Ghent Rehabilitation & Nursing Center
November 6, 2017 Certification Survey

Standard Health Citations

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCP) for two (Residents #'s 67, and 83) of fourteen residents reviewed. Specifically, the facility did not ensure that CCPs included care plans to address Resident #83's splint or cast and Resident #67's communication due to hearing loss. This was evidenced by: Resident #83: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident also suffered a left tibia fracture on 8/9/2017. The Minimum Data Set, dated dated [DATE], assessed the resident as moderately impaired cognitively and understands and is usually understood. Nurses notes dated 8/9/17 at 11:30 am, documented the resident hit forward instead of reverse in her electronic wheelchair and hit her left lower extremity on a chair causing bleeding and pain. The resident was transferred to the Emergency Department and diagnosed a splint was placed on her left lower leg for a left tibia fracture. Orthopedic progress note dated 8/15/2017, documented the distal tibia fracture was in acceptable alignment, to maintain the splint and follow up in one week. Orthopedic progress note dated 8/24/17, documented the resident complained of left heel pain. The splint was removed to reveal a small area of decubitus ulceration on the heel. A well-padded fiberglass cast was applied and a recommendation for the resident be placed on a high-calorie, high-protein diet, non-weight bearing on left foot and no pressure on her heel while at rest. Return visit for 1 week to repeat x-ray for alignment. Orthopedic progress note dated 9/1/2017, documented the x-ray of the left distal tibia showed healing. The continued plan of care documented; a high calorie, high protein diet, to keep heel off the bed and to remain strictly non-weight bearing. Return visit scheduled for 4 weeks for an out of cast x-ray. Report of Consultation dated 9/7/17, documented the orthopedic consult was for a follow up due to the resident's complaint of burning of the left heel and left shin pain. The resident was seen by a different orthopedic physician, the cast was windowed, wrapped with an ace with relief. Orthopedic progress note dated 9/26/2017, documented the resident had burning in the ankle and pinky toe. The sign off status of the progress note was pending and did not include further documentation of treatment, plan or notes, however, a letter signed by the provider, dated 9/26/2017, documented the resident to wear her walking boot on left leg/foot that can be removed for general hygiene only. Review of care plans did not include a care plan related to the splint or cast. During an interview on 11/2/2017 at 2:45 pm, LPN Charge Nurse #5 stated, after review of resident's record, that there was no splint or cast care plans and they should have been in place. Resident #67: The resident was admitted to the nursing home on 6/16/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognitive skills for daily decision making. The resident sometimes understood, was sometimes understood by others, and the hearing moderately impaired. A Resident Care Card (a guide that tells Certified Nursing Assistants what to do for the resident) dated 6/16/17, documented the resident was hard of hearing and did not wear hearing aids. The MDS Care Area Assessment (CAA) Summary for communication dated 6/29/17, documented an X in the boxes for the care area triggered and that a care plan was necessary to address the care area. The CCP did not include a care plan to address the resident's communication. During an interview on 11/6/17 at 12:30 pm, RN #2 stated that she was responsible for care planning and not aware that the resident was hard of hearing. Additionally, she did not see the CAA and did not know how to ensure care areas triggered for care planning on the CAA were care planned. During an interview on 11/6/17 at 1:15 pm, RN #4 stated that when she completed CAA, she would give copies of the worksheets to the NM so that care planning could be done. 10NYCRR 415.11 (c)(1)

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Comprehensive Care Plans (CCP?s) for residents # 67 and #83 were reviewed to ensure CCP?s included all active ?care areas? as either indicated on the CAA generated by MDS RN, or as a result of current treatment being provided to the residents affected. Resident # 67 has already had the orthopedic problem resolved, so a CCP is no longer needed. Resident # 83 had a communication care plan which was initiated on 11/6/2017 due to being hard of hearing.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents charts will be reviewed to ensure that any ?active care areas? noted have an associated CCP in place.
All CAA triggers will be cross-referenced with the Residents care plans to ensure that all active care areas are addressed with a care plan.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
When a new active ?care area? is identified on a resident, the Registered Nurse will initiate a CCP for the new ?care area?.
MDS nurses will ensure CAA?s are printed and given to the respective unit RN for care planning purposes. Unit leadership will ensure that any new active care area listed on the CAA report has a CCP initiated.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? 5 charts per unit will be randomly audited for CCP and ?care areas? by the Director of Nursing Services, or his designee. The audits will be completed weekly for 4 weeks, then monthly for 5 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The unit RN?s will audit all active CCP?s in the resident?s chart against the resident?s active ?care areas? and any CAA triggers to ensure there is a CCP for each item. The audits will be completed weekly for 4 weeks, then monthly for 5 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
The Director of Nursing Services will be responsible for correction and compliance.

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during a recertification survey, the facility did not ensure treatment and care in a manner that promotes quality of life for 1(Resident #94) of 23 residents reviewed. Specifically, the facility did not ensure Resident #94's self-esteem and self-worth were enhanced, when the resident's excessive salivation was not attended to in a timely manner. This is evidenced by: Resident #94: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident as moderately impaired cognitively and understands and is usually understood. On 11/2/2017 at 11:05 am, the resident was observed sitting in the hall by the nurse's station. The resident's head was hanging down and a string of saliva hung from his mouth to his lap. A large pool of saliva was on his shirt and lap. At 11:20 am, the resident remained unchanged. At 11:25 am, the surveyor approached Licensed Practical Nurse (LPN) #2 to identify the resident. LPN #2 donned gloves and cleaned the resident's face and lap. Observation on 11/3/2017 at 12:10 pm, the resident was in the hallway with his head down with a long string of saliva hanging from his lips to his shirt. On 11/6/2017 at 12:10 pm, the resident was observed in the main dining room. The resident's head hung down and a string of saliva hung from his lips to his lap. Hospitality Aide # 5 delivered a drink and placed a clothing protector on the resident. At 12:19 pm, the resident wiped his mouth with the clothing protector. On 11/6/2017 at 12:53 pm, the resident was observed in the hall by the nurse's station. The resident's head was down and a long string of saliva hung from his lips to his lap. At 12:53 pm, Certified Nursing Assistant (CNA) #4 walked past the resident twice. The LPN Charge Nurse was in the nurse's station. At 12:56 pm, CNA #5 walked by the resident pushing another resident in a lounge chair. At 12:59 pm, CNA #5 walked past the resident again. At 1:00 pm, CNA #6 and LPN #1 walked past the resident. At 1:01 pm observed LPN #2 clean the resident's face and lap. During an interview on 11/6/2017 at 11:30 am, LPN #2 stated that the resident usually wears a protective bib for his drooling. She stated she could not find it. During an interview on 11/6/2017 at 2:00 pm, LPN #2 stated the resident drools most of the time. During an interview on 11/6/2017 at 2:05 pm, the Director of Nursing (DON) stated the staff should clean the resident's face when they see it and should be aware that this his baseline. The DON also stated that this is a dignity issue. 10 NYCRR415.5(a)

Plan of Correction: ApprovedDecember 13, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #94 was assisted with cleaning up his face and his clothing immediately after identification of excessive salivation. He will be monitored routinely while on the unit by staff to ensure that any excessive salivation is immediately tended to in order to maintain his dignity.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All other residents were reviewed for excessive salivation. No other residents were identified as exhibiting excessive salivation.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
All nursing staff will receive mandatory education on maintaining resident dignity. This education will include ensuring a timely response to any resident dignity concerns. Staff will be educated in identifying dignity concerns and will be provided with appropriate ways to address those concerns.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? 10 residents will be audited per unit focusing on dignity of residents (excessive salivation, cleanliness of clothing, notable odors, and personal hygiene) will be completed and documented by unit leadership. The audits will be completed weekly for 4 weeks, then monthly for 5 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
The Director of Nursing Services will be responsible for correction and compliance.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs for four (4) (Resident's # 13, 15, 83, and #96) of fourteen (14) residents reviewed during the recertification survey. Specifically, as needed (PRN) pain medications were prescribed and were not adequately monitored and documented to determine the effectivenss of the medications and the need for their continued use. This is evidenced by: A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): (MONTH) 18.23. A facility policy titled Pain Management, last revised 2/2016, documented; the back of the Medication Administration Record (MAR) will be used to document the resident's level of pain prior to administration of medication and the effectiveness of PRN medication 15-30 minutes after administration. The documentation will reflect the numerical pain management scale. Resident #13: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 9/20/17, assessed the resident as being cognitively intact, was able to understand and was able to be understood by others. A physician's orders [REDACTED]. The Medication Administration Record (MAR) and Nursing Progress Notes for (MONTH) (YEAR), documented the location of the resident's pain, numeric pain scale prior to administration, and follow-up pain scale for 2 of the 19 times the PRN [MEDICATION NAME] was administered. The MAR and Nursing Progress Notes for (MONTH) (YEAR), documented the location of the resident's pain, numeric pain scale prior to administration, and follow-up pain scale for 0 of 7 times the PRN [MEDICATION NAME] was administered. During an interview on 11/3/17 at 1:45 pm, Licensed Practical Nurse (LPN) #8 reported, the medication nurse should document the location of the pain and a pain scale before PRN medications are given and a follow-up note documenting effectiveness of the medication. During an interview on 11/3/17 at 2:00 pm, LPN #7 reported the medication nurses should document a before and after pain scale on the back of the MAR. Resident #83: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident also suffered a left tibial fracture on 8/9/2017. The MDS dated [DATE], assessed the resident as having moderately impaired cognition and is able to understand and is usually understood. MARs dated (MONTH) and (MONTH) (YEAR), documented [MEDICATION NAME] 5/325 mg tablet PRN was administered 18 times. Pre-administration pain scale was documented 17 times and a post administration pain scale was documented 2 times. Positive effect was documented 10 times. Tylenol 650 mg was administered 3 times with post administration pain scale documented once. Review of nursing progress notes from (MONTH) and (MONTH) (YEAR) documented one time that pain was a 0/10 after administration of [MEDICATION NAME] and no nurses' notes after Tylenol administration. Resident #96: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], assessed the resident as being cognitively intact, is able to understand and is able to be understood. MAR's dated July, August, September, (MONTH) and (MONTH) (YEAR), documented Tylenol was administered 14 times for complaints of pain. Post administration pain level was documented on two occasions. 10NYCRR415.12(l)(1)

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #13, #15, #83 and #96 have had pain assessments completed to ensure current pain management regimen is adequate. There have been no reports of inadequate pain management from the 4 residents affected by the deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All resident charts will be reviewed by the nursing leadership team to ensure pain scale documentation or non-verbal pain scale is being used for both pre and post pain medication administration.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
Mandatory education will be provided to all nursing staff on pain medication documentation and completeness of documentation. Nursing staff will sign a commitment to ensure pain medication documentation is completed every time a pain medication is administered.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place?
10 random audits will be completed by each unit?s respective leadership staff on pre and post pain medication documentation. The audits will be completed weekly for 4 weeks, then monthly for 5 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
The Director of Nursing Services will be responsible for correction and compliance.

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

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not prepare food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that foods time/temperature controlled for safety (formerly: potentially hazardous foods) be cooled to 41 degrees Fahrenheit (F) within 6 hours. Specifically, the internal temperature of turkey breast roasts was greater than 41 F after being cooled. This is evidenced as follows. The temperature of 2 turkey breast roasts stored in the reach-in refrigerator was 56 F and 54 F when measured on 11/06/2017 at 8:15 am. The turkey breasts were discarded. The Culinary Director stated in an interview conducted on 11/06/2017 at 8:15 am, that the turkey breasts were cooked yesterday afternoon, no cooling chart or log was used to monitor the cooling process, and he does not remember when staff were last educated on safe cooling practices. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(b)

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The turkeys were immediately thrown out and all other items in the cooler were checked for proper temperature and found to be compliant.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? As all residents are at potential risk of being affected by the deficient practice, all other items in the cooler were checked for proper temperature and were found to be compliant.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
A list of menu items and the procedure for documenting the temperatures of those items that are a potential risk for repeating this deficiency have been created by the Culinary Director and were posted in the kitchen. A monitoring tool for tracking cooling foods through the temperature danger zone has been implemented to verify that food items being cooled drop to the safe zone in less than six hours or are discarded. All dietary staff will be in-serviced on proper food handling, cooling, storage, reheating techniques, and how to use the appropriate documentation tool for recording temperature of foods being cooled.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Culinary Director will conduct weekly audits for three months then monthly for three months to verify that all appropriate standards are being meet to avoid repeat deficient practices. The audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
(NAME) Montague - Director of Culinary Services.

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (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. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during a recertification survey, the facility did not ensure the environment remained as free from accident hazards over which the facility has control and provided supervision to prevent avoidable accidents, for 1 (Resident #91) or 1 resident. Specifically, the facility did not ensure that Resident #91 was not in possession of lighters, on his person or in his room. Resident #91: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], assessed the resident as cognitively intact, understands and is understood. Resident Smoking Policy, dated as reviewed on 1/2012, documented the enforcement of a smoking policy designed to eliminate smoking in the facility and anywhere on the facility grounds. The policy documented residents are not allowed to keep lighters, matches or other combustible materials on their person or in their room at any time while in the facility. Review of the previous Facility Smoking Policy, dated 1/11/2011, which was replaced by the 1/2012 Resident Smoking Policy, documented residents are not allowed to keep lighters, matches on their person or in their room, unless the resident has been assessed as capable of keeping it safely locked away. The resident signed the policy on 2/16/2011. Review of the smoking assessment dated [DATE], documented that the resident was alert and oriented; with decreased dexterity of upper extremities; smoking policy reviewed and signed, and level of assistance as independent. Review of the smoking assessment dated [DATE], documented resident as alert and oriented; neuropathy and limited dexterity and needs set up cigarette and light; smoking policy reviewed and signed on 2/16/11. Review the resident's smoking care plan, dated 4/21/2015, documented interventions that included: Instruct resident about the facility policy on smoking: locations, times, safety concerns and notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Additional interventions dated 5/6/2015, documented: Staff assist with donning apron, putting cigarette on stick, and lighting cigarette and independent during actual smoking process/activity, during which staff member must be present - outside with resident at all times. During an interview on 11/1/2017 at 2:40 pm, the Licensed Practical Nurse (LPN) Charge Nurse #5, stated that the resident rolls his own cigarettes and keeps them in his room and the Activities Department keeps his lighter and takes him out to smoke. She stated that his cigarettes and lighters used to be locked in the medication cart. During an interview on 11/1/2017 at 3:10 pm, Activity Aide #3 stated the resident carries his own lighter and cigarettes. During an interview on 11/1/2017 at 3:19 pm, the resident stated that his lighter was in his pocket. During an interview on 11/1/2017 at 3:20 pm, LPN Charge Nurse #5 stated that the resident is not supposed to have a lighter and stated she would go and get it from the resident. During an interview on 11/1/2017 at 3:29 pm, The DON reviewed the facility's current smoking policy and care plan and went to get the lighter. On 11/1/2017 at 3:30 pm, LPN Charge Nurse #5 stated the resident would not give her his lighter. On 11/1/2017 at 3:35 pm, the DON stated we are trying to get his lighter from him, but he is noncompliant. During an interview on 11/2/2017 at 8:34 pm, Social Worker #1 stated the resident had 3 lighters and they were all taken from him. On 11/2/2017 at 11:05 am, during an attempt to interview, the resident stated go away, I'm not in a very good mood. During an interview on 11/2/2017 at 11:33 am, the Administrator stated the resident should not have had any lighters and he is the only smoker in the facility. He stated the staff were educated and a lock box was placed in the Activities Department for the lighters. 10NYCRR 415.12 (h)(1)

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The lighters that Resident #91 had were removed from his possession on 11/2/17 and locked in a secure box that has been installed in the activity room.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? There are no other residents who are allowed to smoke while in the facility. A full facility check was completed on 11/2/2017 to ensure there are no other residents with lighters in their possession.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
A new facility policy was implemented on 11/2/2017 in regards to the grandfathered-in resident who is allowed to smoke while residing in the facility. An audit tool was created to ensure that every time resident # 91 comes in from smoking; his lighter(s) are placed in the lock box on the activities windowsill. Resident # 91 has the key to the lock box on his wristband so security of his belongings can be assured.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The smoking audit tool will be reviewed by the Director of Nursing daily weekly for 4 weeks, then monthly for 5 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
The Director of Nursing Services will be responsible for correction and compliance.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

Based on personnel record review, staff interview, and Infection Control policy review during the recertification survey, the facility did not maintain a comprehensive Infection Control Program to help prevent the development and transmission of disease. Specifically, within the past year, the facility did not provide education on the risks and benefits for the pneumococcal vaccine for 1 of 10 employees reviewed. This is evidenced by the following. Record review of the employee health records for Staff Person #3 on 11/06/2017 revealed that she was last educated on the risks and benefits of the pneumococcal vaccine on 06/20/2016. The Staff Development Nurse stated in an interview conducted on11/06/2017 at 11:05 am, that she did not know why Staff Person #3 did not receive the pneumococcal vaccination education as required. The Infection Control policies were reviewed on 11/06/2017. No policy was provided relative to providing education to employees on the risks and benefits of the pneumococcal vaccine. 10 NYCRR 483.65

Plan of Correction: ApprovedDecember 10, 2017

What corrective action(s) will be accomplished for those employees found to have been affected by the deficient practice? The employee who had the form missing was offered the Pneumococcal Vaccine on 11/6/17.
How will you identify other employees having the potential to be affected by the same deficient practice and what corrective action will be taken? A complete Medical Record Audit will be completed for all current employees; those found to be missing the Pneumococcal Vaccine offer form will be contacted and offered the Pneumococcal Vaccine or they will have to sign the declination form.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur? All employees will be offered the Pneumococcal education annually. An ?Employee Medical File Audit? form has been created and will be placed in the front of employee medical files to ensure that this annual education is provided.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? All new employees will have a medical file audit preformed within their first 30 days of employment and all current employees will have the audit completed on the month of their anniversary, this will be documented on the ?Employee Medical File Audit? form and will be kept in the front of the employee medical file. The monthly employee medical file audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
Marjorie(NAME)Horner BS, RN ? Director Staff Development & Employee Health

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 6, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during a recertification survey the facility did not ensure that it established an infection prevention and control program (IPCP) that included, at a minimum, the following elements, a system for preventing, identifying, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services and standard and transmission-based precautions to be followed to prevent spread of infections for two (Resident #'s 67 and 83) of four residents reviewed for wounds. Specifically, the facility did not ensure that proper hand hygiene and supply handling were done in a manner that prevented cross contamination during Resident # 67 and #83's dressing changes. This is evidenced by: Resident #67: The resident was admitted to the nursing home on 6/16/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognitive skills for daily decision making; The resident sometimes understood, was sometimes understood, and was moderately hearing impaired. During a dressing change observation on 11/1/17 at 2:45 pm, RN #3 removed a pair of scissors from his pocket, cut off the dressing to the resident's heel and placed the scissors back in his pocket; RN #3 cleansed the wound with saline and with the now soiled gloves dispensed wound gel from a tube, to apply to the heel; RN #3 picked up and used the tape with the same soiled gloves; When the dressing was completed, RN#3 picked up the contaminated items and placed them back in the treatment cart. During an interview on 11/1/17 at 3:20 pm, RN #3 stated that he was not aware that the scissors could not be placed back in his pocket and that hand hygiene should have been performed prior to touching supplies and should not have been put back in the treatment cart. During an interview on 11/6/17 at 2:00 pm, the Director of Nursing/Infection Control Nurse stated that items should not be brought into the rooms; The creams should be dispensed into medicine cups to take in the room; The nurse should have washed his hands and put on clean gloves before proceeding with the dressing and the contaminated items should not have been placed back in the cart. Resident #83 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident also suffered a left tibial fracture on 8/9/2017. The Minimum Data Set, dated dated [DATE], assessed the resident as moderately impaired cognitively; understands and is usually understood. On 11/2/2017 at 10:35 am, Licensed Practical Nurse (LPN) #1 was observed during a dressing change to the resident's left heel. LPN #1 washed her hands, donned clean gloves and removed left heel dressing. She observed the drainage on the dressing, removed gloves and donned another pair of gloves. On 11/2/2017 at 10:45 am, LPN #1 verbalized that she should have washed her hands or used hand sanitizer after rermoving the dressing and before putting on another pair of gloves. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedDecember 13, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Both nurses involved (LPN # 1 and RN # 3) were provided immediate re-education on proper infection control guidelines. Residents #67 and #83 were immediately assessed by an RN to ensure no signs or symptoms of infection were noted as a result of the deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Any resident who is receiving wound care is classified ?potentially affected? by the deficient practice. Nursing leadership will observe all nurses providing wound care to ensure appropriate infection control practices are being followed.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
Mandatory education will be provided to licensed nursing staff regarding appropriate standard precautions and appropriate steps to be taken during a dressing change.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? Nursing leadership will complete 3 random observations per unit of dressing changes to ensure appropriate infection control guidelines are followed (hand hygiene before and after dressing changes, glove changes between removing the old dressing and applying the new dressing, and appropriate handling of dressing supplies). The audits will be completed weekly for 4 weeks, then monthly for 5 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.

The title of the individual response for continued compliance:
The Director of Nursing Services will be responsible for correction and compliance.

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: December 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the exit discharges to the public way were not free of all impediments for full instant use. CMS Survey and Certification Letter 05-38 requires that exit discharges to a hard-packed all-weather travel surface. Specifically, the connecting lounge exit discharge was not a hard-packed all-weather travel surface. This is evidenced as follows. Observation of the connecting lounge exit discharge on 11/07/2017 at 2:00 pm, revealed a 3-foot square section of grass between the exit door and the public way. The Director of Maintenance stated in an interview conducted on 11/07/2017 at 2:00 pm, that he will replace the grass with a hard-packed surface. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.2.7; S&C 05-38; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
The damaged area has been removed and a temporary patch was laid down on 11/13/17 that will last through the winter months. In the spring, when the weather permits, a permanent repair will be done at the affected area.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All exit walkways have been inspected for damage and repaired as needed by 11/13/17.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
An in-service will be conducted with all maintenance staff on how to identify and report outside walkway damage.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place?
The Director of Maintenance initiated ongoing monthly inspections of exit walkways to ensure compliance. Any issues will be reported to the QAPI committee.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.4 requires that all electrical adapters be listed for the purpose. NFPA 70 National Electrical Code 2011 Edition Article 590 section 590.3 (D) prohibits the use of mulit-plug adapters. Specifically, non-compliant power strips and multi-plug adapters were used to power non-patient care electrical devices in 2 of 9 resident care areas checked. This is evidenced as follows. A selection of resident areas was inspected for the use of power strips and multi-plug adapters on 11/06/2017 at 12:45 pm. A non-compliant power strip was used to power a table fan and a wheelchair charger in resident room [ROOM NUMBER], and a multi-plug adapter was used to power personal electronics in resident room [ROOM NUMBER]. The Director of Maintenance stated in an interview conducted on 11/06/2017 at 12:45 pm, that he had checked all rooms for power strips and was not aware of the power strip and multi-plug adapter found. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.4; 2011 NFPA 70 590.3(D); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The one multi plug was removed the same day that the issue was discovered. The one power strip with the wrong UL listing was removed on the following day after it was discovered when a suitable replacement was obtained.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A complete facility inspection has been done to ensure that no multi plugs are in use and all power strips are of the proper UL listing.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur? An in-service will be conducted with all maintenance staff concerning the proper identification and use of power strips. All staff will be trained to identify and report all power strips and multi plugs.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Maintenance Department will conduct room inspections to check for improper power strips and multi plugs on a weekly basis for 4 weeks then on an ongoing monthly basis. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

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: November 7, 2017
Corrected date: December 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm and Signaling Code 2010 Edition Section 14.4.5 requires that initiating devices, such as smoke detectors, heat detectors, and manual pull stations (fire alarm system), require annual tests. Specifically, the fire alarm system was not tested annually. This is evidenced as follows. The fire alarm testing records were reviewed on 11/07/2017. This review revealed that the fire alarm system was tested on [DATE] and next on 04/25/2017, a period of 13 months and 15 days. The Director of Maintenance stated in an interview conducted on 11/07/2017 at 9:40 am, that the annual fire alarm test was late due to difficulty in scheduling the company contracted to testing. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.6.1.3; 1999 NFPA 72: 14.4.5; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-2.2, 7-3.2

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Fire Alarm System inspection that was due within one year from 3/10/16 was conducted on 4/25/17.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All annual inspections have been reviewed to ensure they have been completed timely.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
All annual inspections will be scheduled at 11 months to ensure that they are completed on time. A call will be placed to the fire alarm company thirty days prior to the due date of the inspection for confirmation of upcoming inspection. A second call will be placed to the fire alarm company one week prior to the due date of the inspection for confirmation of upcoming inspection. If the fire alarm company does not show up on the scheduled day, they will be called by the end of the business day and rescheduled before 12 months have passed since the last deadline.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Director of Maintenance will be the one calling the fire alarm company prior to the inspection date and on the date in case of a no show. If the fire alarm company or any inspection company fails to meet their inspection date, the Administrator and QAPI committee will be notified.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: December 21, 2017

Citation Details

Based on staff interview and record review during the recertification survey, the staff were not familiar with the basic response to fire. NFPA 101 Life Safety Code 2012 edition section 19.7.2.3 states that employees shall be trained in the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire). Specifically, 3 of 9 employees interviewed were not familiar with the code phrase for fire. This is evidenced as follows. Licensed Practical Nurse #5 stated she would announce fire upon discovery of fire when interviewed on 11/06/2017 at 8:50 am. Certified Nursing Assistant #3 stated she would announce fire upon discovery of fire when interviewed on 11/06/2017 at 8:35 am. Staff Person #3 stated she would announce fire upon discovery of fire when interviewed on 11/06/2017 at 8:55 am. The facility emergency fire procedure was reviewed on 11/06/2017. The policy requires that staff persons are to call out Code Red and the location upon discovering a fire situation. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.2.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7.2.3

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? All staff will be educated on the facility Fire Response Policy.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All staff will be educated on the facility Fire Response Policy.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?Department heads and Unit Managers will be trained to teach the facility Fire Response Policy. They will then be responsible for teaching their respective departments and nursing units.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Director of Maintenance will audit staff to ensure that staff are knowledgeable on the Fire response procedure. Audits will be done weekly for 3 months then monthly for three months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: December 21, 2017

Citation Details

Based on staff interview during the recertification survey, the facility did not conduct a building systems risk assessment as required by adopted regulation. NFPA 99 Health Care Facilities Code 2012 Edition section 4.2 requires that building systems, such as gas and vacuum systems; electrical systems; heating, air conditioning, and ventilation systems; electrical equipment; and gas equipment are to undergo a formal, defined, and documented risk assessment procedure by qualified personnel. Specifically, the required building systems risk assessments were not conducted. This is evidenced as follows. The Director of Maintenance stated in an interview conducted on 11/07/2017 at 12:50 pm, that the facility building systems have not undergone a risk assessment and been assigned risk categories. 42 CFR 483.70 (a) (1); 2012 NFPA 99 4.2

Plan of Correction: ApprovedDecember 10, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Medical Equipment Management sub-committee will compile a comprehensive list of building systems and electrical medical equipment and will assigning a risk to each one. They will complete a Building Systems Risk Assessment in accordance with NFPA 99 Health Care Facilities Code 2012 Edition Section 4.2 which will encompass all of the building systems and electrical medical equipment.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The Medical Equipment Management sub-committee will complete the Building Systems Risk Assessment in accordance with NFPA 99 Health Care Facilities Code 2012 Edition Section 4.2.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur? The Medical Equipment Management sub-committee will meet on a monthly basis to review the Building System Risk Assessment and add any equipment that has entered the facility and assign a risk to that equipment. They will remove any equipment that has been removed from our inventory.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Medical Equipment Management sub-committee will report directly to the Safety Committee, the Director of Maintenance, QAPI committee and Administrator of any issues or discrepancies and report at the Safety meetings.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: December 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did protect pressurized oxygen cylinders from damage in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.6.2.3 requires that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. Specifically, freestanding oxygen cylinders were not properly supported. This is evidenced as follows. The oxygen transferring room was inspected on 11/07/2017 at 9:00 am. Two cylinders were freestanding and not secured in a stand or cart. The Director of Maintenance stated in an interview conducted on 11/07/2017 at 9:40 am, that he did not have enough racks for all cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.6.2.3(11); 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-3.5.2.2(b)2

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The two oxygen cylinders that were not in a rack were placed into racks in the oxygen fill room the same day that the issue was discovered.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A complete facility inspection has been done to ensure that all oxygen cylinders are stored properly.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur? An in-service will be conducted with all staff concerning the proper storage of oxygen tanks. Signage has been placed in all areas where oxygen is stored stating that all oxygen tanks must be stored in oxygen storage racks.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Director of Maintenance will conduct inspections of oxygen storage areas to ensure compliance; daily for 2 weeks, weekly for 10 weeks followed by monthly for 3 months. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 7, 2017
Corrected date: December 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.6.4.1.1.1 states that the distance between the deflector of a pendent sprinkler head and the ceiling shall be a minimum of 1 inch (25.4 mm) and a maximum of 12 inches (305 mm) throughout the area of coverage of the sprinkler. Specifically, the deflectors of several pendent sprinkler heads were less than 1 inch from the ceiling. This is evidenced as follows. Observations of the sprinkler system 11/07/2017 at 8:20 am, revealed the deflectors of two (2) sprinkler heads in the main kitchen dishwashing machine area were ½-inch from the ceiling. The Director of Maintenance stated in an interview on 11/06/2017 at 9:20 am, that he will have the sprinkler heads adjusted for compliance. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.7.5; 2010 NFPA 13: 8.5.6, 8.6.4.1.1.1; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 9.7.5; 1999 NFPA 13: 5-5.6, 5-6.4.1.1

Plan of Correction: ApprovedDecember 10, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 11/8/17, the ceiling in the main kitchen dishwashing machine area was raised and the pipes were adjusted so that the clearance between the sprinkler head deflector and the ceiling was changed from 1/2th of an inch to over 1 inch.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? A facility wide inspection has been completed to identify sprinkler heads with less than 1 inch of clearance with no findings.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur?
All maintenance staff will be trained to identify and report sprinkler heads which do not have over 1 inch clearance from the deflector head to the ceiling.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Maintenance Department will conduct sprinkler head inspections weekly for 4 weeks then monthly for 2 months then on an ongoing quarterly basis. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance

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: November 7, 2017
Corrected date: December 21, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Specifically, metal electrical boxes in 1 of 1 smoke barriers observed were not fire-protected as required. This is evidenced as follows. The Unit 3 west smoke barrier wall (wall) was inspected on 11/07/2017 at 8:30 am. Three duplex and two single metal electrical boxes were within 24-inches of each other on opposite sides of the wall in resident rooms 323, 325, 324 and the storage room. These metal electrical boxes were not fire separated with any listed materials. The Director of Maintenance stated in an interview conducted on 11/07/2017 at 9:40 am, that he will seal the electrical boxes noted. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedNovember 28, 2017

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Our facility electrician was contacted on 11/15/17 to discuss options to remediate the issue of sealing the electrical boxes in the smoke walls. Facility maintenance staff will cut holes in the Unit 3 west smoke wall to gain access to the back of the electrical boxes in order to seal them with approved fire caulk and/or putty against smoke penetration.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All smoke walls in the facility will be checked to make sure that any electrical boxes are either separated by the proper distance or have fire protection. If any electrical boxes are found to be too close without proper protection, facility maintenance staff will cut holes in the smoke wall to gain access to the back of the electrical boxes in order to seal them with approved fire caulk and/or putty against smoke penetration.
What measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur? An in-service will be conducted with all maintenance staff concerning the regulations and identification of electrical boxes in smoke walls and the appropriate fire protection that is required.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into place? The Maintenance Department will conduct smoke wall inspections to check for improperly located or protected electrical boxes weekly for 4 weeks then monthly for 2 months then on an ongoing quarterly basis. Audit findings will be reported to the QAPI Committee for six months then as deemed necessary by the QAPI committee.
The title of the individual response for continued compliance:
Tom(NAME)? Director of Maintenance