings are: Review of a policy entitled Pharmacy Services overview with a revised date of (MONTH) 2007 (identified as current by the Director of Nursing (DON)) revealed a licensed pharmacist will collaborate with the facility and Medical Director to develop, implement, evaluate, and revise the procedures for the provision of all aspects of pharmacy services, including ordering, delivery, storage, distribution, preparation, dispensing, administration, disposal, documentation and reconciliation of all mediations and biologicals in the facility. Upon a written request for all narcotic policies, the DON provided a policy entitled Controlled Substances with a revision date of (MONTH) 2012 and stated it was the only policy the facility had related to narcotics. The policy revealed that an individual resident controlled substance record must be made for each resident which must contain the resident's name, medication name and strength, quantity received, number on hand, and signature of nurse administering medication; the policy does not describe the wasting of narcotic medication. The policy refers to related documents entitled: a) Controlled Drug Record, b) Discarding and Destroying Medications and c) Individual Resident's Controlled Substance Record. These documents were not provided to the survey team. 1. Resident #152 was initially admitted to the facility on [DATE] and readmitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/25/18 revealed that the resident's cognitive assessment was not completed and the resident understands and was understood. The resident was on as needed pain medication for frequent moderate pain. Review of the Clinical Physician order [REDACTED]. Review of the comprehensive care plan dated 6/12/18 revealed the resident uses [MEDICAL CONDITION] medication related to a [DIAGNOSES REDACTED]. Review of a Control Substance Record for [MEDICATION NAME] 2 mg/ml injectable (1 ml SDV (single dose vial)) dated 6/9/18 to 6/25/18 revealed eight doses of medication were signed for that were not accounted for on the (MONTH) (YEAR) Medication Administration Record [REDACTED]. In addition, the physician ordered dose required wasting 0.5 cc (cubic centimeters) of medication. Thirty-three, [MEDICATION NAME] doses signed out did not either indicate wastage and/or had no second signature witnessing wasting of the medication. During the interview on 6/26/18 at 8:30 AM, Licensed Practical Nurse (LPN #3) Unit Manager stated there should be two signatures for wasting the 0.5 cc of the [MEDICATION NAME] injectable and she was not aware that the narcotic record was not properly reconciled. Attempts to interview the individual Licensed Practical Nurses (LPN's) involved in the discrepancy revealed a lack of success in reaching them by phone and they were not scheduled in the facility after the discovery from the record review. During an interview on 6/27/18 at 10:26 AM, the Corporate Pharmacy Consultant stated that monthly audits are completed by corporate auditors to ensure that medications, including controlled substances, are properly administered and accounted for and had no recollection of a previous issue at the facility. During the interview, the Corporate Pharmacy Consultant stated the last review was probably completed in (MONTH) (YEAR). A request for audits done in (YEAR) revealed that none were provided to the survey team prior to exit. 2. Resident #96 was admitted to the facility admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact, understands and was understood. Review of the Order Summary Report (physician's orders [REDACTED]. Review of a comprehensive care plan last revised 5/21/18 revealed the resident had septic arthritis and chronic pain with plans to administer pain medications as ordered. Review of a Control Substance Record for [MEDICATION NAME] 2 mg tablets dated 6/12/18 revealed from 6/14/18 to 6/26/18 there were six signatures for drug removal which were not accounted for on the (MONTH) Medication Administration Record [REDACTED]. Attempts to interview the individual Licensed Practical Nurses (LPN's) involved in the discrepancy revealed a lack of success in reaching them by phone and they were not scheduled in the facility after the discovery from the record review. During an interview on 6/27/18 at 10:26 AM, the Corporate Pharmacy Consultant stated that monthly audits are completed by corporate auditors to ensure that medications, including controlled substances, are properly administered and accounted for and had no recollection of a previous issue at the facility. During the interview, the Corporate Pharmacy Consultant stated the last review was probably completed in (MONTH) (YEAR). A request for audits done in (YEAR) revealed that none were provided to the survey team prior to exit. 3. Resident #531 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact, understands, and was understood. The MDS documented the resident received pain medication as needed, had pain frequently and made it hard to sleep at night. Review of an Order Recap Report dated 6/1/18 through 6/30/18 revealed the resident had an order for [REDACTED]. Review of a Medication Administration Record [REDACTED]. Instructions included to give one tablet for a pain level of 1 to 5, and give two tablets for severe pain 6 to 10. Review of a Control Substance Record for [MEDICATION NAME]/APAP 7.5/325 mg tablet dated 6/15/18 to 6/19/18 revealed 14 doses of the medication were signed as removed which were not accounted for on the (MONTH) (YEAR) MAR indicated [REDACTED] During an interview on 6/27/18 at 10:20 AM, the Assistant Director of Nursing (ADON) reviewed the Control Substance Record for the [MEDICATION NAME]/APAP 7.5/325 mg dated 6/15/18 to 6/19/18 and the electronic medical record of progress notes and the MAR indicated [REDACTED]. She stated there was no documentation to match the Control Substance Record for the following 14 doses: 6/15/18 - 11:30 AM, 9:00 PM 6/16/18 - 10:00 AM, 8:45 PM 6/17/18 - 6:10 AM, 11:15 AM, 5:20 PM 6/18/18 - 4:45 PM, 8:45 PM, 6/19/18 - 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, 10:00 PM The ADON further stated multiple nurses were involved and the nurses should be signing out the medication on the Control Substance Record, the MAR, and documenting the effectiveness of the medication. During an interview on 6/27/18 at 10:26 AM, the Corporate Pharmacy Consultant stated that monthly audits are completed by corporate auditors to ensure that medications, including controlled substances, are properly administered and accounted for and had no recollection of a previous issue at the facility. During the interview, the Corporate Pharmacy Consultant stated the last review was probably completed in (MONTH) (YEAR). A request for audits done in (YEAR) revealed that none were provided to the survey team prior to exit. During an interview on 6/27/18 at 11:20 AM, the Director of Nursing (DON) stated there was no auditing completed comparing the control sheets to the MARs, therefore a new auditing system will need to be developed. 415.4(b)(1)(i)

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Nurses responsible for administering narcotics to residents # 96, 152 and 531 will be counseled by the DON regarding appropriate narcotic administration and documentation.
Residents # 152 and 531?s pain management regime were reviewed by the MD on 7/21/18 with no new orders noted.
Resident # 96 was admitted to the hospital on [DATE]; her pain management regime will be reviewed upon return .
All residents have the potential to be affected.
Residents receiving narcotics will be reviewed by the Administrative nursing staff . This review will ensure that narcotics are appropriately documented as per facility policy. Any issues noted will be immediately addressed.

The RN Educator/ designee will re-educate licensed nurses regarding proper narcotic administration and documentation.
The DON reviewed the ? Controlled Substances ? policy with no revisions required.
Licensed Pharmacist will conduct audits bimonthly to ensure accurate record keeping and accounting of controlled substances .
The Unit Managers will each conduct 5 weekly Narcotic Administration audits for a period of 12 weeks. Audits will ensure that narcotics administered are appropriately documented.
Any issues noted will be immediately addressed .
The results of the audits , along with Pharmacy consultant audits , will be forwarded to the QAPI Committee for review and input.
Responsibility: DON

FF11 483.10(f)(10(i)(ii):PROTECTION/MANAGEMENT OF PERSONAL FUNDS

REGULATION: §483.10(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds. (i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section. (ii) Deposit of Funds. (A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund. (B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.

Scope: Isolated
Severity: Potential to cause minimal harm
Citation date: June 27, 2018
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 6/27/18, the facility did not ensure action as a fiduciary (trustee) of the resident's funds and hold, safeguard, manage, and account for the residents' personal funds deposited with the facility for two (Residents #97 and #160) of two residents reviewed for personal funds. Specifically, the facility did not honor the resident's request to access personal funds during on weekends. The findings are: 1. Resident #97 was admitted to the facility 12/9/15 with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 1/29/18 revealed the resident was understood, understands and was cognitively intact. During an interview on 6/21/18 at 10:38 AM, Resident #97 revealed she could not get money on the weekends, just Monday through Friday. 2. Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was understood, understands and was cognitively intact. During an interview on 6/20/18 at 9:48 AM, Resident #160 revealed she could not get money on the weekends. If she needs money, she had to get it by Friday because no one had access to the money on the weekends. During an interview on 6/25/18 at 12:36 PM, the Front Desk Receptionist stated he works Monday through Friday 8:00 AM to 4:00 PM. He receives a cash box from the business office when they open and it is returned to the business office around 3:00 PM. There is a locked cash box in the safe under the desk and the nursing supervisor is responsible for. The residents' can get money pretty much at any time, and any day of the week but was unsure of what the process was after he left for the day. During an interview on 6/25/18 at 1:07 PM, the Financial Coordinator stated residents' can get money anytime. There are two cash boxes, one for the day time receptionist and the other for the nursing supervisor. The boxes contain $300.00 during the week for during business hours. For the evening and weekends there is a supervisor's box with $100.00 for non-business hours in the safe under the front desk. The money in that box is hardly ever used. During an interview on 6/25/18 at 3:05 PM, Registered Nurse (RN #7) Evening Supervisor stated, she was part time and had worked at the facility for two years. If a resident wanted money on the weekends or after the business office closed she would send the resident to the front desk, we used to have a box in the supervisor's office but when it got remodeled the box never came back so I just send them to the from desk. During an interview on 6/27/18 at 7:01 AM, RN #6 Evening Supervisor stated he does not have access to money in the evening, the receptionist is here until 8:30 PM and maybe they have access. He also stated he does not have access to the safe at the front desk. During an additional interview on 6/27/18 at 7:08 AM, RN #6 revealed he spoke with the business office and they are getting him the combination to the safe and explained the process to him. He stated he was unaware of the process and now he knows. 415.26(h)(5)(b)(1)

Plan of Correction: ApprovedJuly 23, 2018

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

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 6/27/18, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Two (Residents #5, 25) of two residents observed for quality of care related to wound and respiratory care were not provided necessary care and services. Specifically, a nurse did not wash hands or change gloves during wound care (Resident #5) and admission orders [REDACTED]. The findings are: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS - a resident assessment tool) dated 3/2/18 revealed that the resident is cognitively intact, usually understands others, and usually understood by others. Review of the facility's Policy and Procedures (P&P) dated 4/2017 revealed that the nurse should remove gloves and wash hands after removing a dirty dressing and before applying a clean dressing to a wound. Comprehensive Care Plan dated 1/22/17 revealed the resident is at risk for skin integrity related to fragile skin and history of ulceration, incontinence, noncompliance with toileting, and staying up in the wheelchair for extended periods of time. Wound Consult notes dated 5/22/18 revealed that the resident had a full thickness ulceration wound on their right calf measuring 2.0-centimeter (cm) width by 2.0 cm length by 0.2 cm depth. The Wound Consultant recommended a treatment of [REDACTED]. Physician order [REDACTED]. During an observation on 6/22/18 at 11:04 AM revealed the resident lying on the bed with a dressing taped to the right calf. Licensed Practical Nurse (LPN) #2 with gloved hands removed the dressing that had a small amount of yellow colored and bloody drainage and placed the old bandage on the clean barrier next to the resident. Without changing gloves or washing her hands LPN #2 dipped a piece of gauze into a new jar of normal saline and cleansed the wound. She put Santyl on her gloved fingers and applied to the wound. She removed her gloves and applied new gloves but did not wash her hands. She then applied a new dry dressing. During an interview on 6/22/18 at 11:11 AM, LPN #2 stated that normally she does not do wound dressings; there was always a wound nurse to do the treatments. She is an agency nurse and did not have an in-service on wound treatments from the facility. During an interview on 6/22/18 at 11:22 AM, Registered Nurse (RN) #2 In-service Coordinator stated that she expects the nurse to throw out the dirty, old bandage, change her gloves and wash her hands after removing the old dressing, use an applicator to apply the Santyl, and that the wound should have been cleansed with a normal saline syringe. She stated, I believe I have some educating to do. During an interview on 6/27/18 at 9:34 AM, the Director of Nursing (DON) stated that she expects her staff to change gloves and wash their hands when performing wound care and to apply wound treatment with an appliance, not their fingers. She also expects the wound care educator to meet with a new nurse and educate them. 2. Resident #25 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Policy entitled Electronic Health Record Medication (Revised (MONTH) 2014) revealed that nursing staff are responsible to transcribe written orders in the EMR (electronic Medical Record) and new orders will be printed and placed in the resident's chart for MD (medical doctor) signature and checked by an additional licensed nurse to verify that it is correct. Text messaging is not an acceptable method of communicating an order. Review of the facility's policy entitled Medication Orders (Revised (MONTH) 2014) revealed each resident must be under the care of a Licensed Physician and a current list of orders must be maintained in the clinical record of each resident. Review of the hospital Inpatient Discharge Summary dated 6/7/18 revealed the resident entered the hospital with a right humerus fracture after a fall and had a previous medical history of [REDACTED]. Further review of the Inpatient Discharge Summary revealed discharge [DIAGNOSES REDACTED]. Review of a Readmission History & Physical dated 6/11/18 revealed the resident was in the facility for rehabilitation after a fracture and had a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During an interview on 6/21/18 at 8:36 AM, the resident stated that she is not receiving her inhalers and she frequently gets dyspnea (shortness of breath) on exertion. She has asked several nurses including LPN #3 Unit Manager and was told she probably does not need them anymore. Review of the Comprehensive Care Plan dated 6/21/18 revealed the resident has altered respiratory status related to [MEDICAL CONDITION] with plans to administer treatments (nebulizer), medications and oxygen therapy per MD orders. During an interview on 6/27/18 at 7:09 AM, the physician stated the resident has a history of [MEDICAL CONDITION], which was known from the hospital and a previous admission this year, and that he ordered [MEDICATION NAME] inhalers for the resident. When asked about the resident's concern of dyspnea and lack of receiving inhalers, the physician stated both concerns were new to him and he knows he ordered the residents inhalers. The physician stated that the nurses enter the order in the EMR based on a verbal order and the providers sign them electronically once entered. During an interview on 6/27/18 at 12:23 PM, LPN #9, stated she entered most of the admission orders [REDACTED]. The admission nurse is responsible to review the entire admission paperwork. Once the medications are ordered an e-mail is sent to the provider, who signs them, there is usually no verbal communication with the provider. When asked why the inhalers were not ordered upon Resident #25's readmission, LPN #9 stated she had no answers. 415.12

Plan of Correction: ApprovedJuly 23, 2018

Resident # 5 was seen by Nurse practitioner for wound assessment on 6/26/18 with no adverse effects noted from dressing change of 6/22/18.
LPN # 2 was counseled by the RN Educator regarding proper wound care/ dressing change on 6/22/18.
Inhaler for resident # 25 was ordered and transcribed on 6/25/18 .
Resident # 25 was seen by the physician on 6/25/18 with no adverse effects noted from initial exclusion of inhaler.
All residents have the potential to be affected .
Agency nurses currently working at facility will have wound care competencies conducted by the RN Educator to ensure proper technique. Any issues noted will be immediately addressed and on the spot education provided as needed.
Administrative nursing staff will review the previous 30 days of admissions to ensure that all medications are accurately transcribed. This review will compare discharge summary to hospital MARs & other applicable information to check for inclusion of all medications on admission orders [REDACTED].
Nurses newly assigned to the facility from staffing agencies will have wound care competency conducted by RN Educator prior to unit assignment . Any education needed as a result of the competency will be provided at that time.
Licensed nursing staff will be re-educated regarding wound care/ dressing change policy .
Administrative nursing staff will review discharge packets for new admissions following morning report. This review will include discharge summary vs MAR indicated [REDACTED].
The RN Educator will conduct 5 weekly Wound care / dressing change competencies for licensed nurses for a period of 12 weeks. Any issues noted will be immediately addressed.
The ADON will conduct 5 weekly new admission audits to verify accuracy of medications ordered. Any issues noted will be immediately addressed.
The results of the audits will be forwarded to the QAPI Committee for review and input.
Responsibility : DON


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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during the Standard survey completed on 6/27/18, the facility did not ensure that 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 for one (Resident #151) of four residents observed for pressure ulcers. Specifically, treatment was not provided as ordered by the physican for a resident with a stage 3 right gluteal fold pressure ulcer. The finding is: 1. Resident #151 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 5/24/18 revealed the resident was cognitively intact and had one unhealed pressure ulcer. Review of the facility's policy entitled Pressure Ulcer Treatment with a revised date of (MONTH) 2014 revealed pressure ulcer treatment requires a comprehensive approach, including: cleansing the wound, protect peri-wound (skin surrounding the wound) and dress the wound according to drainage, depth and wound appearance. A Progress Note entitled RN (registered nurse) Assessment dated 5/19/18 documented a stage 3 pressure ulcer located on the right gluteal fold, measuring 2 centimeters (cm) x 3 cm and a treatment was ordered. Review of the Medication Review Report with a print date of (MONTH) 22, (YEAR) revealed an active order dated 5/19/18 to cleanse the right gluteal fold with normal saline (NS), apply [MEDICATION NAME] (sterile dressing) and cover with a dry clean dressing (DCD) every day (QD) and as needed (PRN). Review of the Registered Nurse (RN): Weekly Wound Assessment form dated 5/22/18 revealed resident had two wounds to be documented on, interventions include a specialty mattress, protein supplements and resident education. Review of the additional comments revealed the resident was seen on this date by Nurse Practitioner (NP) (wound consultant), and to refer to assessments and recommendations. The RN assessment did not include locations of wounds, staging or measurements. Review of the wound consultant's notes dated 5/22/18, 5/29/18, and 6/5/18 revealed there were no documented assessments regarding the stage 3 right gluteal fold pressure ulcer. Review of the RN: Weekly Wound Assessment form dated 6/12/18 revealed the resident had three wounds to be documented on, which included a stage 4 sacral pressure ulcer measuring 10.5 cm in length (L) by (x) 8 cm in width (W) x 3 cm in depth (D), a stage 3 right gluteal fold pressure ulcer measuring of 3 cm (L) x 2 cm (W) x 0.3 (D). The treatment order was to the cleanse wound, apply xeroform and cover with DCD. Thirdly, a surgical wound to the left lower extremity. Review of the RN: Weekly Wound Assessment form dated 6/19/18 revealed the resident has three wounds to be documented on, which included a stage 4 sacral pressure ulcer, a stage 2 right gluteal fold pressure ulcer measuring 3 cm (L) x 2.5 cm (W) x 0.5 (D). The treatment order was to cleanse the wound, apply xeroform and cover with DCD. Thirdly, a surgical wound to the left lower extremity. During a wound care observation on 6/22/18 at 9:02 AM in the presence of Licensed Practical Nurse (LPN #3) Unit Manager. The resident was observed to have a stage 4 sacral pressure ulcer and a stage 3 right gluteal fold pressure ulcer. LPN #5 provided the treatment to resident's stage 4 sacral pressure ulcer. LPN #3 and LPN #5 both identified the open area on the right gluteal fold however, a treatment treatment was not applied to the stage 3 pressure ulcer on the right gluteal fold during the observation. Review of the Medication Administration Record [REDACTED]. Thus there was not documentation that treatment was provided to the right gluteal fold as ordered. During an interview on 6/22/18 at 1:01 PM, LPN #5 stated he had not treated the right gluteal fold in the past and believed it was a new area. He stated an order needed to be obtained. LPN #5 reviewed the electronic physician orders [REDACTED]. During an interview on 6/22/18 at 1:11 PM, LPN #3 Unit Manager stated, the Assitant Director of Nursing (ADON) and wound consultant, or the ADON and RN Educator complete skin rounds. An RN was responsible to complete skin assessments. This was the first day she saw the pressure ulcer on the right gluteal fold. LPN #3 reviewed the physician orders [REDACTED]. She futher stated the treatment order was not on the MAR indicated [REDACTED]. LPN #3 stated the resident should have been receiving the treatment since 5/19/18. During an interview on 6/26/18 at 8:17 AM, the NP wound consultant stated she doesn't recall an area on the resident's right gluteal fold. The NP stated she had completed weekly skin rounds with the ADON of the areas that the facility requested she assess, but if there was a definitive area then it would be addressed. During an interview on 6/26/18 at 10:31 AM, the ADON stated she completed weekly skin rounds on this resident. The resident had a sacral pressure ulcer and recalled first noting the stage 3 pressure ulcer on the right gluteal fold on 6/12/18. She reviewed the physician orders [REDACTED]. She then reviewed the TAR and stated the treatment was not transcribed to the TAR and the treatment was not being completed as ordered. The ADON clarified the documentation on 6/19/18 had a typo, the right gluteal fold was a stage 3 not a stage 2. 415.12(c)(2)

Plan of Correction: ApprovedJuly 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The order for resident # 151?s treatment to right gluteal fold was confirmed and accurately transcribed on 6/22/18.
The ADON was counseled by the DON on 6/22/18 regarding the need to confirm that all orders are accurately transcribed and appear in the TAR as ordered.
The LPNS caring for resident # 151 will be counseled by the DON; this counseling will include the need to clarify any discrepancies for resident treatment orders and to consult the RN when orders are in question.
All residents have the potential to be affected .
A full house of residents with pressure ulcers was conducted by the DON on 6/23/18 . This audit insured that all physician orders [REDACTED]. No issues were noted .
The RN Educator/designee will re-educate all licensed nurses regarding treatment orders and accurate transcription to the TAR.
The DON reviewed the facilities ? Pressure Ulcer Treatment? policy with no revisions required.
The DON will conduct 10 weekly pressure ulcer audits for a period of 12 weeks. Audits will ensure that all residents with pressure ulcers have physician orders [REDACTED].
Any issues noted will be immediately addressed.
Responsibility : DON



Standard Life Safety Code Citations

K307 NFPA 101:BUILDING REHABILITATION

REGULATION: Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, an area of the building that was under renovation was not properly maintained. Issues included interior walls, corridor walls, and corridor doors that separated areas under renovation from resident and staff use areas were not designed to resist the passage of smoke. This affected two (First and Third Floors) of four resident use floors. The findings are: 1. a) Observation on the Third Floor on 6/20/18, at approximately 9:53 AM, revealed the Nurse Manager's office was under renovation and the tiles for the lay-in style ceiling assembly had been removed. Further observation at this time revealed three approximate two-inch long by one-inch wide penetrations through the corridor wall above the office's corridor door. During an interview at the time of this observation the Maintenance Director stated, the office had been under construction since 6/18/18. b) Observation on the First Floor, on 6/20/18 at approximately 12:42 PM, revealed the dining room's servery was under renovation and the tiles for the lay-in style ceiling assembly had been removed. Further observation at this time revealed the corridor doors that separated the servery from the service corridor were in a fully closed position and there was an approximate three-foot long by two-inch wide gap between the doors. Continued observation at this time revealed three, two-inch long by two-inch wide penetrations through the corridor wall above the corridor doors. The observation also revealed the wall that separated the servery from the dining room was a single layer of five-eighths inch thick gypsum board and an approximate 12-foot long by two-foot wide area of the wall below the ceiling deck was missing. The observation also revealed an approximate three-inch long by two-inch wide penetration through the wall that allowed the surveyor to look directly into the dining room. During an interview at the time of this observation the Maintenance Director stated, the servery had been under construction for approximately two weeks. c) Observation on the First Floor on 6/20/18, at approximately 12:46 PM, revealed an approximate three-inch long by two-inch wide penetration through the wall that separated the dining room from the dining room's servery that allowed the surveyor to look directly into the servery. Further observation at this time revealed three, two-foot long by two-foot wide ceiling tiles were missing from the dining room's ceiling revealing a six-foot long wide by two-foot wide area of the wall between the dining room and the servery was missing. During an interview at the time of this observation the Maintenance Director stated, the dining room was still being used for the activity's program and it was used today, 6/20/18, for the picnic lunch. Per the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code: construction shall not make the building less conforming with other sections of this Code, or with any previous approved alternative arrangements, than it was before the renovation was undertaken. Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted. Corridor walls shall have a minimum one half-hour fire resistance rating and corridor walls shall form a barrier to limit the transfer of smoke. Corridor doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.2.1,19.3.6.2.2, 19.3.6.2.3, 19.3.6.3.1, 43.5.1.1, 43.4, 43.4.1.3, 43.5, 43.5.1.1, 43.5.1.3

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will repair interior walls, corridor walls, and corridor doors that do not resist the passage of smoke.
Finding 1a: The maintenance department had repaired the penetrations in the wall.
Finding 1b: The maintenance department repaired the drywall issues and fixed the doors so that they would close properly.
Finding 1c: The maintenance department repaired the penetration and put in drywall. An audit for penetrations in the walls will be conducted and any repairs will be completed.
A monthly audit for penetrations will be conducted.
Any work by outside contractor will need to be inspected and repairs done if needed for the job to be considered complete.
A member of the maintenance department will complete the monthly audit of penetrations.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to ensure the audits are being completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, the kitchen hood extinguishment system was not properly maintained. Issues include the facility did not have documentation that verified the kitchen hood extinguishment system had been inspected at least every six months. This affected one (First Floor) of four resident use floors. The findings are: Observation on the First Floor, on 6/20/18 at approximately 12:40 AM, revealed the kitchen's hood was equipped with an extinguishment system. Review of a pre-engineered restaurant fire suppression system report and a suppression hood inspection and testing report revealed the kitchen hood's extinguishment system had been inspected on 8/25/17 and 6/14/18. Inspections of the kitchen hood's extinguishment system had been conducted approximately ten months apart. During an interview on 6/26/18 at approximately 11:26 AM the Maintenance Director stated, the facility had no documentation verifying the kitchen hood's extinguishment system had been inspected between the 8/25/17 and 6/14/18 inspections. Per the 2011 edition of National Fire Protection Association (NFPA) 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: Chapter 11 - Procedures for the Use, Inspection, Testing, and Maintenance of Equipment: Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at least every six months. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.2.3 2011 NFPA 96:11.2.1

Plan of Correction: ApprovedJuly 27, 2018

The kitchen hood?s extinguishment system will be inspected every 6 months.
All residents have the potential to be affected The facility will prevent future incidents by scheduling inspections out every 6 months. Along with monthly inspections of the Kitchen hood extinguishment system to ensure we are in compliance with 6 month period.
The maintenance department will handle the scheduling of inspections and conduct monthly a monthly inspection to ensure compliance with the 6 month window.
The results of the inspection will be reviewed each month, and presented at the QAPI meeting to ensure they are being completed.
Responsibility:
Facilities Maintenance Director




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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, corridor doors were not properly maintained. Issues included: corridor doors were obstructed from closing, were not designed to resist the passage of smoke, and could not be latched into their frames. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1. a) Observations on the First Floor service corridor, on 6/20/18 from approximately 8:25 AM to 8:31 AM revealed the corridor door to the disinfection room was obstructed from closing by a floor cleaning machine that was stored in front of the door. Further observations revealed the corridor door to the elevator equipment room was obstructed from closing by an approximate ten-inch long by six-inch wide metal flange that was stored in front of the door. b) Observations on the Second Floor, on 6/20/18 at approximately 10:26 AM and on 6/21/16 at approximately 10:42 AM, revealed the two corridor doors to the therapy room were held in fully open positions by wooden door chocks (wedges) that were wedged under the doors. During an interview on 6/20/18 at approximately 10:26 AM, the Maintenance Director stated the door chocks should not be there and the doors should be able to be closed. c) Observations on the First Floor, on 6/21/18 at approximately 8:21 AM and on 6/22/18 at approximately 9:11 AM, revealed the corridor door to the Director of Nursing's office was held in a fully open position by a plastic door chock that was wedged under the door. d) Observation on the Fourth Floor, on 6/21/18 at approximately 9:33 AM, revealed the corridor door to Resident Room #426 was obstructed from closing by a chair that was stored in front of the door. e) Observations on the Fourth Floor, on 6/22/18 at from approximately 12:02 PM, revealed the corridor door to Resident Room #440 was obstructed from closing by a trash receptacle that was stored in front of the door. 2. a) Observation on the Fourth Floor, on 6/20/18 at approximately 9:02 AM, revealed the corridor door to the shower/ bath room located near Resident Room #420 had an approximate one quarter inch circular penetration through it. Further observation at this time revealed a sign on the door read as follows Out of Order. During an interview at the time of the observation the Maintenance Director stated the room was under construction and being remodeled as part of the facility's construction project. b) Observation on the First Floor service corridor, on 6/20/18 at approximately 12:12 PM, revealed the corridor door to the dish washing room located closest to the elevator had an approximate one quarter inch circular penetration through it. 3. a) Observations on the Fourth Floor, on 6/22/18 at from approximately 12:04 PM, revealed the corridor door to Resident Room #439 could not be latched into its frame. During an interview at the time of the observation the Maintenance Director stated, the corridor doors were checked monthly and the facility had logs for the checks. Review of Doors, locks and alarms: Test operation of doors and locks logs revealed the building's corridor doors were last checked on 5/18/18. b) Observation on the Third Floor, on 6/22/18 at approximately 12:27 PM, revealed the corridor door of the Resident Room #335 could not be latched into its frame. c) Observation on the Second Floor, on 6/22/18 at approximately 12:45 PM, revealed the corridor door of the Resident Room #236 could not be latched into its frame. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.3.1, 19.3.6.3.5, 19.3.6.3.10

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will remove items obstructing corridor doors from closing. The maintenance department will replace any doors not designed to resist the passage of smoke. The maintenance department will also repair doors that could not be latched into their frames.
Finding 1a: The maintenance department removed the items obstructing the door from closing properly.
Finding 1b: The maintenance department removed the two wooden door chocks from doors.
Finding 1c: the maintenance department removed the plastic door chock from the door.
Finding 1d: The maintenance department removed the chair that was obstructing the door from closing.
Finding 1e: The maintenance department removed the trash can obstructing the door from closing.
Finding 2a: The maintenance department has sealed the penetration in the door.
Finding 2b: The maintenance department has sealed the penetration in the dish washing room door.
Finding 3a: The maintenance department has repaired the latch on the resident?s door.
Finding 3b: The maintenance department has repaired the latch on the resident?s door.
Finding 3c: The maintenance department has repaired the latch on the resident?s door.

An audit will be conducted of all doors to ensure they are all working properly and have no penetrations.
Doors not currently on the Door, Locks and Alarms will be added and audited on a monthly basis.
In-service will be given to staff members about not holding doors open.

A member from the maintenance department will conduct the audit of Doors, Locks and Alarms.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to ensure the audits are being completed.
Responsibility:
Facilities Maintenance Director



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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, hazardous area doors and smoke barrier doors were not properly maintained. Issues included hazardous area doors and smoke barrier doors equipped with self-closing devices were held open and obstructed from closing by devices that were not arranged to automatically close upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system, and loss of power. This affected two (First and Fourth Floors) of four resident use floors. The findings are: 1. a) Observation on the Fourth Floor, on 6/20/18 at approximately 8:45 AM, revealed the smoke barrier door located closest to Resident room [ROOM NUMBER] was obstructed from closing by an approximate four-foot tall by four-foot long by three-foot wide dietary cart that was stored in front of the door. b) Observation on the First Floor, on 6/20/18 at approximately 10:45 AM, revealed the corridor door to the maintenance shop was in a fully open position. Further observation at this time revealed the door was held open by a one-gallon can of paint that was stored on the floor in front of the door. Continued observation at this time revealed the room was greater than 50 square feet in size and was being used to store maintenance equipment and supplies. c) Observation on the First Floor, on 6/22/18 at approximately 7:56 AM, revealed the corridor smoke barrier door located closest to the environment office/ storage room was obstructed from closing by an approximate 32-gallon transparent plastic bag full of cigarette butts, plastic bags, paper bags, paper plates, foam plates, paper cups, foam cups, paper napkins, and plastic bottles that was stored in front of the door. Further observation on the First Floor, on 6/22/18 at approximately 8:25 AM, revealed the corridor smoke barrier door located closest to the environment office/ storage room was obstructed from closing by a floor cleaning machine that was stored in front of the door. Further observation on the First Floor on 6/25/18, at approximately 10:15 AM, revealed the corridor door to the environmental office/ storage room was being held in a fully open position by an approximate 32-gallon transparent plastic bag full of blankets that was stored on the floor in front of the door. Further observation at this time revealed the room was greater than 50 square feet in size and being used to store one six-foot tall by six-foot long by two-foot wide rack full of blankets, towels, sheets, pillow cases, and towels and one six-foot tall by four-foot long by two-foot wide rack containing mop heads, one-gallon containers of glass cleaner and other cleaning supplies. Review of the undated Fire and Smoke Barrier Doors policy located within the facility's Emergency Preparedness Planning and Resource Manual revision date of 6/20/18 revealed the following: Fire and smoke barrier doors shall not be blocked at any time, or held open by any means other than the automatic holding device build into the door. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.2.7, 7.2.1.8.2

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will conduct daily rounds to prevent self-closing doors from being held open.
Finding 1a: the maintenance department moved the object obstructing the door from closing.
Finding 1b: The maintenance department removed the object that was holding the door open.
Finding 1c: The maintenance department removed the items from the door way that had blocked the door from closing.
The maintenance department has added a daily audit of the doors to their daily rounds.
A member of the maintenance department will conduct an audit of blocked self-closing doors during their daily rounds.
Staff will be re-educated regarding the facility Fire and Smoke Barrier Doors policy.
The results of the daily rounds will be reviewed each month, and presented at the QAPI meeting to ensure the daily audits are being completed.
Responsibility:
Facilities Maintenance Director

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: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, doors in required means of egress were not properly maintained. Issues included: an exit egress door could not be opened and an exit egress door equipped with an electromagnetic delayed-egress locking mechanism did not open per the instructions posted on the door. This affected one (First Floor) of four resident use floors. The findings are: 1. Observation in the First Floor Boiler Room, on 6/21/18 at approximately 7:47 AM, revealed the exit door from the boiler room to the exterior of the building could not be opened by the Maintenance Director. Further observation at this time revealed there was an illuminated exit sign above the door. Continued observation at this time revealed the Maintenance Director left the boiler room and tried to open the door from the exterior of the building and the door would not open. During an interview at the time of the observation the Maintenance Director stated, the door must have settled and it was wedged against its frame. 2. Observation on the First Floor, on 6/21/18 at approximately 8:00 AM, revealed the stairway exit door located at the rear of the dining room was equipped with an electromagnetic delayed-egress locking mechanism. An instructional sign posted on the door read as follows; Push until door alarm sounds door can be opened in 15 seconds. Further observation revealed when the Maintenance Director pushed the door's crash bar assembly (device for unlocking the door during emergency conditions), which was electronically connected to the door's electromagnetic delayed-egress locking mechanism, the electromagnetic delayed-egress locking mechanism had not released after 40 seconds and the door would not open. During an interview at this time the Maintenance Director stated, the stairway exit door located at the rear of the dining room was equipped with an electromagnetic delayed-egress locking mechanism, the building's stairway doors were checked monthly, and the facility had logs for the checks. The Maintenance Director further stated he would contact the outside contractor that serviced the building's doors and have them fix the door. Record review of Doors, Locks and Alarms: Test operation of doors and locks log, revealed the boiler room and the dining room corridor doors had been checked on 5/18/18. Further review of the log revealed the boiler room door that led to the exterior of the building and the dining room stairway exit door were not listed on the log. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.2.5.2(1), 19.2.2.2.6(1)(c), 19.2.2.2.1, 7.2.1, 7.2.1.4.1

Plan of Correction: ApprovedJuly 27, 2018

The Maintenance Department will repair or replace doors that are not properly functioning.
Finding 1: The maintenance department will repair the door so that it will operate properly.
Finding 2: The maintenance department has contacted an outside vendor to change out the electromagnetic delayed-egress locking mechanism.
An audit of all the doors will be conducted. Any not properly functioning will be repaired.
The doors not currently on the Doors, Locks and Alarms audit will be added to the audit. All doors then will be checked on a monthly basis.
A member of the maintenance department will complete a monthly audit of all doors. This audit is called the Doors, Locks and Alarms.
The results of this audit will be reviewed each month, and presented at the QAPI
Meeting to ensure audits are completed.
Responsibility:
Facilities Maintenance Director

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, power cords, power strips, extension cords, and adapters were not properly maintained. Issues included, in-use: power cords were run through cupboards and doors, power strips and extension cords were plugged together (daisy chained) and unapproved power strips and an adapter were being used to supply power to various equipment. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1. a) Observation on the Third Floor, on 6/20/18 at 9:40 AM, revealed the power cord for a fan located in the Nursing Supervisor's office was run through a closed cupboard door and its frame. Further observation at this time revealed the fan was on and running. During an interview at the time of this observation the Maintenance Director stated, the fan's power cord should not have been run through the cabinet door. b) Observation on the First Floor, on 6/20/18 at approximately 1:08 PM, revealed the power cord of a portable air conditioning unit in the Director of Social Work's office was run through the door that separated the Director of Social Work's office from the Admissions office. 2) a) Observation on the Third Floor, on 6/20/18 at approximately 10:16 AM, revealed three power strips were daisy chained together and supplying power to a portable air conditioning unit, a fan, and a computer in the Nurse Manger's office. During an interview at the time of this observation the Maintenance Director stated, he was not aware the power strips were plugged together. b) Observation on the Second Floor, on 6/20/18 at approximately 10:38 AM, revealed a power strip daisy chained to an extension cord was supplying power to a portable air conditioning unit in the Social Work office. Further observation at this time revealed a five-outlet adapter was plugged into a duplex outlet and supplying power to a telephone phone charger located in the office. During an interview at the time of this observation the Maintenance Director stated, he was not aware the power strip was plugged into the extension cord and the adapter was being used in the building. c) Observation on the First Floor in the maintenance shop, on 6/20/18 at approximately 11:47 AM, revealed two power strips were daisy chained together supplying power to the building's phone and speaker systems. d) Observation on the First Floor in the dishwashing room, on 6/20/18 at approximately 12:12 PM, revealed an extension cord was being used to power a wall mounted fan that was on and running. e) Observation on the First Floor in the Business office, on 6/20/18 at approximately 1:21 PM, revealed a power strip daisy chained to a second power strip was supplying power to a computer and a refrigerator. f) Observation on the Fourth Floor in Resident room [ROOM NUMBER], on 6/22/18 at approximately 10:53 AM, revealed an unapproved power strip was being used to supply power to television. g) Observation on the Second Floor in Resident room [ROOM NUMBER], on 6/22/18 at 12:45 PM, revealed an unapproved power strip was being used to supply power to a cellular phone charger. Further observation at this time revealed the power strip was turned upside down to obtain its specifications, and approximately one ounce of water poured out of it. During an interview at the time of the observation the Housekeeping Director stated, the power strip appeared to belong to the resident, and he is not sure how the water got into it. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 2.1, 2.2, 10.2.3.6(5), 10.2.4, 10.2.4.2.1 2011 NFPA 70: 110.3(A)(1)(7)(8), 400.3, 400.8(1)(3)(7), 590.3(B)

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will remove power cords running though cupboards, and doors, power strips and extension cords plugged together, and unapproved power strips from being in use.
Finding 1a: The maintenance department removed the power cord.
Finding 1b: The maintenance department removed the power cord and are installing a new outlet into the office.
Finding 2a: The maintenance department removed the power strips and are install a new outlet.
Finding 2b: The maintenance department removed the power strip and extension cord and will be installing a new outlet in the office.
Finding 2c: The maintenance department removed the power strips and are installing new outlets.
Finding 2d: The maintenance department removed the extension cord and replaced the cord on the fan.
Finding 2e: The maintenance department removed the power strips and installing a new outlet in the office.
Finding 2f: The maintenance department will replace the power strip with an approved power strip.
Finding 2g: The maintenance department will replace the power strip with an approved power strip.
An audit will be conducted on the power strips in the building and offices to ensure the power strips are only approved power strips and that there are no daisy chains.
All staff will be re-educated regarding the facility power cord policies .
A monthly audit will be conducted to ensure what power strips that are being used are 100% in compliance.
A member of the maintenance department will complete the monthly audit of power strips.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to ensure the audits are being completed.
Responsibility:
Facilities Director



K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 6/27/18, the facility did not develop a program for the maintenance of electrical equipment per manufacturer's recommendations. Issues included, the facility did not have a procedure for the maintenance of oxygen concentrators, humidifiers, and suction machines, per manufacturer's recommendations. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1. Observation on the Third Floor, on 6/22/18 at approximately 12:25 PM, revealed an oxygen concentrator located in Resident room [ROOM NUMBER] had a sticker from an outside contractor on it. The only information on the sticker was the control number # 2. Further observation at this time revealed a humidifier in the room had a sticker from an outside contractor on it with an inspection date of 8/16 and an inspection due date of 8/17. Continued observation at this time revealed a suction machine in the room did not have any visible stickers identifying the machine had been inspected or tested . During an interview on 6/22/18 at the time of these observations the Director of Maintenance stated, the facility had outside contractors that inspected and tested the facility's equipment and he would contact them to get the inspection and testing reports. a) Review of a manufacturer's oxygen concentrator patient manual reveled the following instructions: Wash the air intake gross filter, which is located in the back of the unit at least one time each week. Your Equipment provider may advise you to clean it more often, depending upon your operating conditions. Follow these steps to properly clean the air filter. 1. Remove the filter and wash it in a warm solution of soap and water. 2. Rinse the filter thoroughly, and remove excess water with a soft. Adsorbent towel. Ensure that the filter is dry before replacing it. 3. Replace the dry filter. During an interview on 6/26/18 at approximately 10:50 AM the Maintenance Director stated, the facility had no documentation verifying the oxygen concentrator's filters had been cleaned weekly. b) Review of a manufacturer's humidifier user manual reveled the following instruction: The maximum period of use for the mask interface adapter was one week. The maximum period of use for the heated breathing tube auto-fill chamber and adapter was two weeks. The maximum period of use for the air filter was three months or 1000 hours (or more often if significantly discolored). During an interview on 6/26/18 at approximately 11:19 AM the Maintenance Director stated, the facility had no documentation for how long parts or attachments for the humidifier had been used or when they had been replaced. c) Review of a manufacturer's suction machine operator's manual reveled the following instructions: Inspect suction tubing and collection bottle for leaks and cracks before each use. The collection bottle should be thoroughly cleaned after each use. The bacteria filter should be replaced every two months During an interview on 6/26/18 at approximately 11:50 AM the Director of Maintenance stated, the facility had no documentation verifying the suction machine's tubing and collection bottle had been inspected and thoroughly cleaned before each use or that the bacteria filter had been replaced every two months. The Maintenance Director further stated, the facility had no documentation that verified the facility was following the manufactures requirements for oxygen concentrators, humidifiers, and suction machines and he had not received an inspection or testing reports from the outside contractors that inspected and tested the facility's equipment. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.5.2, 10.5.2.1, 10.5.2.1.1, 10.5.3, 10.5.3.1.2, 10.5.6, 10.5.6.2, 10.5.6.2.1, 10.5.6.2.2

Plan of Correction: ApprovedAugust 2, 2018

The maintenance department will develop a procedure for the maintenance of oxygen concentrators, humidifiers, and suction machines as per manufacturer?s recommendations.
Finding 1: The maintenance department will setup an inspection and maintenance log for the equipment.
Finding 1b: The maintenance department will setup an inspection and maintenance log for the humidifiers.
Finding 1c: The maintenance department will setup an inspection and maintenance log for the suction machines.
The maintenance department will establish an inspection and maintenance log for all pieces of medical equipment.
The maintenance department will develop new inspection and maintenance logs for each piece of medical equipment according to the manufacturer?s recommendations.
An in-service will be given to the members of the maintenance department on the care and maintenance of the medical equipment as per manufacturers recommendations.
A member of the maintenance department will complete inspections and maintenance logs according to manufacturer?s recommendations.
The results of these logs will be reviewed each month, and presented at the QUAPI meeting to ensure logs are being completed.
Responsibility:
Facilities Maintenance Director


K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/27/18, essential electrical systems were not properly maintained. Issues included, the facility did not have remote annunciators installed in an area readily observable by staff at a regular work station, for the building's emergency generators. This affected two of two emergency generators. The finding is: 1. Observation on the First Floor, on 6/20/18 at approximately 11:47 AM, revealed the remote annunciator for the building's two emergency generators was installed in the maintenance shop in the service corridor. The maintenance shop was not a regularly staffed work station that was readily observed by operating personnel. Observation on 6/20/18 at approximately 2:30 PM, revealed the facility had two emergency generators located at the exterior of the building. During an interview on 6/25/18 at approximately 9:23 AM the Director of Maintenance stated, he was not aware of any remote annunciators located in the building where the facility's staff regularly worked. Further interview revealed the facility does not have maintenance personnel staffed 24 hours per day. The 1999 edition of NFPA 99, Health Care Facilities Code, requires a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 6.4.1.1.17

Plan of Correction: ApprovedAugust 2, 2018

The maintenance department will make sure that the remote annunciator is installed into an area that is readily observable by staff at a regular work station 24/7.
Finding 1: The maintenance department is relocating the remote annunciator to the second floor nurses station.
The maintenance department will contact an outside contractor to install the remote anunciator to the second floor nurses station.
An in-service will be given to the second floor staff on the remote annunciator and the procedure if the alarm goes off.
The Maintenance department will insure that the remote annunciator is installed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 6/27/18, the facility did not have documentation demonstrating that the emergency generators were tested under load for at least 30 minutes per month. This affected two of two emergency generators, that provided emergency backup power to four (First, Second, Third, Fourth Floors) of four resident use floors. The findings are: 1. Record review of the facility's generator information on 6/20/18 revealed two new generators were brought online in (MONTH) (YEAR), a 50-kilowatt generator which provided emergency power to the fire pump, and a 100-kilowatt generator which provided emergency power to the entire building, with the exception of the fire pump. Record review of the Weekly Inspection Checklist for the 50-kilowatt generator between 3/7/17 and 6/19/18 revealed weekly inspections were performed, and at the top of the checklist was handwritten, Run on load weekly one hour, but this checklist gave no indication of when the required monthly load tests occurred. The 50-kilowatt generator Weekly Inspection Checklist also did not indicate how long the load tests lasted, with no column to add clock time or generator hour-meter time. 2. Record review of the Weekly Inspection Checklist for the 100-kilowatt generator between 3/7/17 and 6/19/18 revealed weekly inspections were performed, and in the Comments column, the word, load was written on specific dates, spaced approximately one week apart between 3/14/17 and 5/30/17 and spaced approximately one month apart between 6/27/17 and 5/22/18. The 100-kilowatt generator Weekly Inspection Checklist did not indicate how long the load tests lasted, with no column to add clock time or generator hour-meter time. During an interview on 6/20/18 at 1:35 PM, the Maintenance Director stated monthly generator load tests are digitally programmed and last for over one hour, but there is no way to confirm the time elapsed from the written record. At this time, the Maintenance Director also stated he does not know how many hours are on each generator's hour-meter because he does not know how to find it on the digital readout and he does not have the user's manuals from either generator, but he will request them from the manufacturer. According to the 2010 edition of the NFPA Standard for Emergency and Standby Power Systems, the operational test shall be a period of not less than 30 minutes under operating temperature, a written schedule for routine maintenance and operational testing of the emergency power supply system shall be established, and a permanent record of its inspections, tests, exercising, operation, and repairs shall be maintained and readily available. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.5.1, 19.5.1.1, 9.1.3, 9.1.3.1 2010 NFPA 110: 8.3, 8.3.2.1, 8.3.3, 8.3.4 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(e)(2)

Plan of Correction: ApprovedAugust 2, 2018

The maintenance department will provide documentation demonstrating that the emergency generators were tested under load for at least 30 minutes per month.
Finding 1: The maintenance department has created a new log sheet to show the generators run times for the 50 kilowatt generator.
Finding 2: The maintenance department has created a new log sheet to document the 100 kilowatt generator run times.
There are only the two generators at the location.
The maintenance department will fill out the log sheets during the generator test cycles and document the readings.
An in-service will be given for the members of the maintenance department on the proper running and documentation of the generator tests.
A member of the maintenance department will fill out the generator log sheets.
The results of the log sheet will reviewed each month, and presented at the QAPI meeting to insure that the log sheets are being completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, electrical systems were not properly maintained. Issues included: items were stored less than three feet from electrical panels, and electrical junction boxes were missing covers. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1. a) Observation on the Fourth Floor, on 6/20/18 at approximately 8:58 AM, revealed a ladder, a chair, and a partially full 32-gallon trash receptacle were stored in front of and less than three feet away from three electrical panels in the electrical room located between the B-Wing and the nurse's station. During an interview at the time of this observation, the Maintenance Director stated he was not aware the ladder, chair, and trash receptacle were stored less than three feet away from three electrical panels. b) Observation on the Second Floor, on 6/20/18 at approximately 11:14 AM, revealed a table and two chairs were stored in front of and less than three feet away from three electrical panels in the storage room/ doctor's office located between the B-Wing and the nurse's station. 2. a) Observation on the First Floor, on 6/20/18 at from approximately 11:54 AM to 1:09 PM, revealed the covers were missing from electrical junction boxes located behind dryer #4 in the laundry washer and dryer room and in the electrical room located in the Admission's office. During an interview on 6/20/18 at approximately 1:09 PM the Maintenance Director stated, he was not aware the junction boxes were missing covers. b) Observation above the corridor ceiling tiles on the Fourth Floor, on 6/21/18 at from approximately 9:13 AM to 9:37 AM revealed the covers were missing from electrical junction boxes: in the nourishment room, by the illuminated exit sign located near the stairway exit door by Resident room [ROOM NUMBER], and in the corridor by Resident room [ROOM NUMBER]. c) Observations above the corridor ceiling tiles on the Third Floor, on 6/21/18 from approximately 10:01 AM to 10:30 AM revealed the covers were missing from electrical junction boxes that were part of the electrical wiring for illuminated exit signs located near the stairway exit doors by: Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], Resident room [ROOM NUMBER], and Resident room [ROOM NUMBER]. Further observations at these times revealed one electrical junction box was missing its cover at each of the locations. Further observations above the corridor ceiling tiles at these times revealed the covers were missing from two electrical junction boxes located between Resident Rooms #336 and 338. During an interview on 6/21/18 at approximately 10:11 AM the Maintenance Director stated, the exit signs were replaced as part of the building's construction project. d) Observation above the corridor ceiling tiles on the First Floor, on 6/21/18 from approximately 11:37 AM to 12:02 PM, revealed the covers were missing from two electrical junction boxes in the elevator lobby, and from one electrical junction box by the service corridor smoke barrier doors near the staff lounge. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.1, 6.1.1, 1.3, 1.3.2.1, 6.3.2, 6.3.2.1, 2011 NFPA 70: 110.3(A)(8), 314.25, 314.72(C), 110.26(A)(1), Table 110.26(A)(1)

Plan of Correction: ApprovedJuly 27, 2018

Remove items obstructing the electrical panels. Electrical panels have been added to daily rounds to ensure that future items are removed from the electrical panels.
Findings 1a: The maintenance department has removed items obstructing the electrical panels.
Findings 1b: The maintenance department has removed the items obstructing the electrical panels.
Findings 2a: The maintenance department has purchased and installed electrical junction box covers.
Findings 2b: The maintenance department has purchased and installed electrical junction box covers.
Findings 2c: The maintenance department has purchased and installed electrical junction box covers.
Findings 2d: The maintenance department has purchased and installed electrical junction box covers.
The electrical panels on the all floors have been added to the daily rounds checklist and will be inspected daily.
An audit of electrical junction boxes will be conducted any boxes out of compliance will be corrected. The electrical panels for all the floors have been added to the daily rounds checklist.
A monthly audit of electrical junction boxes will be conducted on a monthly basis.
An audit of any outside contractor doing electrical work in the building will be completed before contractors job is considered completed.
A member of the maintenance department will complete the daily rounds checklist.
A member of the maintenance department will complete an audit of the electrical junction boxes on a monthly basis.
The results of the daily rounds checklist and the monthly electrical junction box audit will be reviewed each month, and presented at the QAPI meeting to ensure completion of audit and checklist.
Responsibility:
Facilities Maintenance Director


EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/27/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, emergency preparedness training for agency staff was not documented and three of five employees lacked basic knowledge of the emergency procedures. The findings are: 1. During an interview on 6/26/18 at 10:35 AM, the Assistant Administrator stated he performed most of the Emergency Preparedness training sessions for facility staff over several days during (MONTH) (YEAR). The Assistant Administrator also stated these training sessions were for all staff members, including agency staff, and it was a Power Point presentation that covered topics including evacuation, policies about specific disasters, and a synopsis of the facility's Emergency Preparedness Plan. Review on 6/26/18 of a collection of staff signatures with a cover sheet advising staff to sign the sheet to indicate that they picked up their pay check and were trained on emergency preparedness revealed it contained 137 signatures. During an interview on 6/26/18 at 10:40 AM, the Director of Human Resources stated she looked at the list of 137 signatures, with the exception of a few that were illegible, and she was able to determine that all of the names were facility employees and none were agency staff. Additionally, on 6/26/18 at 3:00 PM, the Director of Human Resources stated the facility has approximately 50 agency staff that are active, and of those, approximately 20 work at this facility regularly, and at this time, the Administrator added that the facility has approximately 260 current employees. During an interview on 6/26/18 at 10:45 AM, the Assistant Administrator stated during the emergency preparedness training sessions in (MONTH) of (YEAR), sign-in sheets were not available, so he later created a sign-in sheet to be signed when staff picked up their pay checks on 4/3/18 and added the cover sheet that advised staff to sign the sheet to indicate that they picked up their pay check and were trained on emergency preparedness. The Assistant Administrator added because agency staff do not pick up paychecks at the facility, he has no record of their emergency preparedness training. During an interview on 6/22/18 at 2:50 PM a Licensed Practical Nurse (LPN A) on the Fourth Floor stated she has been a facility employee for the last two years, but prior to that, she worked here through an agency. Record review on 6/26/18 of the collection of staff signatures that indicate who attended emergency preparedness training revealed LPN A's name did not appear. During an interview on 6/26/18 at 1:45 PM, the Administrator stated LPN A's name does not appear on the list because she was an agency employee up until about two months ago. 2. Interview with randomly-chosen employees, regarding their knowledge of emergency procedures, on 6/22/18 from 2:35 PM until 3:00 PM revealed the following: - Housekeeping Aide A on the First Floor stated he has worked in this facility for two years and he has not had any emergency preparedness training. -Certified Nurse Aide (CNA A) on the Second Floor stated she has worked in this facility for one year and there was an in-service about what to do if someone enters the building who shouldn't be here. When asked by this Surveyor if she was referring to an active shooter/intruder scenario she replied, no and added that she could not recall any trainings that covered emergency preparedness topics. -Certified Nurse Aide (CNA B) on the Third Floor stated she has worked in this facility for [AGE] years and she can't remember attending any emergency preparedness trainings. Record review on 6/26/18 of the collection of staff signatures that indicate who attended the emergency preparedness training revealed the names of Housekeeping Aide A, CNA A, and CNA B all appeared. Per Centers for Medicare and Medicaid Services (CMS), Long Term Care facilities must do all of the following: I. Provide initial training in Emergency Preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. II. Provide emergency preparedness training at least annually. III. Maintain documentation of the training. IV. Demonstrate staff knowledge of emergency procedures. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(d)(1)

Plan of Correction: ApprovedAugust 2, 2018

All facility staff will be re-educated regarding the Emergency Preparedness plan . The education will be conducted by the Assistant Administrator/ designee; documentation of the education will be maintained.
All new employees will receive education during initial orientation and annually thereafter.
Staffing agencies have been contacted and provided a copy of the facility Emergency Preparedness plan . The staffing agencies will be responsible for educating their staff on the facility Emergency preparedness plan and for providing documentation of this to the facility.
The progress of staff training/ education will be discussed at the QAPI Committee meeting.
Responsibility : Administrator

K307 NFPA 101:EVACUATION AND RELOCATION PLAN

REGULATION: Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, the facility's fire and evacuation policies and procedures were not properly implemented. Issues included, rooms lacked the device to designate the room had been checked to ensure residents had been removed from the room, in the event of an evacuation, per the facility's Emergency Preparedness Planning and Resource Manual. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1. Review of the undated, Room Search Record of Completion policy, located in the facility's Emergency Preparedness Planning and Resource Manual with a revision date of 6/20/18, revealed the following; Evacuating Resident Rooms: In the instance of an emergency evacuation of either the entire facility or a specific unit, each resident room (including the bathrooms) must be searched to ensure that there are no residents left in rooms. Once a room is searched a sign stating, Room checked and empty will be attached on the outside of the door to indicate that the room has been searched. On 6/22/18 a review of Fire Drill Evaluation forms dated 4/13/18 and 5/11/18 revealed the following question was written on the forms: Was door marked to indicate evacuated room? Further review of the forms revealed: the Yes column was checked on the forms. Observation on the Fourth Floor, on 6/22/18 at 11:37 AM, revealed a red magnet was located on the back of the corridor door in Resident room [ROOM NUMBER]. During an interview at the time of this observation the Maintenance Director stated, the red magnet was used to indicate a room had been checked and was empty during an evacuation. The Maintenance Director further stated the magnet was placed on the corridor side of the door after the room had been checked. Observations on the Fourth Floor, on 6/22/18 from approximately 11:38 AM to 12:04 PM, revealed red magnets were missing from Resident Rooms #406, 408, 409, 410, and 439. Observations on the Third Floor, on 6/22/18 from approximately 12:11 PM to 12:27 PM, revealed red magnets were missing from Resident Rooms #303, 312, 318, 324, 325, and 335. Observations on the Second Floor, on 6/22/18 from approximately 12:34 PM to 12:54 PM, revealed red magnets were missing from Resident Rooms #206, 207, 219, 221, 225, 229, 232, 236, and 237. During an interview on 6/25/18 at 11:22 AM, a Certified Nurse Aide (CNA) on the Second Floor stated the facility previously used red magnets to show which rooms were evacuated during a fire drill, but about a year ago, they stopped using the magnets. The CNA was not sure what method the facility currently used to show which rooms have been evacuated. At the time of the interview, this CNA looked on the back of the door at Resident room [ROOM NUMBER] and stated there was no magnet. This CNA also stated on the first day of the recertification survey, the facility had a fire drill, and that during that drill no one used any method to show evacuated rooms. During an interview on 6/25/18 at approximately 12:19 PM the Maintenance Director stated, the facility had five spare red magnets and he had ordered more magnets. The Maintenance Director stated, the facility was not conducting audits to ensure the red magnets were present in the facility's rooms. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.7.2.1.2(4), 19.7.2.2(6)(8)

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will ensure rooms have the device to designate the room had been checked and that residents had been removed from the room, in the event of an evacuation.
Finding 1 The maintenance department has replaced all missing red magnets on doors stating room has been checked and empty.
The maintenance department has done an audit of all rooms for missing room checked and empty signs and replaced any missing signs.
During fire drills observers will make sure that all doors have the sign on the outside of the doors.
Maintenance department will re-educate all staff regarding the facility fire and evacuation policies .
A monthly audit of the door tags will also be conducted to ensure we remain at 100%.
A member of the maintenance department will conduct the fire drill observation and complete the monthly audit of the tags.
The results of the fire drill and the monthly audit will be reviewed each month, and presented at the QAPI meeting to ensure audits and drills are being completed.
Responsibility:
Facilities Maintenance Director


K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, The building's automatic fire alarm system was not properly maintained. Issues included the facility did not have documentation that verified: annual testing and sensitivity testing had been conducted on all the building's smoke detectors and smoke detectors that failed their sensitivity testing had been replaced and tested within one year of their replacement. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: Observations on the First Floor, on 6/21/18 at between 8:04 AM revealed there were three storage rooms located along the rear wall of the dining room. Further observation at this time revealed smoke detectors were installed in the storage rooms. Review of fire alarm inspection and testing reports dated 2/28/17 and 8/25/17 revealed there was no record of the smoke detectors installed in the storage rooms, listed on these repots. Review of a fire alarm system sensitivity testing report dated 6/4/17 revealed the smoke detectors in the storage rooms located along the rear wall of the First Floor dining room were not listed on the report. Further review of this report revealed nine smoke detectors located on the First, Second, Third, and Fourth Floors had failed their sensitivity testing and this report contained no documentation the smoke detectors had been replaced and tested . During an interview on 6/25/18 at approximately 2:24 PM the Maintenance Director stated, the smoke detectors in the storage rooms located along the rear wall of the First Floor dining room were not listed on the fire alarm inspection and testing reports dated 2/28/17 and 8/25/17 or the fire alarm system sensitivity testing report dated 6/4/17. The Maintenance Director further stated, the facility had no documentation verifying: annual testing or sensitivity testing for the smoke detectors in the storage rooms located along the rear wall of the First Floor dining room had been conducted in (YEAR) or the nine smoke detectors that failed their sensitivity testing on 6/4/17 had been replaced and tested . Per the 2010 edition of National Fire Protection Agency (NFPA) 72: National Fire Alarm and Signaling Code: Smoke detectors shall be tested annually. Sensitivity shall be checked within one year after installation and shall be checked every alternate year thereafter. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.6.1.3 2010 NFPA 72: 14.4.5, Table 14.4.5, 14.4.5.3.1

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will insure that annual testing and sensitivity testing have been conducted on all the building?s detectors and any failing smoke detectors are replaced immediately.
Finding 1: The maintenance department had outside inspection company add smoke detectors added to the building?s data base.
Finding 2: The maintenance department has the outside inspection company sending over paperwork on the replacement of the smoke detectors.
The maintenance department will walk the outside inspection company?s building data base to ensure that there are no other smoke detectors missing from their data base. A member of the maintenance department will walk with the outside inspection company during the yearly inspection to insure all smoke detectors are tested and that any smoke detectors that fail the inspection are replaced immediately.
The results of the inspections will be reviewed and presented at the next QAPI meeting to ensure completion of inspections and repairs.
Responsibility:
Facilities Director


K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, oxygen cylinders were not properly maintained. Issues included oxygen cylinder's flow-control valves were not closed on cylinders that were not in use, oxygen cylinders were not properly restrained and a room where oxygen was being stored did not have signage indicating oxygen was being store in the room. This affected three (Second, Third, and Fourth Floors) of four resident use floors and one of one outdoor oxygen storage area. The findings are: 1. a) Observation on the Fourth Floor, on 6/20/18 at approximately 8:55 AM, revealed one E-size oxygen cylinder in a two-wheeled cart was left on and running at four liters in the nurse's station. b) Observation on the Third Floor, on 6/20/18 at approximately 9:50AM, revealed one E-size oxygen cylinder attached to a wheelchair was left on and running at two liters in the corridor near Resident room [ROOM NUMBER]. During an interview at the time of this observation the Maintenance Director stated, he was not aware the oxygen cylinder had been left on and running. c) Observation on the Second Floor, on 6/20/18 at approximately 10:55 AM, revealed one E-size oxygen cylinder in a two-wheeled cart was left on and running at two liters in the nurse's station. 2. a) Observation on the Third Floor in the Nurse's station, on 6/20/18 at approximately 9:57 AM, revealed one C-size oxygen cylinder, in a nylon carrying case was stored lying on its side unsecured on top of an approximate two-foot tall oxygen storage rack. During an interview at this time of the observation the Maintenance Director stated, the oxygen cylinder did not belong to the facility and must have come into the facility when a resident was transported from the hospital. The Maintenance Director further stated, the staff knew oxygen cylinders had to be properly secured. b) Observation on the Second Floor in the Nurse's station, on 6/20/18 at approximately 10:55 AM, revealed one C-size oxygen cylinder and two D-size oxygen cylinders, in nylon carrying cases were stored lying on their sides unsecured on top of an approximate four-foot tall recyclable paper container. c) Observation at the outdoor oxygen storage cage, on 6/20/18 at approximately 12:54 PM, revealed three D-size oxygen cylinders and one approximate 20 cubic foot nitrogen cylinder were free standing and unsecured. Further observation at this time revealed four E-size oxygen cylinders were store lying on their sides in nylon carrying cases on top of the approximately six-foot tall cage. Continued observation at this time revealed the floor of the cage and the area around it was made of concrete. During an interview at the time of these observations the Maintenance Director stated, he was not aware the oxygen cylinders in the cage were unsecured and the cylinders should not have been stored unsecured on top of the cage. Observation at the outdoor oxygen storage cage on 6/26/18 at approximately 9:45 AM revealed four E-size oxygen cylinders were store lying on their sides in nylon carrying cases on top of the approximate six-foot tall cage. d) Observation on the Second Floor on 6/22/18 at 12:50 PM revealed one D-size oxygen cylinder was standing upright in a nylon bag unsecured on the floor of Resident room [ROOM NUMBER]. During an interview at the time of this observation, the Maintenance Director stated the oxygen cylinder should be secured. 3) Observation on the Third Floor, on 6/20/18 at approximately 10:00 AM, revealed one E-size oxygen cylinder in a two-wheeled cart was stored in the medical equipment room. Further observation at this time revealed the room's door and the corridor walls on either side of the door did not have signage indicating oxygen was stored in the room. During an interview at the time of this observation the Maintenance Director stated, the room was the medical equipment room, but someone had mistakenly installed the room's sign on the electrical room located next to the medical room. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 11.3.3, 11.3.3.1, 11.3.3.2, 11.6.2, 11.6.2.3(1)(11) 11.3.4.1, 11.3.4.2, 11.5.3.3.1

Plan of Correction: ApprovedAugust 2, 2018

The maintenance department will insure that oxygen cylinder?s flow ?control valves are closed when the tanks are not in use, oxygen cylinders will be properly restrained and signage will be present on rooms storing oxygen.
Finding 1a: The maintenance department closed flow control valve.
Finding 1b: The maintenance department had closed the flow-control valve.
Finding 1c: the maintenance department had closed the flow-control valve.
Finding 2a: The maintenance department removed the oxygen cylinder and secured it.
Finding 2b: The maintenance department removed the oxygen cylinders and secured them.
Finding 2c: The maintenance department removed the free standing oxygen cylinders and secured them. Had the oxygen cylinder provider remove the tank of nitrogen.
Finding 2d: The maintenance department removed the oxygen cylinder and secured it.
Finding 3: The maintenance department removed the oxygen cylinder for the room. The maintenance department will conduct daily rounds checking on the oxygen cylinder on all the floors and the cage area.
The maintenance department will conduct a daily round of the oxygen cylinders on all the floors and the cage area.
An in-service will be given to all appropriate staff regarding the proper handling of oxygen.

A member of the maintenance staff will check the oxygen cylinders on all the floors and cage area as part of a daily round checklist.
The results of the daily rounds will be reviewed each month, and presented at the QAPI meeting to ensure the logs are being completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:GENERAL REQUIREMENTS - OTHER

REGULATION: General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, laundry rooms were not properly maintained. Issues included excessive amounts of lint and dust on: the floors, walls, dryers, ventilation ducts and a fan in laundry rooms, that was not maintained to minimize the possibility of a fire emergency requiring the evacuation of occupants. This affected one (First Floor) of four resident use floors rooms. The findings are: 1. Observation on the First Floor in the service corridor, on 6/20/18 at approximately 11:50 AM, revealed an approximate 15-foot long by two-foot wide section of the floor behind the dryers in the laundry washer and dryer room was covered with a layer of lint and dust that ranged from one quarter of an inch to one inch in thickness. Further observation at this time revealed the top and rear of the four dryers were covered with a layer of lint and dust that ranged from one quarter of an inch to one half inch in thickness. Continued observation at this time revealed an approximate 15-foot long section of the top of a ventilation duct located behind and above the dryers was covered with a layer of lint and dust that ranged from one quarter of an inch to one half inch in thickness. The observation also revealed an approximate 15-foot long by six-foot wide area of the wall behind the dryers was covered with an approximate one quarter inch thick layer of lint and dust. During an interview at the time of the observation the Maintenance Director stated, he was not sure when the area around the dryers had last been cleaned and the facility did not have documentation that verified when or how often the areas around the dryers had been cleaned. b) Observation on the First Floor in the service corridor, on 6/20/18 at approximately 11:57 AM, revealed an approximate 12-inch long by 12-inch wide fan installed through the wall of the laundry soiled linen holding room was covered with an approximate one-half inch thick layer of lint and dust. Further observation at this the revealed the fan's blades, cage covering the blades, motor, and power cord were covered with an approximate one-half inch thick layer of lint and dust. During an interview at the time of this observation the Maintenance Director stated he was not sure when the fan had last been cleaned and the facility did not have documentation that verified when or how often the fan had been cleaned. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.1.1.3, 19.1.1.3.1

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department has cleaned affected areas.
Finding 1: the maintenance department has cleaned off areas around the dryers in the laundry room.
Finding 1b: The maintenance department has cleaned off the fans in the laundry room. An audit will be done of the laundry room areas and vents to ensure area is in proper condition.
Cleaning of fans and dryer area will be added to daily checklist of laundry department.
A member of the Laundry department will complete daily log of cleaning area around dryers and laundry department.
The results of the log will be reviewed each month, and presented at the QAPI meeting to ensure logs are being completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code Survey completed on 6/21/18, hazardous area doors were not properly maintained. Issues included hazardous area doors would not self-close and latch into their frames and were not equipped with self-closing devices. This affected three (First, Second, and Third Floors) of four resident use floors. The findings are: 1. a) Observation on the First Floor in the Administrative suite, on 6/20/18 at approximately 8:23 AM, revealed the corridor door to the business office was in a fully open position. Further observation at this time revealed the door would not self-close and latch into its frame and the door was not equipped with a self-closing device. Continued observation at this time revealed the office was greater than 50 square feet in size and was being used to store 15 cardboard boxes full of paper files. During an interview on 6/25/18 at approximately 3:01 PM the Medicaid Coordinator stated, the 15 cardboard boxes full of paper files had been stored in the office since (MONTH) of (YEAR). b) Observation on the Third Floor, on 6/20/18 at approximately 10:21 AM, revealed the corridor door to the construction storage room would not self-close and latch into its frame. Further observation at this time revealed the room was greater than 50 square feet in size and was being used to store five tubes of fast drying floor adhesive, five, five-gallon buckets of paint, 20, one-gallon cans of paint, cases of silicon sealant, and other construction supplies and tools. d) Observation on the Second Floor, on 6/201/8 at approximately 10:34 AM, revealed the door to the storage room located at the rear of the therapy room would not self-close and latch into its frame. Further observation at this time revealed the door did not have a self-closing device, the room was larger than 50 square feet in size, and the room was being used to store therapy supplies. e) Observation on the Second Floor, on 6/20/18 at approximately 10:42 AM, revealed the corridor door to the clean utility room near Resident room [ROOM NUMBER] was in a fully open position. Further observation at this time revealed the door would not self-close and latch into its frame and it did not have a self-closing device. Further observation at this time revealed the room was greater than 50 square feet in size and being used to store medical supplies including gauze pads and drain sponges. During an interview at the time of the observation the Maintenance Director stated the room had been reconfigured as part of the building's construction project and he was not sure how long the room had been used as a storage room. f) Observation on the First Floor in the service corridor, on 6/20/18 at approximately 12:22 PM, revealed the corridor door to the in-service/ activities storage room would not self-close and latch into its frame and the door was not equipped with a self-closing device. Further observation at this time revealed the room was greater that 50 square feet in size and was being used to store two approximate six-foot tall by five-foot long by two-foot wide racks full of board games and other activity supplies and two four-foot tall by three-foot long by two-foot wide book cases full of digital video disks and other activity supplies. During an interview at the time of the observation the Maintenance Director stated, the room's corridor door should have a self-closing device. g) Observation on the First Floor, on 6/21/18 at approximately 8:08 AM, revealed the door to the storage room located near the left rear corner of the dining room would not self-close and latch into its frame. Further observation at this time revealed the door was not equipped with a self-closing device. Continued observation at this time revealed the room was larger than 50 square feet in size and was being used to store a mattress, framed pictures, bulletin boards, and plastic totes. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.2.1

Plan of Correction: ApprovedJuly 27, 2018

Finding 1a: Maintenance department will install a self-closer on the door.
Finding 1b: Maintenance department will install a self-closer on the door.
Finding 1c: Maintenance department will install a self-closer on the door.
Finding 1d: Maintenance department will install a self-closer on the door.
Finding 1e: Maintenance department will install a self-closer on the door.
Finding 1f: Maintenance department will install a self-closer on the door.
Finding 1g: Maintenance department will install a self-closer on the door.
An audit will be conducted of all storage rooms to ensure they are self-closing and latch.
All storage room doors will be added to the monthly audit of Doors, Locks and Alarms.
The monthly audit of Doors, Locks and Alarms will be completed by a member of the Maintenance staff.
The monthly audit of Doors, Locks and Alarms will be reviewed each month, and presented at the QAPI meeting to ensure, they are completed.
Responsibility:
Facilities Maintenance Director



K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 6/27/18, exit egress corridors were not properly maintained. Issues included, exit egress corridors were not continuously maintained free of all obstructions and an exit access corridor was not clear and unobstructed to a width of at least four feet. This affected two (First and Fourth Floors) of four resident use floors. The findings are: 1. Observation on the Fourth Floor on 6/20/18, at approximately 9:25 AM, revealed a dietary car, two wheelchairs, and a Geri chair were stored across the corridor between Resident Rooms #339 and 340 constricting the corridor to less than two feet in clear width. During an interview at the time of the observation the Maintenance Director stated, the staff knew corridors could not be blocked and equipment had to be placed on one side of the corridor. 2. a) Observation on the First Floor on 6/20/18, at approximately 11:44 AM, revealed the following items were stored in the service corridor, near the boiler room: six wheelchairs, two, five-foot tall by five-foot long by two-foot wide laundry racks full of clean shirts, pants, sweaters, and jackets, two, six-foot tall by five-foot long by two-foot wide laundry racks full of towels, blankets and sheets, one, 44-gallon trash receptacle partially full of broken ceiling tiles, plastic bottles, pieces of paper, plastic bags, pieces of card board, plastic cups, and paper cups, two, 32-gallon trash receptacles partially full of mop heads, four oxygen concentrators, two plastic totes, six plastic milk crates, two mop buckets, one approximate 20-gallon soiled linen receptacle, three, 32-gallon metal soiled linen hamper frames, 14 ceiling tiles, one air mattress, two hand carts, one six-foot tall ladder, four overbed tables, one house keeping cart, three approximate three-foot tall by two-foot long by two-foot wide carts, two, two-wheeled hand carts, and five unlabeled cardboard boxes. b) Observation on the First Floor on 6/20/18, at approximately 12:25 PM, revealed the following were stored in the service corridor near the medical records storage room: one five-foot long by four-foot wide wooden pallet with six, four-foot long by three-foot wide framed photographs stored on it, six cardboard boxes containing alcohol based hand rub dispensers, 50 unlabeled cardboard boxes, 13 plastic milk crates, three plastic bread racks, two, six foot-long folding tables, one flat top cooking range in a four-foot long by three-foot wide wooden crate, two four-foot long by two-foot wide hand carts, 12 empty cardboard boxes, one approximate six foot-tall by three-foot long by two-foot wide heated food-holding cabinet, and one approximate four foot-long by two foot-wide pallet jack. During an interview on 6/25/18 at 3:27 PM the Maintenance Director stated, none of the items stored in the service corridor are moved during fire drills. During an interview on 6/26/18 at 8:46 AM the Food Service Director stated, the flat top cooking range had been stored in the service corridor for approximately one and half weeks. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.1, 7.1.10.1, 7.1.10.2.1, 19.2.3.4(1)

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will check the corridors during their daily rounds and correct any obstructions in the corridors.
Finding 1: The maintenance department removed items that were blocking the paths of egress.
Finding 2a: The maintenance department removed items that were obstructing the paths of egress.
Finding 2b: The maintenance department removed the items that were obstructing the paths of egress.
The maintenance department will check the corridors on a daily basis and correct any obstructions to the path of egress.
An in-service will be given to all staff members on the importance of keeping the corridors clear.
The maintenance department will conduct daily rounds of the corridors and document findings on the daily rounds log sheet.
The results of the daily rounds log will be reviewed each month, and presented at the QAPI meeting to ensure that the logs are being completed.
Responsibility:
Facilities Maintenance Director

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on interview and record review during the Emergency Preparedness Plan review, in conjunction with the Life Safety Code survey completed on 6/27/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not develop policies and procedures regarding the use of volunteers in an emergency, or other emergency staffing strategies. The finding is: Record review on 6/20/18 of the facility's Emergency Preparedness Plan, last updated 3/14/18, revealed the use of volunteers in an emergency, or other emergency staffing strategies, were not addressed. During an interview on 6/26/18 at 9:53 AM, the Administrator stated the facility has contracts with three staffing agencies, and if an emergency occurs, his current staff would be advised to stay, and he would consider changing staffing patterns to include 12-hour shifts. During an interview at the same time, the Assistant Administrator stated the staffing agencies that they utilize are not discussed in the facility's Emergency Preparedness Plan, but their local Mutual Aid Plan lists a few different staffing agencies, which they would consider using if necessary. 42 CFR 483.73-Emergency Preparedness 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedAugust 2, 2018

The facility policy/ procedure for the use of volunteers and other emergency staffing strategies will be revised and this will be included in the Emergency Preparedness plan. Policy revisions will include specifics regarding staffing agencies and their use in emergencies.
Facility staff will be educated by the Assistant Administrator regarding the above policy and procedure and documentation of this education will be maintained.
All new employees will be educated on the above policy during their initial orientation and yearly thereafter.
The updates to the emergency plan, including policy revisions as above, will be discussed at the QAPI Committee meeting .
Responsibility: Assistant Administrator


K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, portable fire extinguishers were not properly maintained. Issues included portable fire extinguishers were missing safety seals/ tamper indicators, were not properly stored, needed to be recharged, or were obstructed. The facility did not have documentation that monthly inspections and annual maintenance was being conducted on all fire extinguishers. This affected four (First, Second, Third, Fourth Floors) of four resident use floors. The findings are: 1. a) Observation on the Fourth Floor, on 6/20/18 at approximately 8:42 AM revealed the portable fire extinguisher located in the corridor near Resident room [ROOM NUMBER] was missing its safety seal/ tamper indicator. Further observation of the tag attached to the extinguisher revealed the extinguisher was inspected on 5/30/18. b) Observation on the First Floor, on 6/20/18 at approximately 1:06 PM, revealed the portable fire extinguisher located near the public rest rooms was missing its safety seal/ tamper indicator. Further observation of the tag attached to the extinguisher revealed the extinguisher was inspected on 5/30/18. 2. a) Observation on the Fourth Floor, on 6/20/18 at approximately 8:52 AM, revealed a portable fire extinguisher was stored free standing and unsecured under the desk at the nurse's station. During an interview at the time of the observation the Unit Manager stated, the extinguisher was under the desk because a resident had taken it out of a fire extinguisher cabinet on the A-Wing. The Unit Manager further stated the extinguisher was taken away from the resident, placed under the desk, and she was not sure how long the extinguisher had been under the desk. During an interview at the time of the observation the Maintenance Director stated, the fire extinguisher located near resident room [ROOM NUMBER] was missing from its cabinet when fire extinguishers were checked in (MONTH) of (YEAR). The Maintenance Director further stated, the fire extinguisher had been under the nurse's station desk since (MONTH) of (YEAR). b) Observation on the Third Floor, on 6/20/18 at approximately 10:21 AM, revealed two portable fire extinguishers were stored free standing and unsecured on the floor in the construction storage room. Further observation at this time revealed the extinguishers did not have inspection tags attached to them. During an interview at the time of the observation the Maintenance Director stated, the fire extinguishers belonged to the construction company that was working at the facility, the facility had no documentation for the inspection, testing, and maintenance of the fire extinguishers, and he was not aware the extinguishers were in the building. 3. a) Observation on the Third Floor, on 6/20/18 at approximately 9:47 AM, revealed the gauge on the portable fire extinguisher located in the A-Wing corridor between Resident Rooms #312 and 313 read Recharge. Further observation of the tag attached to the extinguisher at this time revealed the extinguisher had been inspected on 5/30/18. During an interview at the time of the observation the Maintenance Director stated he was not aware the extinguisher needed to be recharged. b) Observation on the Second Floor, on 6/20/18 at approximately 11:25 AM, revealed the gauge on the portable fire extinguisher located in the C-Wing corridor between Resident Rooms #237 and 239 read Recharge. Further observation of the tag attached to the extinguisher at this time revealed the extinguisher had been inspected on 5/30/18. c) Observation on the First Floor in the service corridor, on 6/20/18 at approximately 12:07 PM, revealed the gauge on the portable fire extinguisher located in the Maintenance Director's office read Recharge. Further observation of the tag attached to the extinguisher at this time revealed the extinguisher had been inspected on 5/30/18. 4. a) Observation on the First Floor, on 6/20/18 at approximately 1:06 PM, revealed the portable fire extinguisher located in the boiler room was obstructed by a sink, two card board boxes, a one-gallon can of latex paint, and an approximate two-foot long by ten-inch wide metal grate. b) Observation on the First Floor in the service corridor, on 6/25/18 at approximately 8:31 AM, revealed the portable fire extinguisher located in the corridor between the kitchen and the environmental office/ storage room was obstructed by an overbed table. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.5.12 2010 NFPA 10: 7.1.1, 7.2.1.2, 7.2.2(2)(3), 7.2.2.1(3), 7.2.2.2(2), 7.2.4.1

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will ensure that the portable fire extinguishers are 100% and will remain unobstructed.
Finding 1a: The maintenance department had replaced missing safety seal/tamper indicator.
Finding 1b: The maintenance department has replaced missing safety seal/tamper indicator.
Finding 2a: The maintenance department has secured the fire extinguisher.
Finding 2b: The maintenance department had the two fire extinguisher inspected.
Finding 3a: The maintenance department has had the fire extinguisher recharged.
Finding 3b: The maintenance department has had the fire extinguisher recharged.
Finding 3c: The maintenance department has had the fire extinguisher recharged.
Finding 4a: The maintenance department has removed items obstructing the fire extinguisher.
Finding 4b: The maintenance department has removed the item obstructing the fire extinguisher.

The maintenance department will conduct an audit to insure all fire extinguisher are in compliance.
The maintenance department will perform monthly audits of the fire extinguishers in the building on a monthly basis.
The Maintenance Director will re-educate the Maintenance staff regarding proper maintaining of the fire extinguishers.
A member of the maintenance department will work the fire extinguisher audit on a monthly basis and document on the fire extinguisher log.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to ensure completion of audit.
Responsibility:
Facilities Maintenance Director


K307 NFPA 101:PORTABLE SPACE HEATERS

REGULATION: Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 6/27/18, the facility could not provide documentation that ensured the heating element of a portable space heater would not exceed 212F (Fahrenheit) and this portable space heater was not being used per manufacturer's directions. This affected one (First Floor) of four resident use floors. The finding is: Observation on the First Floor, on 6/20/18 at 1:16 PM, revealed a portable electric space heater was stored on the floor below the reception desk. Further observation at this time revealed the heater was plugged in and ready for use, a cardboard box labeled wound vac was stored directly against the front of the heater, and three power cords for a computer were draped over the heater. Continued observation, at this time, revealed the following was written on the heater: Caution high temperature, keep electrical cords, drapery and other furniture at least three feet from the front of the heater and away from the sides. The observation also revealed the following warning was written on the tag attached to the heater's power cord: Warning: To reduce the risk of fire: Always unplug heater when not in use. During an interview at the time of the observation the Maintenance Director stated, he was not aware the heater was in the building. During an interview on 6/26/18 at approximately 11:26 AM the Maintenance Director stated, the facility had no documentation to verify the temperature of the portable space heater's heating element. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.7.8(2)

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department removed the portable heaters from the building.
Findings 1: The portable heater was removed from the building.
The maintenance department will conduct an audit of rooms to ensure there are no portable heaters in the building.
An in-service will be given to all staff members that portable heaters are not allowed in the building.
The maintenance staff will conduct monthly audits of the rooms to ensure that no portable heaters are present in the building.
A member of the maintenance department will conduct a monthly room audit to ensure that no portable heaters are located in the building.
The results of the audit will be reviewed each month, and presented at the QUAPI meeting to ensure that the audit has been completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:SMOKING REGULATIONS

REGULATION: Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 6/27/18, outdoor smoking areas were not properly maintained. Issues include cigarette butts scattered on the ground, cigarette butts mixed with combustible material, and outdoor smoking areas lacked proper ashtrays and metal containers with self-closing covers into which ashtrays could be emptied. This affected two of two outdoor smoking areas. The findings are: 1. Observation of the exterior of the building on 6/21/18 at 2:15 PM revealed the Residents' Smoking Area was located against the building on the northwest side, under an awning that measured approximately ten feet long by eight feet wide. Further observation revealed there were at least 50 cigarette butts on the ground under the awning. In this area, there was also a plastic smokers' receptacle, an uncovered 55-gallon plastic garbage receptacle that was lined with a plastic bag and contained used single service plates and cups, food wrappers, used vinyl gloves, two approximately five-inch long wood splints, and at least six cigarette butts. Additional observation in the Residents' Smoking Area revealed a one-gallon uncovered plastic bucket that contained a layer of sand, food wrappers, one singed bandage, one single service cup and at least 60 cigarette butts. Additional observation in the Residents' Smoking Area revealed a five-gallon uncovered plastic bucket that contained used single service cups, empty soda bottles, empty cigarette packaging, and at least five cigarette butts. During an interview on 6/25/18 at 3:05 PM, the Maintenance Director stated the Residents' Smoking Area has two plastic smokers' receptacles and he expects cigarette butts to be disposed of in them and the facility does not have ashtrays or metal containers with self-closing lids. 2. Observation of the exterior of the building along the Administrative Wing on 6/21/18 at 2:15 PM revealed the approximately 70-foot long strip of land between the building and the sidewalk contained at least 300 cigarette butts, approximately 30 plastic cigarette/cigar filters, empty cigarette packaging, used vinyl gloves, used paper towels, and various weeds. 3. Observation of the exterior of the building along the Administrative Wing on 6/21/18 at 2:15 PM revealed the approximately 20-foot long strip of land at the parking lot curb edge contained at least 200 cigarette butts, used paper towels, empty cigarette packaging, and various weeds. 4. Observation of the exterior of the building on 6/21/18 at 2:55 PM revealed the Employees' Smoking Area was located at the edge of the parking lot, approximately 100 to 150 feet from the building. Further observation revealed this area had a plastic smokers' receptacle that was broken, with the top half laying on the grass and the bottom half filled with garbage and standing water. Additional observation revealed the Employee's Smoking Area had at least 400 cigarette butts on the ground, along with food wrappers, empty cigarette packaging, large cardboard sheets, and a pile of tree branches and twigs, and did not have ashtrays or a metal container with a self-closing lid. Observation at this time revealed one staff member was smoking in the Employees' Smoking Area and during an interview at the time of this observation, this staff member stated when he is finished with his cigarette, he planned to dispose of it on the ground. During an interview on 6/25/18 at 3:10 PM, the Maintenance Director stated the smokers' receptacle at the Employees' Smoking Area needs to be fixed and he expects employees to dispose of their cigarette butts in this receptacle. Additionally, the Director of Maintenance stated he was unaware of the condition of the Employee's Smoking Area and the area needed to be cleaned, but he was not sure if the Housekeeping Department or the Maintenance Department was responsible for this area. During an interview on 6/25/18 at 4:10 PM, the Housekeeping Director stated the exterior was the responsibility of the Maintenance Department, but the Housekeeping Department will pitch-in if needed. The Housekeeping Department most recently pitched-in earlier today to clean the exterior. During an interview on 6/26/18 at 11:26 AM, the Maintenance Director stated the plastic bucket with sand in it cannot be used as an ash tray in the Residents' Smoking Area and the Employees' Smoking Area did not have an ashtray. The Maintenance Director further stated neither smoking area had a metal container with a self-closing lid that ashtrays could be emptied into. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101:19.7.4(5), 19.7.4(6)

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will purchase proper ash trays and metal containers with self- closing cover into which ashtrays can be emptied and maintain the smoke areas cleanliness.
Finding 1: The maintenance department has gone out and cleaned up the area.
Finding 2: The maintenance department has gone out and cleaned up this area.
Finding 3: The maintenance department has gone out and cleaned up this area.
Finding 4: The maintenance department has gone out and cleaned this area and will be getting proper ash trays and trash containers for this area.
The maintenance department will walk the exterior of the building to identify any other areas that need to be addressed.
The maintenance department will conduct a morning and evening clean-up of these areas and document clean-ups in log book.
The staff will be re-educated regarding proper cigarette and garbage disposal.
A member of the maintenance department will complete the clean-up and document conditions and times.
The results of the logs will be reviewed each month, and presented at the QAPI meeting to insure logs are being completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:SOILED LINEN AND TRASH CONTAINERS

REGULATION: Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, soiled linen and trash receptacles were not properly maintained. Issues included soiled linen and trash receptacles with capacities greater than 32-gallons were stored in areas that were not protected as hazardous areas. This affected one (First Floor) of four resident use floors. The findings are: 1. a) Observations on the First Floor, on 6/20/18 at approximately 8:22 AM and 1:22 PM, and on 6/25/18 at approximately 2:23 PM, revealed one uncovered 44-gallon trash receptacle full of paper plates, paper bags, paper cups, paper bags, pieces of paper, foam cups, foam plates, plastic cup lids, plastic bottles, and pieces of cardboard was stored in the Administrative suite corridor. During an interview on 6/25/18 at approximately 2:23 PM the Director of Maintenance stated, the trash receptacle located in the Administrative suite had a capacity of 44-gallon. b) Observations on the First Floor, on 6/20/18 at approximately 8:31AM and 11:44 AM, revealed one uncovered 44-gallon trash receptacle partially full of broken ceiling tiles, plastic bottles, pieces of paper, plastic bags, pieces of card board, plastic cups, and paper cups was stored in the service corridor near the boiler room. c) Observations on the First Floor, on 6/21/18 at approximately 8:19 AM, revealed one uncovered 44-gallon soiled linen receptacle partially full of mop heads was stored in the service corridor near the laundry. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.7.5.7.1(1)(2)

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will replace all 44 gallon trash receptacles with 32 gallon trash receptacles.
Finding 1a: The maintenance department has replaced the 44 gal trash receptacle with a 32 gal trash receptacle.
Finding 1b: The maintenance department has replaced the 44 gal trash receptacle with a 32 gal.
Finding 1c: The maintenance department has replaced the 44 gal trash receptacle with a 32 gal trash receptacle.
The maintenance department will do an audit of the building for any 44gal trash receptacles that are not in hazardous areas.
The maintenance department will do a monthly audit of the trash receptacles in the building to insure we remain in 100% compliance.
A member of the maintenance department will conduct an audit of the trash receptacles on a monthly basis.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to ensure that the audits are being completed.
Responsibility:
Facilities Maintenance Director


08/22/18

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: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, the facility's automatic sprinkler system was not properly maintained. Issues included the facility did not have documentation that verified the fire pump had been run under emergency power and had been consistently tested monthly; items were stored less than 18 inches away from sprinkler heads, and sprinkler piping was exposed to external loads. This affected one (First, Second, Third, and Fourth Floors) of four resident use floors. The findings are: 1. a) Observation in the First Floor boiler room, on 6/21/18 at approximately 7:40 AM, revealed the building's automatic sprinkler system was equipped with a fire pump. During an interview at the time of the observation the Maintenance Director stated, the fire pump was part of the facility's automatic sprinkler system and the facility's emergency generators supplied emergency power to the fire pump. Review of a fire pump inspection report dated 6/1/17 revealed the report contained no documentation that verified the fire pump had been run under emergency power and the following was documented on the report: Owner's Section: Please note: Periodic tests of transfer switches and emergency generators may be necessary in accordance with NFPA 110 but are not part of this inspection. During an interview on 6/26/18 at approximately 11:26 AM the Director of Maintenance stated, the facility had no documentation verifying the fire pump had been run under emergency power in (YEAR). Review of monthly fire pump testing reports revealed the fire pump had not been tested in (MONTH) of (YEAR) and (MONTH) of (YEAR). During an interview on 6/26/18 at approximately 11:26 AM the Director of Maintenance stated, the facility had no documentation verifying the fire pump had been tested in (MONTH) of (YEAR) and (MONTH) of (YEAR). Per the 2011 edition National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Chapter 8 - Fire Pumps: For installations having an automatic transfer switch, the following test shall be performed to ensure that the overcurrent protective devices (i.e., fuses or circuit breakers) do not open: (1) Simulate a power failure condition while the pump is operating at peak load (2) Verify that the transfer switch transfers power to the alternate power source (3) Verify that the pump continues to perform at peak load (4) Remove the power failure condition and verify that, after a time delay, the pump is reconnected to the normal power source. 2) a) Observation above the corridor ceiling tiles on the Fourth Floor, on 6/21/18 at approximately 9:10 AM, revealed a bundle of at least six electrical wires was hung from a sprinkler pipe with plastic ties in five locations between the nourishment room and the A-Wing smoke barrier doors. b) Observation above the corridor ceiling tiles on the Fourth Floor, on 6/21/18 at approximately 9:27 AM, revealed the grid work for the lay-in style ceiling assembly was hung from a sprinkler pipe with metal wire in one location between the electrical room and the C-Wing smoke barrier doors. During an interview at the time of the observation the Maintenance Director stated, he was not aware the ceiling grid was hung from the sprinkler pipe. c) Observation above the ceiling tiles on the Fourth Floor, on 6/21/18 at approximately 9:43 AM, revealed a bundle of at least five electrical wires and two transformers were wrapped around an approximate one-foot long section of a sprinkler pipe located near the stairway exit door by Resident room [ROOM NUMBER]. d) Observation above the corridor ceiling tiles on the Third Floor, on 6/21/18 at approximately 10:11 AM, revealed two flexible electrical conduits were hung from a sprinkler pipe with metal wire in one location between Resident room [ROOM NUMBER] and the A-Wing smoke barrier doors. e) Observation above the ceiling tiles on the Third Floor, on 6/21/18 at approximately 10:19 AM, revealed electrical wires were hung from a sprinkler pipe with plastic ties in four locations between the electrical room and the B-Wing smoke doors. f) Observation above the ceiling tile on the Third Floor, on 6/21/18 at approximately 10:23 AM, revealed electrical wires were hung from a sprinkler pipe with plastic ties in three locations above the smoke barrier doors near Resident room [ROOM NUMBER]. 3) a) Observation on the Fourth Floor, on 6/20/18 at approximately 9:22 AM, revealed two cardboard boxes containing construction supplies were stored on a shelf directly below and less than 18 inches away from a sprinkler head located in the construction storage room near Resident room [ROOM NUMBER]. During an interview at the time of the observation, the Maintenance Director stated he was not aware the boxes were being stored so close to the sprinkler head. b) Observation on the Third Floor, on 6/20/18 at approximately 9:45 AM, revealed two packages of disposable briefs were stored on top of a linen cart directly below and less than 18 inches away from a sprinkler head located in the clean linen closet by the shower/ bath room by Resident room [ROOM NUMBER]. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5 2011 NFPA 25: 8.3.3.4, 8.3.4.1, 8.3.4.2, 8.3.1.2, 5.2.2.2 2010 NFPA 110: Standard for Emergency and Stand by Power Systems

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will document that the fire pump had been run under emergency power and has been consistently tested monthly. Items will be removed that are less than 18 inches from sprinkler heads. That all objects hanging on sprinkler piping will be removed.
Finding 1a: The maintenance department will document the running of the fire pump when the monthly fire pump generator test is conducted.
Finding 2a: Removed bundle of wires hanging on the sprinkler pipe.
Finding 2b: Removed metal wiring attached to sprinkler pipe and the ceiling grid.
Finding 2c: Removed bundle of wiring from the sprinkler piping.
Finding 2d: Removed flexible electrical conduits from the sprinkler piping.
Finding 2e: Removed electrical wires attached to the sprinkler piping.
Finding 2f: Removed electrical wiring attached to the sprinkler piping.
Finding 3a: Removed boxes from around the sprinkler head.
Finding 3b: Removed packaged from around the sprinkler head.
An audit will be conducted to check the rest of the building to ensure that nothing else is hanging on sprinkler piping and 18 inches from the sprinkler heads. The running of the fire pump will be documented when the fire pump generator is operating.
An audit of sprinkler piping will be completed monthly. The piping will also be checked after any work in the area has been done.
Sprinkler heads will be added to the daily rounds log and checked regularly.
The maintenance department will complete the documentation of the fire pump, audits of the sprinkler piping and the daily log of the sprinkler heads.
The results of the audits and logs will be reviewed each month, and presented at the QAPI meeting to ensure audits and logs have been completed.
Responsibility:
Facilities Maintenance Director



K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, stairway exit doors were not properly maintained. Issues included stairway exit doors did not self-close and latch into their frames. This affected two (First and Third Floors) of four resident use floors. The findings are: 1. a) Observation on the Third Floor, on 6/20/18 at approximately 9:34 AM, revealed the D-Wing stairway exit door located near Resident room [ROOM NUMBER] would not self-close and latch into its frame. b) Observation on the Third Floor, on 6/20/18 at approximately 10:11 AM, revealed the C-Wing stairway exit door located near Resident room [ROOM NUMBER] would not self-close and latch into its frame. During an interview at the time of the observation the Maintenance Director stated, the stairway doors were checked monthly and the facility had logs for the checks. Review of a Doors, locks and alarms: Test operation of doors and locks log dated 5/18/18 revealed the building's stairway exit doors were not listed on the logs. As of 6/26/18 the facility had not provided documentation for the monthly checks of the building's stairway doors. c) Observation on the First Floor, on 6/20/18 at approximately 1:28 PM, revealed the stairway exit door located in the Administrative suite would not self-close and latch into its frame. Further observation at this time revealed the door was hung-up on its frame. Observation the First Floor on 6/20/18, at approximately 1:30 PM revealed a sign posted on the interior side of the Administrative suite's corridor door read as follows: Wait did you remember to pull the stairway door completely closed? The alarm will go off if the door is left slightly open. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.2.4, 7.2, 7.2.3.3, 7.2.3.3.1

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will repair or replace non- working doors.
Finding 1a: Maintenance department replaced latch to door.
Finding 1b: Maintenance department replaced latch to door.
Finding 1c: Maintenance department will repair door so it will not hang up on frame.

An audit of the doors will be conducted to ensure all doors are working properly.
Storage room doors will be added to the Doors, Locks and Alarms monthly audit and inspected on a monthly basis to ensure the doors are in proper working condition.
A member of the maintenance department will complete the audit of the Doors, Locks and Alarms on a monthly basis.
The results of the inspection will be reviewed by each month, and presented at the QAPI meeting to ensure they are being completed.
Responsibility:
Facilities Maintenance Director

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 27, 2018
Corrected date: August 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code Survey completed on 6/27/18, a smoke barrier door was not properly maintained. Issues included a smoke barrier door that was not self-closing or automatic-closing. This affected one (Second Floor) of four resident use floors. The finding is: 1) Observation on the Second Floor, on 6/20/18 at approximately 10:46 AM, revealed the door to the Minimum Data Set (MDS) office was in a fully open position. Further observation at this time revealed this door was a smoke barrier door, the door was not self-closing, and it was not equipped with self-closing device. Continued observation at this time revealed the (MDS) office was located inside the clean utility room near Resident room [ROOM NUMBER]. Observation above the ceiling tiles on the Second Floor in the (MDS) office, on 6/21/18 at approximately 10:57 AM, revealed the (MDS) office door was located within a smoke barrier wall. During an interview at the time of this observation the Maintenance Director stated the MDS office door was a smoke barrier door, this area of the building had been reconfigured during the facility's construction project, and he was not sure how long the door had been in-use. Review of the undated Fire and Smoke Barrier Doors policy located within the facility's Emergency Preparedness Planning and Resource Manual revision date of 6/20/18 on 6/22/18 revealed the following: Fire and smoke barrier doors that are partially open or do not close properly must be promptly reported to the maintenance department. Per the 2012 edition of National Fire Protection Association (NFPA) 101: Doors in smoke barriers shall be self-closing or automatic-closing and shall close the opening, leaving only the minimum clearance necessary for proper operation. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.7.8(1), 8.5.4.1

Plan of Correction: ApprovedJuly 27, 2018

The maintenance department will install a self-closer on to the smoke barrier door.
Finding 1: The maintenance department has installed a self-closer on the door.
An audit of the smoke barrier doors will be completed.
The maintenance department will add any doors not currently on the Doors, Locks and Alarms audit to it.
A member of the maintenance department will complete the monthly audit for Doors, Locks and Alarms.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to insure that the audits are being completed.
Responsibility:
Facilities Maintenance Director

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: June 27, 2018
Corrected date: August 22, 2018

Citation Details

Based on observation and interview during a Life Safety Code Survey completed on 6/27/18, smoke barrier walls were not properly maintained. Issues included, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating, and were not designed to resist the passage of smoke, due to unsealed penetrations. This affected three (First, Second, and Third Floors) of four resident use floors. The findings are: 1. a) Observation above the corridor ceiling tiles, on the Third Floor on 6/21/18 at approximately 10:11 AM, revealed an approximate three-inch long by one-inch wide penetration above two flexible electrical conduits that were installed through the smoke barrier wall above the smoke barrier doors near Resident Room #302. b) Observation above the corridor ceiling tiles, on the Second Floor on 6/21/18 at approximately 10:41 AM, revealed an approximate three-inch long by one-inch wide and an approximate two-inch long by one-inch wide penetrations above electrical wiring that was installed through the smoke barrier wall above the smoke barrier doors that lead from the elevator lobby into the D-Wing. Further observation revealed an approximate two-inch long by one-inch wide penetration around electrical wiring that was run through an approximate two-inch circular conduit that was installed through the smoke barrier wall. Continued observation at this time revealed the D-Wing is the facility's therapy suite. Observation above the corridor ceiling tiles on the Second Floor, on 6/21/18 at approximately 10:44 AM on the therapy side of the corridor smoke barrier doors, revealed an approximate 16-inch long by nine-inch wide penetration through the smoke barrier wall above the smoke barrier doors. c) Observation above the ceiling tile, on the Second Floor on 6/21/18 at approximately 10:55 AM, revealed an approximate one-half inch long by one-half inch wide penetration through the smoke barrier wall in the clean utility room near Resident Room #202. d) Observation above the ceiling tile, on the Second Floor on 6/21/18 at approximately 10:57 AM, revealed an approximate 20-foot long by ten-inch wide section of the smoke barrier wall that separated the Minimum Data Set (MDS) office and the social work office from the clean utility room was missing. During an interview at the time of this observation the Maintenance Director stated this area of the building had been reconfigured during the facility's construction project and he was not sure how long the rooms had been in use. e) Observation above the ceiling tile on the Second Floor, on 6/21/18 at approximately 11:15 AM, revealed an approximate four-inch long by three-inch wide penetration above television wiring that was installed through the smoke barrier wall above the smoke barrier doors between the electrical room and the B-Wing smoke barrier doors. During an interview at the time of this observation the Maintenance Director stated, an outside contractor had installed the television cables through the smoke barrier wall on 6/14/18. f) Observation above the ceiling tile on the First Floor, on 6/21/18 at approximately 11:43 AM, revealed an approximate four-foot long by three-inch wide penetration in the smoke barrier wall above the smoke barrier doors in the elevator lobby. Further observation at this time revealed the penetration was filled with pink fiber glass insulation that was not sealed with a fire rated material. Continued observation at this time revealed the penetration was located along the right side of a ventilation duct that was installed through the smoke barrier wall. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedAugust 2, 2018

The maintenance department will make sure that smoke barrier walls are complete from floor to ceiling/roof deck with at least a 30 minute fire resistance rating and resist the passage of smoke.
Finding 1a: The maintenance department repaired the penetration above two flexible electrical conduits.
Finding 1b: The maintenance department repaired the penetration above the smoke doors.
Finding 1c The maintenance department has repaired the penetration in the wall in the clean utility room.
Finding 1d: The maintenance department has repaired the 20 foot by 10 inch section in the MDS office.
Finding 1e: The maintenance department has repaired the penetration in the wall above the smoke doors on the second floor b wing.
Finding 1f: The maintenance department has repaired the penetration in the elevator lobby.
An audit of the smoke barrier walls will be conducted to ensure there are no other issues.
An in-service will be given to members of the maintenance department on conducting the penetrations audit and repairs of the issues.
A monthly penetrations audit will be conducted to ensure we remain at 100% compliance. All outside contractors work must be checked to ensure that smoke barrier walls are a 100 % before work is considered complete.
A member of the maintenance department will work the penetrations audit on a monthly basis.
The results of the audit will be reviewed each month, and presented at the QAPI meeting to ensure completion of audits.
Responsibility:
Facilities Maintenance Director