Alpine Rehabilitation and Nursing Center
February 1, 2017 Certification Survey

Standard Health Citations

FF10 483.24(a)(b):ADLS DO NOT DECLINE UNLESS UNAVOIDABLE

REGULATION: (a) Based on the comprehensive assessment of a resident and consistent with the resident?s needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: (1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section, ? (b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: (1) Hygiene -bathing, dressing, grooming, and oral care, (2) Mobility-transfer and ambulation, including walking, (3) Elimination-toileting, (4) Dining-eating, including meals and snacks, (5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure the ability to perform ADLs did not diminish for 2 (Residents #38 and 48) of 13 residents reviewed for activities of daily living (ADLs). Specifically, staff did not ensure Resident #'s 38 and 48 were properly positioned at meals and received the most appropriate assistive devices to promote independence in eating. This is evidenced by: Resident #48: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderate cognitive impairment, was non ambulatory, required extensive assistance with transfers and supervision eating. On 12/7/2016, a physical therapy assistant documented a scoot chair was issued to increase the resident's safety, improve posture and increase her ability to self propel with her feet. The Comprehensive Care Plan (CCP) reviewed 12/7/2016, documented the resident was independent in eating, with set up. The resident had the potential for alteration in her nutritional status as she ate less than 75% of her meals. The goal was to improve her intake. Staff were to monitor her intake records and report any changes to the interdisciplinary team, update her meal pattern for dietary preferences and meals were to be served on the unit. The CCP reprinted for annual review on 12/8/2016, documented the resident was to use a Sippy (spill proof) cup and supplements included 8 ounces of milk at breakfast, and 8 ounces of chocolate milk with lunch and dinner. The CCP updated on 12/30/2016, documented the resident was non compliant with transfers, had poor safety awareness, and was impulsive. The plan included transferring and ambulating the resident per therapy recommendations, low bed with bolster pillow, and a scoot chair (chair low to the ground with the back of the seat lower than the front). The resident was documented to be at risk to develop constipation and the plan was to encourage fluid intake and meal completion. The meal consumption record for 1/2017, documented the resident's meal consumption was 50% or less at breakfast on 24 out of 27 days, for lunch on 21 of 25 days, and at supper on 14 of 26 days. The resident's fluid intake at meals was 240 CC's (cubic centimeters) or less at breakfast on 14 of 27 days, at lunch on 19 of 27 days, and for supper on 16 out of 26 days. The resident was observed during survey: - On 1/27/2017 at 12:20 pm, seated in the dining room in her scoot chair, low to the table (chin height); - On 1/30/2017 at 5:14 pm, in the hallway lounge seated in a straight back chair drinking her fluids independently; - On 1/31/2017 at 8:25 am, the resident's tray was left on the table in the hallway/lounge. The resident was seated to the side of the table in her scoot chair and certified nurse aide (CNA) #5 told the resident she was waiting for another staff member to help transfer her into a straight back chair. At 8:40 am, the resident was observed seated at the table in her scoot chair, the table at her chin height. The resident remained at the table without attempting to eat. A staff member was assisting the resident on the left of Resident #48 and was heard encouraging her to eat and drink, without success. On 2/1/2017 at 8:53 am, the resident was observed seated in a straight back chair in the dining room and was attempting to drink her chocolate milk. The milk was in a regular glass and the resident was spilling the milk on herself and the floor as she attempted to lift the glass. When CNA #5 approached the resident and asked her if she wanted a clothing protector, she observed the resident having difficulty with the glass. When asked by the surveyor to review the resident's menu slip, the CNA stated the resident was suppose to have Sippy (spillproof) cups and the dietary server was to provide them when setting up the place setting. The CNA obtained the Sippy cups, and the resident was observed utilizing the special cup without difficulty, proceeding to drink the chocolate milk. During an interview with CNA #5 at 8:58 am on 2/1/2017, she stated it was the resident's choice whether she ate in the dining room or in the hallway. If the resident was in the dining room at a lower table, the resident did not need to be transferred from the scoot chair to the regular straight back chair. She stated when on the unit (in the hallway lounge) she was suppose to be transferred to the straight back chair. On 2/1/2017 at 10:15 am, during an interview with the registered dietitian (RD), she stated she did not know why Resident #48 did not have her Sippy cups at the breakfast meal. She thought the mix up occurred when the resident changed her mind from eating in the hallway lounge to eating in the dining room, and her tray was taken into the dining room from the cart on the unit. She said no one double checked it to be sure she had what she needed. During an interview with the Regional Therapy Manager (occupational therapist) on 2/1/2017 at 11:15 am, she stated the resident was to be transferred from the scoot chair to a straight back chair for all meals, whether eating in the dining room or on the unit. The scoot chair was provided for mobility, and positioning at the table was better in a straight back chair for promoting independent eating. Resident #38: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderate cognitive impairment, was non ambulatory, required extensive assistance transferring and limited assistance eating. The comprehensive care plan (CCP) reviewed on 11/10/2016, documented the resident was at risk for falls and utilized a scoot chair (low chair with seat tilted back) when out of bed. She was at risk for alteration in her nutritional status as she left 25% of her food uneaten at meals, and had a history of [REDACTED]. The plan included encouraging and monitoring her intake. A dietary quarterly review note dated 1/24/2017, documented the resident was on a regular diet with thin liquids and did not utilize any adaptive equipment. Her average intake was 43% of solids and 1435 cc's (cubic centimeters) of fluids. Her estimated needs were 1500 cc's per 24 hours. The resident's weight was 101.8 pounds, down 3 pounds in 1 month. The resident was observed on 1/27/2017, in the dining room at 12:20 pm. She was seated low to the table in her scoot chair and had spilled her chocolate milk on the table, on her placemat. The chocolate milk was in a glass with no lid. The resident's menu slip documented EZ sip lids. The resident had a plastic lid on her hot beverage mug. On 1/30/2017 at 12:58 pm, the resident was observed in the dining room seated low to the table (chest level) and was being assisted by a certified nurse aide (CNA) with her meal. The resident had 2 mugs with lids and 1 glass without a lid. When the CNA attempted to assist the resident with one of the covered mugs, she removed the lids and stated to the resident the lids are confusing you aren't they? On 1/30/2017 at 5:30 pm, the resident was observed in the dining room seated in her scoot chair. She had orange juice and milk in a Sippy (spillproof) cups and a hot beverage in a mug with no top. The resident was observed drinking from the sippy cups independently. On 2/1/2017, the resident was observed at 8:50 am in the dining room. She had the EZ lid on her hot beverage with a straw. During an interview with CNA #4, who was seated next to her assisting at the table, she stated the lid with the straw was what she was suppose to be using. During an interview with the registered dietitian (RD) on 2/1/2017 at 10:20 am, she stated the resident had an EZ sip lid for her hot beverages. The nursing staff passed out the hot drinks in the dining room. She stated the resident possible needed an occupational therapy (OT) evaluation to determine if the resident needed an assistive device (special type of cup) and if so, the most appropriate type to use. During an interview with the Regional Therapy Manager (OT) on 2/1/2017 at 11:15 am, she stated OT did not issue the EZ lid for the resident and did not know where the directive was initiated. She questioned if there may have been an incident report and the request came from the nurse or from the interdisciplinary team. She stated meal observations by therapy were usually conducted if they received a referral for an evaluation. She was not sure what happened with Resident #38 as therapy never received a referral related to feeding concerns. She stated the resident was a Hoyer lift (mechanical lift) and otherwise, would have recommended the resident be transferred to a straight back chair to improve her positioning and independence in eating. 10NYCRR 415.12(a)(1)(iv)

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
Resident #38 ? Use of scoot chair at the meal will be reassessed by therapy to ensure resident is appropriately positioned and if use still appropriate to allow resident to move about the facility. Therapy will assess for the use of adaptive devices specifically special cups that help promote independence, care plan will be updated to reflect any changes.
Resident #48- Resident is currently in the hospital, upon her return, use of scoot chair, will be assessed by therapy. To ensure resident is appropriately positioned at meals resident will be helped to a straight backed chair if her condition allows. Therapy will also assess for use of adaptive devices, that help promote independence, and care plan will be updated.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if the facility does not ensure the resident?s ability to perform ADLs does not diminish. Specifically, residents are properly positioned at meals and receive the most appropriate assistive devices to promote independence in eating. All residents in scoot chairs will be assessed by nursing for positioning at meals and any resident that is not properly positioned will be referred to therapy to assess for changes that would be most appropriate. Therapy will assess need of adaptive cups to ensure they are the most appropriate and help to promote independence. Residents who have need of assistive devices, specifically adaptive cups, will have all drinks in adaptive cups. If a resident is assessed to need a scoot chair to promote ability to move about the facility, they will be moved to an upright chair at meals or be placed at a table that is lowered to allow use by residents who may be in smaller chairs or scoot chairs. Scoot chair will have the position raised. Care plans will be updated to reflect any changes.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
All assistive devices will be ordered by therapy after assessment and then communicated to dietary and nursing for inclusion on the care plan, resident ?pocket sheet? (directions for care staff) and resident meal ticket to ensure consistency of use. Staff will receive education regarding the use of special cups to promote independence, how they are to be used and the purpose.
Staff will receive education regarding the positioning of residents at the meal that use scoot chairs. If a resident is assessed to need a scoot chair to promote ability to move about the facility, they will be helped to an upright chair at meals or be placed at a table that is lowered to allow use by residents who may be in smaller chairs or scoot chairs. Scoot chair will be put in the upright position if used at a table with the proper height.
Education will also include the use of the ?Stop n Watch? tool for any resident that is having trouble with positioning at meals. ?Stop n Watch tool will then go to the Interdisciplinary Care Plan team for discussion at morning meeting and team will ask therapy for an evaluation of resident positioning.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
There will be audit of therapy order for assistive devices as compared to the ?pocket sheet? and care plan for the use of nursing and meal tickets for the use of dietary and nursing weekly to ensure therapy orders are consistently documented and implemented, for 4 weeks. Results will be presented to the QA committee. Frequency of the audit will be determined by QA committee based on these findings of compliance.
There will be audit of resident positioning at the meal to include residents in scoot chairs for proper positioning at the table weekly for four weeks with results presented to the QA committee. Frequency of the audit will be determined by QA committee based on these findings of compliance.
Responsible party: Director of Nursing

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on observation, record review, and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food sanitation practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that automatic dishwashing machine are to operate in accordance with the manufacturer's instructions, and food contact equipment is to be cleaned after use. Specifically, the automatic dish washing machine was not rinsing in accordance with the manufacturer ' s instructions, and various equipment required cleaning. This is evidenced as follows: The main kitchen was inspected on 01/27/2017 at 9:45 am. The automatic dish washing machine was rinsing at zero (0) parts per million (ppm) of available chlorine at (0) pounds per square inch (psi) water flow pressure. The can opener and holder, mixer, slicer, and knife holders required cleaning. The automatic dish washing machine instructions were reviewed on 01/27/2017. These instructions state that the final rinse flow pressure is to be between 15 and 25 psi. The Food Service Director stated in an interview conducted on 01/27/2017 at 9:45 am, that the dish washing machine should rinse at 50 ppm of chlorine, she will contact the maintenance department to repair the pressure gauge, and she will double check the cleaning schedule. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents have been identified as being affected.

2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if generally accepted food sanitation practices according to FDA guidelines are not followed. Corrections included repair of the automatic dish washing injected sanitizer tubing, replacement of the rinse flow pressure gauge and cleaning of can opener and holder, mixer, slicer and knife holders.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
Pressure gauge for dishwashing machine was replaced to ensure pressure is between 15 and 25 psi.
Although sanitizer injection system is checked daily by staff a documentation sheet was developed to ensure daily checks are recorded of injection of sanitizer system checks, final rinse flow pressures, along with wash and rinse temperature checks. Staff is being trained regarding use of new form and requirement of daily checks and what staff is responsible to conduct and document the checks. In addition to report to the dietary supervisor or director if final rinse flow pressure is out of range and /or dish washing machine is not rinsing within PPM range.
Dietary Director will monitor staff assigned to increase staff accountability.
Cleaning schedules for can opener and holder, mixer, slicer and knife holders were reviewed and revised to ensure cleaning after each use. Staff is receiving training on cleaning responsibilities and methods for cleaning and what staff is responsible for cleaning assignments.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
Weekly audits of the new checklist/ documentation of sanitizer and rinse flow pressure, etc. will be completed by Dietary Director or designee for one month to ensure staff is using the checklist appropriately. Completed checklist will be provided to the QA committee for one month for QA review. Frequency of further audits will be determined by QA committee based on compliance.
Cleaning responsibility lesson plan for staff education and signature sheet will be provided to QA committee. Audits of cleanliness of kitchen equipment after use will be conducted once a week for four weeks, and then frequency of further audits will be determined by QA committee based on compliance.
5. Responsible Party: Dietary Director

FF10 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18):NOTICE OF RIGHTS, RULES, SERVICES, CHARGES

REGULATION: (d)(3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. §483.10(g) Information and Communication. (1) The resident has the right to be informed of his or her rights and of all rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. (g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) [§483.10(g)(4)(ii) will be implemented beginning November 28, 2017 (Phase 2)] (iii) Information regarding Medicare and Medicaid eligibility and coverage; [§483.10(g)(4)(iii) will be implemented beginning November 28, 2017 (Phase 2)] (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; [§483.10(g)(4)(iv) will be implemented beginning November 28, 2017 (Phase 2)] (v) Contact information for the Medicaid Fraud Control Unit; and [§483.10(g)(4)(v) will be implemented beginning November 28, 2017 (Phase 2)] (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives: (i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and (ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community. (g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. (g)(16) The facility must provide a notice of rights and services to the resident prior to or upon admission and during the resident?s stay. (i) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. (ii) The facility must also provide the resident with the State-developed notice of Medicaid rights and obligations, if any. (iii) Receipt of such information, and any amendments to it, must be acknowledged in writing; (g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in paragraphs (g)(17)(i)(A) and (B) of this section. (g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident?s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility?s per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility?s per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident?s date of discharge from the facility. v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on medical record review and staff interview during the recertification survey, it was determined that the facility did not ensure that residents and/or their designated representative was notified (2 day notifications) about their right to appeal the discontinuation of Medicare. This was evident for three (3) out of three (3) sampled residents reviewed for the Notice of Medicare Provider Non-Coverage (Residents #'s 82, 83, and #84). This is evidenced as follows: The records for Residents #'s 82, 83, and #84 were reviewed on 01/21/2017. This review revealed that these residents were discharged into the community after completing rehabilitation services, and had not received a Notice of Medicare Provider Non-Coverage. The Minimum Data Set (MDS) Coordinator stated in an interview conducted on 01/21/2017 at 3:10 pm, that she did not know issuing a Notice of Medicare Provider Non-Coverage prior to completing rehabilitative services was required for residents discharged into the community. 10 NYCRR 415.3 (g)

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
Resident #82 ? This resident is no longer a resident of the facility.
Resident # 83 - This resident is no longer a resident of the facility
Resident # 84 - This resident is no longer a resident of the facility
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All discharged residents have the potential to be affected if they or their designated representative is not notified, with two-day notification, about their right to appeal the discontinuation of Medicare after completing rehabilitation services.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
Policy and procedure will be updated to include a ?Notice of Medicare Provider Non-Coverage? be given to all residents with two days? notice who are going back to the community after completing rehabilitation services. Staff will be alerted at weekly Utilization Review meetings of therapy plans to discharge a resident in preparation to return to the community to alert staff of need for two day notice of discharge from therapy.
Training will be provided for the MDS coordinator and therapy department to ensure therapists and MDS coordinator ensure notices are given to residents scheduled to return to the community and they understand even though discharge may be voluntary Medicare notices still need to be given to ensure residents are aware of their right to appeal the discontinuation of Medicare.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
An audit of each discharge to community will be conducted to ensure residents that are discharged back to the community after completing rehabilitative services are notified appropriately by receipt of ?Notice of Medicare Provider Non-Coverage? two days before the termination of therapy services. A report will be given to the QA committee each month for 3 months with evidence of notices given.
5. Responsible Party: MDS Director

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey it was determined that for 4 (Resident #s 38, 58, 61, and #80) of 16 residents reviewed, the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically: For Resident #'s 61, 58 and 80, who required sliding scale insulin coverage based on finger stick blood sugars (FSBS), the facility did not ensure the documentation on the medication administration record's (MARs) included consistent documentation of nurse's initials, FSBS, insulin coverage and site of injection; For Resident #38, the resident's medical record documented inconsistencies regarding the residents toileting/changing and shower schedule. This was evidenced by: The Facility's Policy & Procedure (P&P) titled Medication Administration (undated) documented, the following standards and procedures will be followed to facilitate the safe and effective administration and handling of all pharmaceuticals. Documented under the heading procedure included: at the start of each shift, the medication nurse will review each resident's entire Medication Administration Record [REDACTED]. If the nurse is unable to reach him/her, the nursing supervisor will be notified; enter initials in the appropriate MAR indicated [REDACTED]. Resident #80: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition and was usually able to make himself understood and understand others. The Medication Administration Record [REDACTED]. Call MD (physician) for fingerstick greater than 400 or less than 100. Strict rotation of site, abdomen only. Sliding scale was documented; FSBS of 200-250 give 2 units insulin. 251-300 give 4 units 301-350 give 6 units 351-400 give 8 units 401-450 give 10 units 451-500 give 12 units The MAR's documentation each time the FSBS was ordered required: the nurse initials corresponding with the time ordered, the FSBS result, the insulin coverage given, and the site on the abdomen. A review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview on 1/31/17 at 3:15 pm, the Director of Nursing (DON) stated that the facility does education on medication administration. During the monthly changeover of the MARs the DON, ADON (Assistant Director of Nursing) and the nurse managers review them (the MARS) for completion. The nurses should be documenting the initials, FSBS, insulin units administered and the injection sites. The DON stated the resident had the insulin injected in the abdomen only in order to improve the absorption of the insulin. Resident #38: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderate cognitive impairment, was non ambulatory and required extensive assistance with transfers and total assistance with toileting, personal hygiene and bathing. The Comprehensive Care Plan (CCP) documented the resident needed assistance for toileting and was incontinent of bladder all the time. The resident had a chronic urinary tract infection [MEDICAL CONDITION] and was at risk for developing an acute UTI. The resident was also at risk for developing skin breakdown due to her incontinence. The resident was to be checked for incontinency every 2 to 3 hours and changed when indicated, providing good peri care. The resident required extensive assistance of one person for bathing, and a Hoyer (mechanical lift with 2 staff) for toileting and for transfers. The certified nurse aide (CNA) care instructions dated 1/26/2017, documented the resident required a Hoyer lift for all transfers and was to be changed every 2 to 4 hours. The resident was observed on 1/30/2017, sitting across from the nurses' desk from 3:50 pm through 4:42 pm. At 4:42 pm, a CNA was heard telling the resident were going to go to dinner and transported her in the scoot chair down the hallway to the dining room. The resident was observed in the dining room through 6:10 pm, when she was transported in the scoot chair back to the area across from the nurses' desk where she remained until 6:30 pm. The toileting record for (MONTH) (YEAR) and (MONTH) (YEAR), documented the resident was scheduled to be toileted every 2 hours. The (MONTH) toileting record was blank on the day shift for 1/2, 1/5, 1/6, 1/9, 1/10, 1/11, 1/15, 1/21, 1/25 and 1/26/2017. On 1/30/2017, the resident was documented as wet at 1:45 pm and dry when checked again at 4:00 pm. The CNA flow sheet for (MONTH) (YEAR), documented the resident's shower day was Tuesday on the day shift (7 am to 3 pm) and it was crossed off and changed to Friday on the night shift 11 pm to 7 am. As of 1/31/2017, the CNA flowsheet documented the resident had a shower on 1/3/2017 (Tuesday) and 1/20/2017 (Friday). There were no other initials documenting a shower was provided or refused during the month of (MONTH) (YEAR). During an interview with CNA #2 on 1/31/2017 at 3:10 pm, she stated the CNAs document the ADLs at the end of their shift. The shower schedule was posted on the nurses' desk and if a resident refused their shower, they were to let the licensed practical nurse know and were to circle it on the flow sheet. She stated all residents who needed assistance toileting were to be toileted at the beginning of the shift, after dinner and before the end of the shift. She stated Resident #38 was not toileted and was changed using the Hoyer lift to transfer her to the bed. Upon reviewing the shower schedule, she stated the documentation was probably not accurate and the resident probably received her weekly shower. During an interview with the Registered Nurse (RN) Manager at 3:30 pm on 1/31/2017, she stated the resident was to be toileted every 2 to 4 hours. Upon reviewing the (MONTH) toileting schedule and the plan to toilet every 2 hours, she stated she did not know that was what was written on the flow sheet and the person at the front desk was the one who made out the forms. She stated the form needed to be updated. The RN stated she reviewed the ADL books once in awhile and had spoken to certain CNAs when she observed the forms were incomplete or inaccurate. Upon reviewing the CCP, she stated she was not sure why it documented toilet every 2 to 3 hours and thought it was set that way automatically in the computer. When the toileting sheet was copied on 2/1/2017, it was changed to document every 2 to 4 hours and documented the resident received a shower on 2/1/2017. When the RN Manager was interviewed on 1/31/2017 at 3:30 pm, regarding the shower schedule, she stated she made changes to the schedule when new residents were admitted and she needed to adjust shower times. She did not recall when or why she changed Resident #38's shower. The CNA who documented on the toileting sheet and who was responsible for the resident's shower, was unavailable for interview. 10NYCRR415.22(a)(1-4)

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
Resident #38 ? This resident?s toileting schedule was revised to better reflect her needs, toileting will be check and change every 2 to 3 hours. Her toileting documentation sheet, care plan and pocket sheet for the nursing staff care instructions now match. Her shower documentation sheet clearly states what day and shift her shower will occur. Staff has been alerted to her updated plan.
Resident #58- Resident?s documentation of diabetic sliding scale testing has a pharmacy printed MAR indicated [REDACTED]. Chart is being audited to ensure proper documentation for monitoring of diabetic testing and medication administration and other testing for medication administration such as blood pressure and pulse rate, etc.
Resident #61- Resident?s documentation of diabetic sliding scale testing has a pharmacy printed MAR indicated [REDACTED]. Chart is being audited to ensure proper documentation for monitoring of diabetic testing and medication administration and other testing for medication administration such as blood pressure and pulse rate, etc.
Resident #80- Resident no longer resides in the facility
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected that are in need of help with toileting, incontinence care and other ADLs such as showers, if those tasks are not documented correctly or consistently.
Toileting and shower sheets will be reviewed to be sure they are completed appropriately. Care plans and ?pocket sheets? will be updated and reviewed to ensure consistency of proper toileting times between documents.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
Medication administration policy was reviewed and revised to ensure consistency of documentation and avoid confusion by staff regarding documentation of sliding scale actions as to what should be documented for sliding scale medication for diabetics including; nurse initials, blood testing result, dose given, and site of injection.
Pharmacy has been asked to pre-print MARs for sliding scale insulin documentation to be used for new residents so that boxes for signature and actions required in administration of insulin would be more clear and consistent.
Care policy was reviewed and revised to make toileting times and need for check and change timing more clear and consistent. Added was the requirements of daily documentation.
Toileting sheet was revised to reflect the proper time frame for toileting.
Licensed staff will receive education on documenting sliding scale insulin administration in the MAR indicated [REDACTED].
A process for communication and alert of any shower time changes is being developed.
All unit nursing staff will receive education regarding the documentation of ADLs, specifically showers and toileting and new communication system for changes. This will include changes of the toileting times and check and change to 2 to 3 hours in order to promote good care and consistency in documentation. Education will also include the possibility of resident specific instructions that may be more often in frequency of toileting, check and change for incontinence and bathing.
4. Facility?s compliance will be monitored utilizing the following quality assurance system.
Audits of toileting sheets will be conducted weekly to ensure there are no blanks, and that they are clear as to instructions and match the Care Plan and ?Pocket Sheets?.
Audits of Shower sheets will be conducted weekly to ensure there are no blanks and to ensure care plan matches the shower/bathing schedule changes and ?Pocket Sheets?.
Audits of MARs for residents that have sliding scale insulin will be completed to ensure all elements are documented, including signatures, testing result, dose given and site of injection. Included will be documentation of medication that need record of blood pressure and pulse rates.
All audits will be conducted for 4 weeks and then frequency of these audits will be determined by QA committee based on these findings of compliance.
Responsible Party: Director of Nursing

FF10 483.10(c)(6)(8)(g)(12), 483.24(a)(3):RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES

REGULATION: 483.10 (c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. (g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident?s option, formulate an advance directive. (ii) This includes a written description of the facility?s policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual?s resident representative in accordance with State law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. 483.24 (a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident?s advance directives.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not ensure to provide resident's the right to formulate an advance directive for 3 (Resident #'s 9, 28, and #48) of 16 residents reviewed during a recertification survey. Specifically: For Resident #9, the decisions documented on the Medical Order for Life-Sustaining Treatment (MOLST) were made by the resident's health care agent after the resident was determined in court to have the capacity to make her own decisions; For Resident #'s 28 and 48, decisions documented the MOLST form were made by the residents' family without evidence that the residents' lacked capacity to make their own decisions. This is evidenced by: Resident #9: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident scored 14 out of 15 on the Brief Interview for Mental Status, indicating she was cognitively intact and was able to understand others and make herself understood. The resident's MOLST (Medical Orders for Life-sustaining treatment) (a medical form that tells others the patient's wishes for life-sustaining treatment) documents the resident wishes to receive cardio-pulmonary resuscitation, a trial period of intubation and mechanical ventilation, intravenous fluids, antibiotics, and hospitalization if necessary. The MOLST form documented a facility staff member's signature based on verbal consent of the resident's family member and dated [DATE]. The MOLST did not include documented evidence of the resident's signature. The resident was hospitalized prior to admission to the facility and a psychiatry progress note dated [DATE], documented the resident's cognitive ability as alert and oriented to person, place and situation. Memory and knowledge grossly normal. The psychiatrist also documented the resident's capacity was limited, but patient deemed legally having capacity to make decisions regarding healthcare (upheld by court earlier this month). During an interview on [DATE] at 11:35 am, physician #1, stated he thought the resident's code status should be readdressed with the resident to be sure the order described her wishes and not an alternate decision maker. During an interview on [DATE], the facility Social Worker stated if a resident or proxy chooses full code status, a determination of capacity was not needed. It was only obtained if the wishes were for a DNR (do not resuscitate); therefore, this resident has not been evaluated at the facility for capacity to make decisions. The Social Worker was not aware of the court determination of the resident's capacity to make healthcare decisions because a previous Social Worker admitted the resident. She further reported that she had known about the court determination, she would have discussed the resident's code status in private and the resident would have signed the MOLST. Resident #28: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderate cognitive impairment, and was able to understand others and be understood. A Social Work Admission Note dated [DATE], documented the resident was awake and mostly non verbal and did say simple words at times. The social worker discussed advanced directives with the resident's family member and documented the resident was a full code. On [DATE], the resident's family member signed a MOLST (Medical Orders for Life-sustaining treatment) that documented if the resident had no pulse and/or was not breathing, cardio-pulmonary resuscitation (CPR) was to be attempted. The physician signed the order on [DATE]. Orders for other life sustaining treatment and future hospitalization included a trial period of intubation and mechanical ventilation and noninvasive ventilation if appropriate. The resident was to be sent to the hospital, could have a trial period of IV (intravenous) fluids, long term feeding tube, if needed, and antibiotics could be used to treat infections if medically indicated. The directives were signed by the resident's family member on [DATE] and the physician on [DATE]. There was no documented evidence the resident was determined to lack capacity to be involved in decisions regarding her wishes. A dated [DATE], documented the resident was alert and oriented with some confusion and short-term memory loss. The resident wished to return home with her family member. Social Work Progress Notes documented the following: [DATE], the resident was alert and oriented with some confusion and short-term memory loss. The resident was able to make her needs known and stated her family member assisted her with decision making as needed. [DATE], the resident had some concerns about returning home with her family member and expressed these concerns to the social worker. The social worker documented she would discuss other discharge options with the resident and would continue to provide support. The social worker did not address any possible concerns with the resident's judgement regarding this change in discharge plans. [DATE], the resident was alert and fairly well oriented, with some short term memory loss and forgetfulness at times. The resident was able to make her needs known and was able to make decisions for herself but may choose to defer to her family member. During an interview with Resident #28 on [DATE] at 4:15 pm, she expressed concerns she had with care, as well as the concerns of other residents. She stated some of the information was from her own observation, some was from conversations she had with other residents, and some from discussion at resident council meetings. This information was validated through review of resident council minutes. During an interview with the Director of Social Services on [DATE] at 11:20 am, she stated if a resident was a full code (CPR), a determination of capacity was not needed. It was only obtained if the wishes were for a DNR (do not resuscitate). During an interview with Physician #1, on [DATE] at 11:35 am, the physician stated the resident's cognition had improved since admission and the resident made a remarkable recovery. The physician stated the resident currently had the capacity to make decisions. Upon reviewing the MOLST, the physician stated he thought it should be readdressed with the resident to be sure the order described her wishes and not an alternate decision maker. Resident #48: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident usually understood others and was able to make herself understood, with a Brief Interview for Mental Status (BIMS) of ,[DATE]: moderate cognitive impairment. It documented that the resident did not exhibit any behavior concerns. On [DATE], a MOLST (medical orders for life sustaining treatment) was completed by the health care proxy (HCP), requesting an order for [REDACTED]. There was no documentation determining the resident lacked capacity to make the decision for advanced directives. A health care proxy was completed by the resident on the same date as the MOLST. The Comprehensive Care Plan (CCP) reviewed on [DATE], documented the resident was alert and able to make her needs known. The CCP documented the resident had a HCP, a full code with MOLST and a Power of Attorney. The resident's wishes were to be honored per the facility policy. During an interview with the Director of Social Services, on [DATE] at 11:20 am, she stated if a resident was a full code (CPR), a determination of capacity was not needed. It was only obtained if the wishes were for a DNR. During an interview on [DATE] at 11:35 am, Physician #1 stated he thought a resident's code status was reassessed by the interdisciplinary team and did not know if it was always documented when addressed. The physician stated a MOLST should be readdressed with the resident to assess capacity, to be sure the order described the resident's wishes and not an alternate decision maker. 10NYCRR415.3(e)(l)(ii)

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
Resident #9 ? This resident has been evaluated at the facility and found to have capacity to make decisions and as a result a new MOLST has been completed by the resident with the help of the social worker and signed by the resident in order to support the right of the resident to formulate an advance directive
Resident # 28 - This resident has been evaluated at the facility for capacity and found to have capacity to make decisions and as a result a new MOLST has been completed by the resident with the help of the social worker and signed by the resident in order to support the right of the resident to formulate an advance directive.
Resident # 48 - This resident is currently in the hospital. Upon return the resident will be evaluated at the facility for capacity and if found to have capacity to make decisions a new MOLST will be completed by the resident with the help of the social worker and signed by the resident in order to support the right of the resident to formulate an advance directive.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if they are not granted the opportunity to exercise their right to formulate an advance directive.
All MOLSTs have been reviewed to ensure residents with capacity have opportunity to formulate their own advance directives. If it is determined that a MOLST was signed by an alternate decision maker but the resident currently has capacity, a new MOLST will be completed with resident signature to ensure resident has opportunity to formulate an advance directive.
All residents who are determined to be ?Full Code? are having their MOLST reviewed to ensure, if they have capacity, they have had opportunity to formulate their own advance directives.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
The Advance Directive policy and procedure has been reviewed and revised to include the facility obligation to provide information to residents concerning the right to accept or refuse medical treatment and at the resident?s option, formulate an advance directive once the resident is able to receive such information. Policy and procedure will also include follow-up procedures to help determine when to provide information to the individual directly at the appropriate time. Follow up procedures include: Assessment by the social worker and physician of a resident?s BIMs, and the ability to understand, and discussion with the resident and family. The appropriate time will generally occur with a change in condition and/or improvement in cognition or ability to understand and formulate an advance directive. The physician and social worker will document the resident?s capacity. For residents who are determined to have capacity a new form is being developed to ensure physician agreement with determination of capacity. If a resident with capacity authorizes the HCP to sign their MOLST that will be documented in the social services notes.
Staff education including the physician, social worker, nursing will be provided regarding the new form ensuring physician agreement with determination of capacity and updated Advance Directive policy and procedure.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
Audit of residents that are new admissions or residents with improvement in condition and/ or improvement of cognition or ability to understand and to formulate their own advance directives will have their MOLST reviewed to ensure they have had opportunity to formulate their own advance directives. This audit will be conducted each month for three months with results given to the QA committee. Frequency of this audit will then be determined by QA committee based on these findings of compliance.
5. Responsible Party: Director of Social Services

Standard Life Safety Code Citations

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: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on employee interview and policy record review during the recertification survey, it was determined that the facility did not develop maintenance policies for and provide records for all testing and repairs of all patient-care electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.5.2.1 requires that facilities shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment (PCREE). Section 10.5.6 requires that records and a log shall be maintained of the tests and associated repairs or modifications of all patient-care electrical equipment. Specifically, the facility did not develop maintenance policies and record all testing and repairs for all patient-care related electrical equipment. This is evidenced as follows: The facility maintenance policies and records were reviewed on 01/27/2017. No maintenance records or policy for PCREE was available for survey review. The Environmental Services Director stated in an interview conducted on 01/27/2017 at 3:45 pm, that the facility does not have a specific maintenance policy for PCREE, and the associated test and repair records and logs for kept by an outside contractor. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.5.2.1.1, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents have been identified as being affected.

2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if there is no clear policy for testing and maintenance of patient ?care related electrical equipment (PCREE) or record of electrical equipment tests, repairs and modifications maintained for patient care related electrical equipment.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
A more specific policy is being developed regarding the testing and maintenance of patient-care related electrical equipment (PCREE) that will include testing intervals for physical integrity, resistance, leakage current and touch current tests for fixed and portable patient ?care related electrical equipment. Service manuals, instructions, and procedures provided by the manufacturer will be considered in the development of the policy and procedure for electrical equipment maintenance. All testing and repairs will be recorded for PCREE in the preventative maintenance log book. The current environmental services ?Room a day? process of inspecting rooms will be expanded to include the testing of PCREE. Other PCREE will be scheduled, such as therapy equipment, patient lifts, etc. according to manufacturer instructions.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
Patient-care related electrical equipment (PCREE) testing records will be presented to the QA committee on a quarterly basis with discussion of findings of inspections.
5. Responsible Party: Director of Environmental Services

K307 NFPA 101:FIRE ALARM SYSTEM - INSTALLATION

REGULATION: Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on observation, staff interview, and record review during the recertification survey, it was determined that the facility was not in compliance with the National Fire Alarm Code. NFPA 72 National Fire Alarm Code 2010 edition section 17.14.4 requires that the operable part of each manual fire alarm box shall be not less than 42 inches (1.07 meters) and not more than 48 inches (1.22 meters) above floor level. Specifically, the manual fire alarm boxes on 2 of 2 resident units were greater than 48 inches above the floor level. This is evidenced as follows. An inspection of all fire alarm boxes was conducted on 01/27/2017 at 3:20 pm. Manual fire alarm boxes were measured and all were found to be greater than 4-feet above the floor. The fire alarm system certification records were reviewed on 01/31/2017. This record reveals that a new fire alarm system was installed in 2012. The Environmental Services Director stated in an interview conducted on 01/31/2017 at 3:50 pm, that the fire panel, smoke detectors, wiring, and manual pull stations were replaced when the new system was installed; and the pull stations were installed in the same locations and electrical boxes as the old system 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.4.1, 9.6; 2010 NFPA 72 17.14.4; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.4, 9.6; 1999 NFPA 72 2-8.1

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were identified.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if manual fire alarm box pull stations are not in compliance with the National Fire Alarm code NFPA 72 National Fire Alarm Code 2010 edition for proper height. Specifically if the operable part of manual fire alarm box pull stations are less than 42 inches or more than 48 inches above floor level. All manual fire alarm boxes will be lowered so that operable part is no more than 48 inches and not less than 42 inches from the floor.
3. The following systems changes will be implemented to assure continuing compliance with regulations:
If there is a need to replace or add manual fire alarm box pull stations in the future they will be installed at the proper height according to the NFPA National Fire Alarm Code in force at the time.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
Audit of all manual fire alarm box pull stations will be completed with measurements to ensure compliance with proper height requirements of not less than 42 inches and not more than 48 inches once pull stations are moved. Results will be presented to QA committee.
Any modifications or additions to fire alarm system in the future will be inspected to ensure NFPA requirements are met and results of inspections will be presented to Administration and QA committee.
5. Responsible Party: Director of Environmental Services

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.6.5.1.2 permits particular limitations on obstructions to the sprinkler system discharge pattern. Specifically, the automatic sprinkler system was encumbered with unacceptable obstructions and did not cover all areas. This is evidenced as follows: An assessment of the sprinkler system was conducted on 01/31/2017 at 1:40 pm. Light fixtures obstructed the automatic sprinkler spray area in the resident room restrooms, Therapy closet, Ladies Restroom, and Medication Storeroom. Ventilation ducts obstructed the automatic sprinkler system spray area in the kitchen janitor closet, soiled area of the main laundry, and the Activities Storeroom. The Environmental Services Director stated in an interview on 01/31/2017 at 3:40 pm, that most of the obstructions found were from changes and oversight from past maintenance. 42 CFR 483.70 (a) (1); 73, FR ; 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1)

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were identified.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if the automatic sprinkler system is not installed in accordance with NFPA 13 standard for the installation of sprinkler systems 2010 Edition. Specifically all residents have the potential to be affected if light fixtures and ventilation ducts obstruct the automatic sprinkler system spray area.
Corrections will include:
a. Moving or replacing light fixtures that block sprinkler spray area in resident room restrooms, therapy closet, ladies public restroom and medication storeroom.
b. For ventilation duct obstructions; to replace sprinkler heads with alternate type of sprinkler, or move sprinkler or duct work to allow proper spray pattern, in kitchen janitor closet, soiled area of main laundry, and activity storeroom.
3. The following systems changes will be implemented to assure continuing compliance with regulations:
All sprinklers will be inspected in the building to ensure there are no obstructions to spray pattern, if any other obstructions are found corrections will be made.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
If there are any modifications or additions to sprinkler system or any other building modifications or upgrades, the sprinklers will be inspected to ensure NFPA requirements are met and results of inspections will be presented to Administration and QA committee. Audit of the sprinkler system will be completed to ensure 100% compliance of no obstructions of sprinkler spray pattern.
5. Responsible Party: Director of Environmental Services

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: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on observation, staff interview, and facility floor plan review during the recertification survey, it was determined that the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.5.2 requires that smoke barriers shall be continuous from an outside wall to an outside wall, and from a floor to a floor; and penetrations and miscellaneous openings in smoke barrier walls be sealed with materials capable of maintaining the smoke rating of the smoke barrier wall. Specifically, 1 of 1 smoke barriers observed was not continuous from floor to the underside of the roof and penetrations were not sealed with the appropriate materials. This is evidenced as follows: The South Unit east smoke barrier wall (wall) was inspected on 02/01/2017 at 8:45 am. In resident rooms 106, 111, and 119 and in the corridor non-fire rated materials, such as plastic bubbles, builders joint compound, and non-fire rated foam was used to seal penetrations. In resident room 108, a 6-foot by ½-inch space where the wall did not meet the underside of the roof and two 1-inch unsealed holes were found. In resident room 111, a 6-foot by ½-inch space where the wall did not meet the underside of the roof and 3 unsealed penetrations were found. In the linen room, one 10-inch by 4-inch hole and one 1-inch hole were found. In the corridor, two 1-inch holes were found. The facility floor plans were reviewed on 02/01/2017. This review revealed that the wall identified as the South Unit east smoke barrier wall was to be constructed to meet the underside of the roof. The Environmental Services Director stated in an interview conducted on 02/01/2017 at 9:15 am, that he relied on a contracted service to have sealed all smoke barrier penetrations. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.2.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were identified. All residents have the potential to be affected
If smoke barriers are not continuous from floor to the underside of the roof and penetrations are not sealed with the appropriate materials.
Rooms, 106, 108, 111, 119 will have the proper materials used to reseal penetrations, and in rooms 108 and 111 spaces identified that do not meet the underside of the roof will be corrected.
Linen room and corridors will have all holes properly filled with fire rated materials appropriate for this application.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if smoke barriers are not continuous from floor to the underside of the roof and penetrations are not sealed with the appropriate materials and if smoke barriers are not continuous through all concealed spaces. The Director of Environmental Services or designee will inspect all smoke barrier walls to identify any other spaces that do not meet the underside of the roof and inspect for any other penetrations that have not been filled or have been improperly filled with non-fire rated materials. Any areas identified will be corrected.
3. The following systems changes will be implemented to assure continuing compliance with regulations:
Above the ceiling inspections will be completed after any work conducted by contractors that may compromise smoke barrier walls. Visual inspections of smoke barrier walls will be completed for each smoke barrier section at least one time per year with written report given to the Administrator of the areas inspected and result. These actions will be added to the preventative maintenance policy.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
Report will be given to the QA committee of completion of repairs identified during survey when repairs completed. Report will also include any other areas identified and corrected as a result of inspection of other smoke barrier walls.
Written reports will be given to the QA committee of inspections after any work conducted by contractors that could possibly compromise smoke barrier walls.
5. Responsible Party: Director of Environmental Services

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 1, 2017
Corrected date: March 30, 2017

Citation Details

Based on observation and staff interview during the recertification survey it was determined that the facility did not maintain electrical wiring and equipment in accordance with the adopted regulations. NFPA 70 National Electrical Code 2011 edition Article 408.4 requires that every panelboard circuit shall be legibly identified as to its clear, evident, and specific purpose or use; and the identification shall be included in a circuit directory that is located on the face or inside of the panel door. Specifically, 20 of 20 panelboards did not have identified circuits and/or complete directories. This is evidenced as follows: An assessment of the electrical panelboard circuit identifications was conducted on 01/31/2017 at 1:40 pm. Panelboards P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, PE1, PE2, PE3, PK1A, PK1B, and PK2 had incomplete or illegible directories or did not identify the circuits. The Environmental Services Director stated in an interview conducted on 01/31/2017 at 3:35 pm, that the circuit identification and circuit directory irregularities found on the panelboards likely due to years of changes and inattention from past maintenance. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.1.2; 2011 NFPA 70 Article 408.4; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 70 Article 384-13

Plan of Correction: ApprovedFebruary 21, 2017

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were identified.

2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if electrical panelboard circuits are not legibly identified as to its clear, evident and specific purpose or use and the identification is not included in a circuit directory that is located on the face or inside of the panel door.
Each of the 20 panelboards in the facility will be legibly identified as to its clear, evident and specific purpose or use and the identification will be included in a circuit directory that is located on the inside of the panel door.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
Anytime an electrical circuit is changed or updated Environmental Services will ensure it is legibly identified as to its clear, evident and specific purpose of use on a circuit directory located on the inside of the panel door. Preventive maintenance policy will be updated to include inspection of electrical panel boards yearly.
4. The Facility?s compliance will be monitored utilizing the following quality assurance system.
Each quarter five electrical panel boards will be inspected so that each of the 20 panelboards is inspected once a year. Inspection will be documented with results in the preventative maintenance book to ensure panel boards are properly labeled as above. Results will be reported to QA committee quarterly.

5. Responsible Party: Director of Environmental Services