Meadowbrook Healthcare
February 28, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.24(c)(1):ACTIVITIES MEET INTEREST/NEEDS EACH RESIDENT

REGULATION: §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it provided, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (Resident #'s 132 and 228) of 4 residents reviewed for activities. Specifically, the facility did not ensure that Resident #'s 132 & 228 were provided with activities on an ongoing basis according to the residents' Comprehensive Care Plans and that activities provided met the residents' preferences. This is evidenced by: The Monthly Event Calendar for (MONTH) 2019 documented for each of the four: Sundays: Communion at 8:30 AM on 3 Sundays, Activity visits on one Sunday at 8:30 AM, and one other activity between 2:00 PM - 4:00 PM on each of the four Sundays. There were no evening activities. Mondays: A daily review at 8:30 AM, and one other activity starting between 2:00 pm - 2:30 PM on each of the four Mondays. There were no evening activities. Tuesdays: Protestant Church Service at 10:00 AM and one activity starting between 2:00 pm - 2:30 PM on each of the four Tuesdays. There were no evening activities. Wednesdays: Rosary at 10:45 AM, one other activity starting between 2:00 pm - 2:30 PM, and bingo at 6:30 PM, on each of the four Wednesdays. Thursdays: Daily Review at 8:30 AM on 3 days, Mass at 2:15 PM on three days, and a Valentine Dessert Cart on 2/14 at 6:00 PM there were no activities prior to mass on this day. Fridays: One morning activity starting from 8:30 AM - 10:30 AM, on 2/22 there was a french fry Friday at 12:00 PM, and one afternoon activity on each Friday starting between 2:00 PM - 2:30 PM. There were no evening activities. Saturdays: One activity during the day and no evening activities. Resident #132: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. Additionally, it documented that being around animals, keeping up on the news, doing things with groups of people, and doing her favorite activities was very important to her. During observations on: 2/24/19 at 6:53 PM, the resident along with 16 other residents were sitting in the dining room with no television, music, or activities. The dinner meal was over and cleared. there was no staff present and the resident did not have a tap bell. 2/28/19 at 10:32 AM, the resident was sitting in a wheel chair in a circle with approximately 8-9 residents. There was no activity, or music. The nurse was in the dining room with the medication cart administering medications. 2/28/19 11:09 AM, the resident along with 9 other residents were in the lounge area pushed up to the tables; no staff were present. There were items in front of some of the residents; two of the residents were unable to engage with the items in front of them. The record did not include a Comprehensive Care Plan for Activities. An Activity assessment dated [DATE], documented that the resident preferred music, trips and shopping, talking or conversing, and watching television. An Activity Attendance log for the 58 days between 1/1/19 - 2/27/19, documented that the resident attended one discussion group, 1 nail art, one bingo, four socials, and one occasion with an R in the box indicating that the resident was offered an activity and refused. Resident #228: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. It documented that it was very important to the resident to listen to music, be around animals, keep up with the news and to participate in religious services. The resident is a high risk for falls and on the falling star program. During an observation on 2/24/19 at 6:53 PM, the resident along with 16 other residents were sitting in the dining room with no television, music, or activities. The dinner meal was over and cleared. During an observation on 2/28/19 at 10:32 AM - 11:29 AM, the resident was sitting in a Geri chair in the lounge facing the wall. There were no staff present in the area and no staff at the nursing station where the lounge camera feed is located. At 10:50 AM, the resident was observed getting restless saying, come on. On 2/28/19 at 11:23 AM, the resident stated, I can't sit here by myself, I am sorry I came, I have no place to go. At 11:10 am, a staff member gave the resident coffee and a magazine. The resident did not open the magazine. On 2/28/19 at 11:25 AM, the resident stated, I am terrified here, what am I going to do, and started crying saying, I feel terrible, why did I come here. An Activity assessment dated [DATE], documented that the resident preferred music, reading and writing, religious activities, and watching television. An Activity Attendance log for the 27 days between 2/1/19 - 2/27/19, documented that the resident attended one social, one gardening activity and received communion twice. The log did not include R's documented for any activities which would indicate activities were offered and refused. Interviews: During an interview on 2/26/19 at 4:46 PM, CNA #13 stated that before dinner, if a resident was not on the falling star program they were placed in the dining room, if they were on a falling star program, they were placed near the bird cage, so you could keep an eye on them as there was no one in the dining room. It was also normal to keep people in DR until bed time. It makes it easier on nurse if all the residents are up in one place. Once a week there is bingo in the evening. On weeks when it is scheduled on their unit they have to move a lot of their people out of the dining room and put them in the hall; it is very crowded when this happens. During an interview on 2/27/19 at 9:28 AM, CNA #16 stated that residents on the falling star program were taken from the lounge and placed next to the bird cage or sit in lounge with a tap bell. A majority of time they do not have activities in evening. The CNA had to give an activity, like a magazine or coloring book, but rarely had time to actually interact with the residents. During an interview on 2/27/19 at 11:12 AM, the Activities Director stated the daily reminder was an activity that entailed giving the residents a paper that had the menu and activity for that day; this was done on Monday, Wednesday, and Fridays. They ask the residents if they want to attend an activity, and if they refuse an R is documented on the participation sheet indicating that the activity was offered and refused. The items placed in front of residents that could not engage with them would not be considered an activity. During an interview on 2/28/19 on 1:40 PM, the Director of Social Services stated the whole facility is trained to do activities and everyone was supposed to help. There were 3 full-time and 2 part-time activity staff trying to cover 2 shifts per day, 7 days a week, and they were stretching themselves very thing. not really an engagement or enrichment for residents to place things in front of them if they cannot get anything from it. Would expect that residents are going to activities 2-3 times a week. 10NYCRR 415.5(f)(1)

Plan of Correction: ApprovedMarch 19, 2019

F 679 ? Activities Meet Interest/Needs of Each Resident
1.The following corrective action was taken for the residents identified in the sample:
a. The comprehensive care plan was reviewed and revised for each of the residents identified in the sample and they have been offered the activities of their choice/interest.
Completion Date: 03/19/2019
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Activity staff will interview all residents to establish their current activity interests and revise their care plans accordingly.
b. Activity programs will be revised to meet the resident interests and leisure time activities will be provided to meet the individual?s needs.
Completion Date: 4/28/2019
3. The following measures will be put into action to prevent future residents from being affected by the same deficient practice:
a. The Activity Director, or her designee, will complete an activity of interest assessment upon admission and quarterly thereafter to ensure a comprehensive care plan is established to meet the resident?s interests and needs.
b. The Activity Director will provide ongoing education to staff to ensure all staff have competent skills to provide enriching activities to residents.
c. Activity calendars will be created and posted throughout the facility daily to inform staff and residents of activity events.
d. A new Music Therapy program will be implemented.
Completion Date: 4/28/2019
4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Program:
a. The Activity Director, or her designee, will audit 5% of the resident population weekly to ensure residents are receiving enriching activities of interest at variable times throughout the day.
b. The Activity Director will review the audit findings weekly. Audit findings will be evaluated, and additional corrective action will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audit findings will be presented to the Corporate Compliance Committee monthly and to the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measures implemented if necessary.
Completion Date: 04/28/2019

5. The Activity Director will be responsible for the compliance of the activity program and ensure corrective action is taken to prevent recurrence of the deficient practice.
Completion Date: 04/28/2019

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for nine (Resident #'s 15, 110, 132, 165, 177, 189, 190, 220, and 246) of 16 residents reviewed. Specifically, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed for Resident #15's [DIAGNOSES REDACTED].#110 had a CCP to address lower extremity [MEDICAL CONDITION], that Resident # 132's &165's Comprehensive Care Plans (CCP) addressed the use of [MEDICAL CONDITION] medications, Gradual Dose Reductions (GDR) attempt, and monitoring for side effects of [MEDICAL CONDITION] medications, that Resident #132 & 190 had CCPs for activities, and that Resident #220 had a nutrition care plan. Additionally, the facility did not ensure that a CCP was developed for Resident #246's communication issues, Resident #189's respiratory condition, and Resident #177's visual impairment. This was evidenced by: Resident #165: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 1/28/19 assessed the resident as having severely impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. Current Physician (MD) orders documented: [MEDICATION NAME] 0.5mg; 1 tid for agitation/anxiety [MEDICATION NAME] 25 mg; 1 bid for hallucinations [MEDICATION NAME] 100 mg; 1.5 tab qd for major [MEDICAL CONDITION] The CCP did not address the use of [MEDICAL CONDITION] medications, GDRs attempts and monitoring for side effects of the [MEDICAL CONDITION] medications. During an interview on 2/28/19 at 11:38 AM, Registered Nurse #12 stated she has been doing care plans for the past 4-5 weeks and prior to that, the Assistant Director of Nursing (ADON) was responsible for care planning. She just does the evaluations and the ADON makes any changes. During an interview on 2/28/19 at 2:14 PM, the Director of Nursing (DON) stated the CCP should include the use of [MEDICAL CONDITION] medication and observing for adverse reactions. Resident #189: The resident was admitted to the facility for rehabilitation on 1/31/19 post-acute hospital stay. Admitting [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident makes self-understood and can understand others. The facility policy titled Comprehensive Care Planning documented the care plan is a continuous process and is modified and updated on a regular basis to meet the patient/resident's changing needs. The nursing notes documented the following: 2/21/19 at 4:12 PM - the resident was noted to have a wet productive cough with a tinge of yellow sputum during nursing rounds. The resident stated the cough started this morning. The nurse encouraged resident to use incentive spirometer (IS) and reeducated the resident on the proper use of the IS and encouraged resident to drink fluids; 2/21/19 at 4:26 PM - wheezing heard to bilateral lungs; 2/21/19 at 10:41 PM - resident continues with intermittent cough; 2/22/19 at 6:01 AM - lungs clear with diminished breath sounds; 2/22/19 1:52 at PM - congested cough with audible wheezes throughout, oxygen saturation at 86% on room air, oxygen at 2 liters nasal cannula applied. Physician made aware of condition with treatments/medications ordered as describe under physician's orders [REDACTED]. 2/24/19 at 6:30 PM - the resident is short of breath, 02 saturation is at 91% with respirations of 22-24, adventitious breath sounds noted with inspiratory and expiratory wheezes present. O2 2 liters applied and nebulizer treatment started. The physician's notes documented: 2.22.19 at 2:46 pm - probable [MEDICAL CONDITIONS] improved with [MEDICATION NAME]. Plan: will administer nebulized [MEDICATION NAME] times a day for 1 week, use supplemental oxygen if needed and monitor; 2.25.19 at 9:58 AM - cough likely [MEDICAL CONDITIONS] with reactive airways, would continue nebulizers and prn oxygen while still symptomatic. Physician order [REDACTED]. -Oxygen 2 liters minute via nasal cannula shortness of breath/dyspnea as needed -Stat order of [MEDICATION NAME] 2.5mg/0.5ml solution stat for 1 days for shortness of breath/wheezing -Start 2.22.19 to end on 3.1.19 [MEDICATION NAME] 2.5mg/3ml solution ([MEDICATION NAME] 0.083%) one-unit dos nebulizer 4 x day at 8AM, 12PM, 4PM and 8PM for 7 days for [MEDICAL CONDITION]. -Chest X-ray The Treatment Administration Record (TAR) documented: 2/24/19 at 17:10 PM - prn oxygen at 2 liters nasal cannula. 2/22/19 to 2/27/19 - every 4 hours nebulizer treatments given. Review of the medical record not include an individualized care plan for the residents change in respiratory status. During an interview on 02/27/19 at 09:37 AM, Licensed Practical Nurse (LPN) #7, stated the resident started early last week with productive cough, then one afternoon, in a flash you could hear the wheezing. Vital signs were obtained with an oxygen saturation of 86% (below acceptable range) and the resident was placed on oxygen at 2 liters nasal cannula. LPN #7 called the physician and obtained order for oxygen, nebulizer treatments, chest x-ray. Writer asked the LPN to show her any care plans related to the change of status and after reviewing the medical record she said there were none. LPN #7 there should have been a care plan with interventions. A change in status goes on the communication sheet and sent to the nursing office. The Director of Nursing (DON) is helping the unit and completing the care plans. During an interview on 02/27/19 at 10:02 AM, the DON stated she supports the unit with initial comprehensive care plans. The nurses on the floor are responsible to update care plans. The resident should have had an updated care plan for her change in status. The unit is still expected to keep up with the care plans based off the daily communication sheets. The sheet is filled out by the DON during the morning report, sent to unit and the unit updates the care plan then sends it back to the nursing office. Resident #246: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented additional [DIAGNOSES REDACTED]. The MDS documented the resident had moderately impaired cognition, sometimes understands and was sometimes understood. During an observation on 02/24/19 5:37 PM, Resident #246 was following staff around the dining room in her wheelchair repeating Hey, hey. The staff continued to pass trays to other residents and intermittently said hello to her. The five other residents seated at the table with Resident #246 had already been served dinner. Multiple staff observed saying hello to Resident #246, or requesting her to return to her place at the table. Resident #246 continued this behavior until her dinner was served to her at 5:51 PM. During an observation on 02/25/19 01:53 PM, Resident #246 was pointing at staff while they walked by in her the main hallway, stating Hey, staff said hello to her as they walked past. Resident #246 continued this behavior several times until a staff member acknowledged her attempts to communicate and worked with the resident to identify her needs. During an observation on 2/27/19 @ 6:04 PM, Resident #246 was sitting in the dining room eating dinner. Resident #246 observed with a plastic cup in her hand and began following staff in the dining room in her chair, stating hey. Several staff observed walking past the resident. The resident continued this behavior until a staff member identified her attempts to communicate a need and assisted her in obtaining a cup of tea. A comprehensive care plan for speech and communication or language deficit was requested and was not provided. During an interview on 2/28/19 at 9:10 AM, Certified Nursing Assistant (CNA)#1 stated the resident has difficulty with expressing her needs. CNA #1 stated the staff need to ask the resident several questions to which the resident will appropriately respond yes or no to, to identify what needs the resident has. CNA #1 stated there is not a care plan in place for communication needs or deficit for Resident #246. During an interview on 2/28/19 at 9:47 AM, Registered Nurse (RN) #1 stated Resident #246 communicates with staff by pointing to something, but usually states a different word than what she wants. RN#1 stated Resident #246 should have a care plan in place for her communication deficit. During an interview on 2/28/19 at 12:37 PM, the Director of Nursing (DON) stated the resident should have a care plan in place for [MEDICAL CONDITION]. The DON stated she would expect the care plans to be reviewed and updated on a regular basis by all licensed staff on the unit. The DON stated the expectation is that if a staff member identifies a need is not identified on the care plan and should be, they would bring this to the DON or Assistant Director of Nursing. 10NYCRR415.4(b)(1)(i)

Plan of Correction: ApprovedMarch 18, 2019

F 656 ? Develop/Implement Comprehensive Care Plans
1. The following corrective action was taken for the residents identified in the sample:
a. The staff directly responsible for the care plan development of residents identified in the sample were inserviced by the Director of Nursing on the policies and procedures of comprehensive care plan development and implementation. Appropriate care plans were developed for the identified areas.
Completion Date: 3/28/2019
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Nursing Administration will review all residents comprehensive care plans to ensure all resident care areas and needs are addressed in the record. Further education will be provided to staff as necessary to develop and implement appropriate care plans.
Completion Date: 4/28/2019
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Medical Director, Interdisciplinary Team and the Director of Nursing will review the policy and procedure on comprehensive care plan development and implementation. The policies will be revised as necessary.
b. The Director of Nursing will monitor compliance of comprehensive care plan development and implementation by conducting weekly care plan audits. Corrective action will be taken if indicated.
Completion Date: 4/28/2019
4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Nursing, or her designee, will audit 5% of all resident care plans weekly to ensure timely and comprehensive care plan development and implementation is completed.
b. The Director of Nursing will review the care plan audit findings weekly. Audit findings will be evaluated and additional corrective actions will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits will be presented to the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 4/28/2019
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Compliance: 4/28/2019

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during a recertification survey and abbreviated survey (Case #NY 249) the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 (Resident #13) of 5 residents reviewed. Specifically, for Resident #13, the facility did not ensure medications were not left unsecured and unattended at the resident's bedside. This was evidenced by. The Policy and Procedure (P&P) titled Medication Administration dated 6/13/16, documented the facility shall administer medications in a safe and timely manner in accordance with current standards of nursing practice. Never leave medications unattended or unsecured. Resident #130: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was cognitively intact, and was able to make herself understood and was usually able to understand others. An observation on 02/25/19 at 08:37 AM, the resident was observed placing pills from a plastic pill cup into her mouth and drinking a cup of water. Prior to entering the resident's room the medication cart was noted to be parked in front of a resident's room three doors down from Resident #130's room and the nurse was not in sight. During an interview on 2/25/19 at 08:37 AM, the resident stated the nurse gave her the pills to take and then left. She always took all her pills when the nurses left them. During an interview on 02/25/19 at 02:42 PM, Licensed Practical Nurse (LPN) #4 stated that Resident #130 had a physician's orders [REDACTED]. The LPN was asked where that order could be found, and the LPN stated that she guessed she did not have an order. She stated she should not have left the 8:00 AM medications at the bedside for Resident #130 to take by herself, she should have stayed and made sure the resident took all her medications. The Medication Administration Record [REDACTED]. During an interview on 2/27/19 at 10:30 AM, the Director of Nursing (DON) stated that nurses should not leave medications at a resident's bedside. The LPN should have stayed with Resident #130 until all her medications had been taken. That practice was not acceptable. 10NYCRR415.12(h)(1)

Plan of Correction: ApprovedMarch 18, 2019

F 689 ? Free of Accident Hazards/Supervision/Devices

1. The following corrective action was taken for the resident identified in the sample:
a. The nurse directly responsible for the medication administration of medication to the resident received education regarding the facility policy and procedure for safe medication administration and disciplinary action for the deficient practice.
Completion Date: 3/1/2019
2. Because all residents have the potential to be affected by the same deficient practice, Nursing Administration provided inservice education to all nurses regarding the facility policy and procedure regarding safe medication administration, with special attention to ensuring all medications are consumed before leaving the resident unattended.
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Medical Director and Director of Nursing will review the policy and procedure on Medication Administration. The policy will be revised as needed.
b. The Director of Nursing, or her designee, will monitor compliance with safe medication administration by conducting random weekly medication administration audits. Corrective action will be taken if indicated.
Completion Date: 4/28/2019
4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Nursing, or her designee, will audit 5% of the medication passes weekly to ensure safe medication administration is maintained. Corrective action will be taken if indicated.
b. The Director of Nursing will review the medication administration audit findings weekly. Audit findings will be evaluated, and additional corrective actions will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administration. Summaries of the audit findings will be presented to the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 4/28/2019
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Completion Date: 4/28/2019

FF11 483.60(f)(1)-(3):FREQUENCY OF MEALS/SNACKS AT BEDTIME

REGULATION: §483.60(f) Frequency of Meals §483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. §483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. §483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure that there were no more than 14 hours between a substantial evening meal and breakfast the following day, except, when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Specifically, the facility did not ensure that a resident group agreed to the 14 1/2 hour or more time span between the facility's scheduled times for the evening and breakfast meals. This was evidenced by: Review of listed meal times on 2/26/2019 at 10:17 AM showed that dinner was served between 4:40 PM and 5:00 PM. Breakfast was served between 7:30 AM and 7:45 AM, a lapse of 14 1/2 to 14 5/6 hours between the two meals. During an interview on 2/27/2019 at 11:13 AM, the Activities Director was unable to locate Resident Council notes in the last 7 months stating the group agreed to the greater-than-14-hour meal span. At 2:45 PM, the Activities Director stated she looked through 12 months of Resident Council notes which did not include discussion of or agreement to the facility's extended span of time between the evening and breakfast meal. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedMarch 18, 2019

F 809 ? Frequency of Meals/Snacks at Bedtime

1. The following corrective action was taken for the deficient practice cited:
a. The Director of Food Service conducted a meal service audit to determine whether or not there was more than 14 hours between a substantial evening meal and breakfast the following day.
Completion Date: 3/28/2019
2. To identify other residents who have the potential to be affected by the same deficient practice:
a. In compliance with 483.60(f)(2), the Director of Food Service and Nursing Administration will assess the dining times on all residential units to ensure residents are served no more than 14 hours between the evening and breakfast meal the next day.
b. To ensure compliance when times may vary a bit, an evening nourishing snack will be offered and served at bedtime.
Completion Date: 4/28/2019
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator and Director of Nursing will review the policy and procedures for meal service and providing nourishment and snacks between meals. The policies will be revised as needed.
b. The Director of Food Service, Director of Nursing and Activity Director will provide inservice training to all nursing staff regarding the facility policies and procedures on meal service, meal times and the offering of snacks between meals.
c. The Activity Director and Director of Food Service will review the policy and procedures with the Resident Council and record the council?s preferences. The Director of Nursing, or her designee, will conduct random weekly snack offering audits. Immediate corrective action will be taken if indicated.
Completion Date: 4/28/2019
4. To ensure the deficient practice will not recur, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Plan:
a. The Director of Nursing, or her designee, will conduct resident audits to ensure they are being offered/served nourishments and snacks between a substantial evening meal and breakfast the following day.
b. On a monthly basis, the Director of Food Service and Activity Director will monitor the Resident Council?s minutes to ensure the Council?s position on meal service times are satisfied.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audit findings will be presented to the Dining Committee monthly and the Quarterly Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measures implemented if necessary.
Completion Date: 4/28/2019
5. The Director of Food Service will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice. The Corporate Compliance Committee will review and monitor the SOD & Plan of Corrections on a monthly basis.
Completion Date: 4/28/2019

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

Based staff interview and the Legionella Sampling and Water Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessments be updated annually. Section 4-2.4 requires that by (MONTH) 1, (YEAR) facilities shall adopt and implement a Legionella culture sampling and management plan for their potable water systems with the initial Legionella sampling at periods not exceeding 90 days prior to annual sampling. Specifically, as required by New York State regulation, the facility did not develop a WMP with a flow chart and written description, did not test for Legionella, and did not maintain a current Legionella Environmental Assessment Form (EAF). This is evidenced by: The Legionella WMP was reviewed on 02/25/2019, the WMP did not include a flow chart with a written description, testing records, and a current EAF. The Administrator stated in an interview on 02/25/2019 at 10:00 AM, that he was not aware an EAF was not completed, he will develop a flow chart of the water system with a written description for the WMP, and will have the potable water system tested as required. 415.19(a)

Plan of Correction: ApprovedMarch 19, 2019

I210

The following Infection Control Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified the deficient practice of not including within the facility?s Infection Control Legionella Sampling and Water Management Plan (WMP) a flow chart with a written description, a written description of the potable water system, testing records, and the required Environmental Assessment Form for Legionella.
Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering completed an assessment and flow chart of the facility?s Water and Management Plan. The facility?s Infection Preventionist completed the required Legionella Environmental Assessment Form. The Director of Engineering conducted and submitted the required 90-day Legionella water samplings as required by the regulation 415.19.
The Director of Engineering will complete a written description of the potable water system.
Completion Date: 4/1/19

III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator, Infection Control Preventionist and Director of Engineering will ensure that it is the facility?s policy to have a compliant and effective Infection Control Legionella Water Management Plan all in accordance with NYS rules and regulations. The facility?s
monthly Infection Control Committee will review the regulations and monitor the facility?s compliance ensuring sampling, flow chart, a written description of the facility's potable water system, assessments and record keeping are maintained.

Completion Date: 4/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
The facility?s Administrator, Infection Control Preventionist and Director of Engineering will be held responsible for continual compliance. A quality assurance audit will be conducted
by the facility?s Infection Control Preventionist and findings reported to the facility?s QAPI program. The Corporate Compliance Committee will review the plan of corrections to ensuring continual compliance. Additional corrective action will be implemented as necessary.
Completion Date: 4/28/19

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(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: §483.80(a)(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; §483.80(a)(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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #15) of one resident's reviewed for isolation precautions. Specifically, for Resident #15, on the Aspen Unit, the facility did not ensure droplet precautions were implemented and maintained to prevent the spread of the Respiratory [MEDICAL CONDITION] (RSV) and on the Oakwood Unit the facility did not ensure that infection control standards were maintained during a dressing change. This is evidenced by: Resident #15: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, and was understood and usually understood verbal content. The Policy and Procedure (P&P) titled, Transmission- Based Precautions, undated, documented when a resident is placed on droplet precautions, staff were required to wear gloves and gowns for all interactions that may involve contact with the resident or potentially contaminated areas in the environment. Additionally, staff were to don PPE upon entering a resident's room on droplet precautions. During an observation on 2/25/19 at 9:08 AM, Resident #15 was observed exiting his room while speaking to Licensed Practical Nurse (LPN) #2. Resident #15 remained in the hallway outside of his room without a mask in place talking to LPN #2. Two Neighborhood Support Assistants (NSAs)(employees of the facility that provide non-hands on care to residents) stopped to talk to the resident in the hallway outside of the resident's room. Resident #15 began coughing while outside of his room while touching the wheelchair of another resident that was in the hallway. LPN #2 or NSA did not provide education to the resident about infection control practices. During an observation on 2/25/19 at 9:30 AM, Registered Nurse (RN) #1 entered the resident's room and removed the resident's breakfast tray. RN #1 did not don PPE prior to entering the room. RN #1 left the resident's room, walked down the hall to the elevator, and placed the resident's tray in a cart. The cart was transported off the unit. A Medical Doctor Progress note dated 2/18/19, documented the resident had a positive nasal swab for RSV (common respiratory virus that usually causes mild, cold-like symptoms). The Comprehensive Care Plan (CCP) titled MRSA: Droplet precautions, created on 2/25/19, documented the staff would maintain droplet precautions when infected and staff would educate and offer the resident hand hygiene. The CCP titled RSV, created on 2/25/19, documented the resident was educated on 2/25/19 regarding the spread of infection and wearing a mask when he sits in his doorway. The CCP documented that on 2/26/19, the resident tested positive for RSV on 2/18/19. During an interview on 2/25/19 at 9:14 AM, LPN #1 stated that Resident #15 was on droplet precautions and all staff were required to don gown, gloves and mask after entering the resident's room. LPN #1 stated he should have educated Resident #15 and requested the resident wear a mask when he sat at the door exiting the room or entered the hallway. LPN #1 stated the facility's P&P was to place all PPE inside of the resident's room, and don PPE after entering the resident's room. During an interview on 2/25/19 at 12:15 PM, Registered Nurse (RN) #3/ Infection Control Nurse/ Assistant Director of Nursing (ADON), stated the facility's policy was that all staff don PPE upon entering a resident's room on droplet precautions. All PPE carts were to be placed inside of the resident's room when isolation precautions were implemented. RN #3 stated that infection control could not be maintained for droplet precautions when the PPE was placed in the resident's room and within 3 feet of the resident. RN #3 stated the expectation is that the staff educate the resident to ensure a mask was in place prior to the resident exiting his room. During an interview on 2/28/19 at 12:26 PM, the Director of Nursing stated the expectation was that all staff would follow infection control practices to help prevent the spread of communicable diseases. The DON stated the expectation was the CCP for RSV and isolation precautions would be implemented within twenty-four hours after diagnosis. Finding #1: During a dressing change observation on 2/27/19 at 2:06 PM, on a resident with a stage 4 pressure area to the right ischium, Registered Nurse (RN) #12 was cleaning the resident who had a bowel movement. While cleaning the resident, RN #1 wiped around the pressure ulcer with the soiled washcloth. During an interview on 2/27/19 at 2:44 PM, RN #1 stated she was trying to wash him with different parts of the washcloth and it was a break in infection control. During an interview on 02/28/19 11:30 AM, the Infection Control Nurse stated that the the soiled wash cloth should not have been used around the wound and that immediate reeducation would be done. 10NYCRR415.19(b)(1)

Plan of Correction: ApprovedMarch 18, 2019

F 880 ? Infection Control and Prevention
1. The following corrective action was taken for the resident identified in the sample:
a. The nursing staff directly responsible for the care of resident #15 was inserviced by the facility Infection Preventionist on the policies and procedures of transmission- based precautions.
b. The nurse directly responsible for the wound care of resident #118 was inserviced by the Assistant Director of Nursing on the policy and procedure of sanitary dressing change techniques
Completion Date: 3/01/2019
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Nursing Administration will identify all residents requiring transmission-based precautions to ensure appropriate infection control measures are provided. Further education will be provided to the nursing staff as necessary.
b. Nursing Administration will identity all residents requiring routine clean and/or sterile dressing changes to ensure sanitary measures are taken to prevent the spread of infection. Further education will be provided to the nursing staff as necessary.
Completion Date: 4/28/2019
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Medical Director, Director of Nursing, and Infection Preventionist will review the policy and procedure on general infection control practices and transmission-based precautions. The policies will be revised as needed.
b. The Administrator, Medical Director, Director of Nursing, and Infection Preventionist will review the policy and procedure on general infection control practices for clean and sterile dressing changes. The policies will be revised as needed.
c. The Infection Preventionist will monitor compliance with general infection control practices, specifically relating to transmission-based precautions by conducting weekly isolation technique audits. Corrective action will be taken if indicated.
d. The Infection Preventionist will monitor compliance with general infection control practices, specifically relating to sanitary dressing changes by conducting weekly dressing change audits. Corrective action will be taken if indicated.
Completion Date: 4/28/2019

4. To ensure the deficient practice will not recur again, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Infection Preventionist, or her designee, will audit isolation technique for 20% of residents requiring transmission-based precautions, weekly to ensure appropriate infection control techniques are followed to prevent the spread of infection.
b. The Infection Preventionist, or her designee, will audit 10% of all nurses performing dressing changes, weekly to ensure dressing changes are performed in a sanitary manner.
c. The Director of Nursing will review the isolation technique and dressing change audit findings weekly. Audit findings will be evaluated and additional corrective actions will be implemented if indicated.
d. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audits will be presented to the Infection Control Committee monthly and the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed and additional corrective measures implemented if necessary.
Completion Date: 4/28/2019
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice. The monthly Corporate Compliance Committee meeting will monitor the SOD?s P(NAME) to ensure compliance.
Completion Date: 4/28/2019

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

Based on observation and staff interview during the recertification survey, carbon monoxide detection was not provided in accordance with adopted regulation. The International Fire Code, (YEAR) Edition Section 915 Carbon Monoxide Detection, requires carbon monoxide detection in all areas with gas operated equipment. Specifically, carbon monoxide detection was not installed in areas with gas fuel fired equipment. This is evidenced as follows. Observations on 02/27/2019 12:00 PM, revealed that carbon monoxide (CO) detection was not provided near fuel burning appliances in the main kitchen (stoves). The Director of Engineering stated in an interview on 02/29/2019 at 1:50 PM, that a CO detector was added to the kitchen today, but no CO detectors are monitored by the fire panel, and staff has not received training on how to respond to the CO alarms. 483.70 (b); (YEAR) International Fire Code, Section 915

Plan of Correction: ApprovedMarch 18, 2019

F 836
I. The following actions were accomplished for the areas identified in the SOD:
The Director of Engineering and the Administrator were made aware by the Sanitarian that there was a new regulation International Fire Code (YEAR) Edition Section 915 Carbon Monoxide Detection that requires carbon monoxide detectors to be installed near fuel burning appliances, that they need to be hard wired to the annunciator panel and staff trained on
monitoring.

Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The facility?s Director of Engineering will conduct an assessment of the facility?s fuel burning properties to determine the location of areas within the building that need carbon monoxide detectors.

Completion Date: 3/15/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
1. The Administrator and Director of Engineering will ensure Carbon Monoxide Detectors are installed within the facility where there are fuel burning appliances. The facility?s Fire Detection & Annunciator Panel vendor will be contracted to complete the installation of the CO Detectors and connection to the Annunciator Panels all in accordance with the International Fire Code (YEAR) Edition Section 915 Carbon Monoxide Detection.

2. The Safety Committees will audit proper usage, and vendor inspection reports that monitor the equipment cited. Audit findings will be followed up with on-going education through the facility?s QAPI program.


Completion Date: 4/28/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
1. The Administrator and Director of Engineering be held responsible for continual compliance of the proper maintenance and usage of the Carbon Monoxide Detectors. The Safety Committee will audit the detector equipment on a monthly basis to ensure compliance.

2. Education and non-compliance will be followed up on in the monthly meetings. Audit results and findings will be reported to the facility?s quarterly QAPI committee.

3. The Corporate Compliance Committee will review audit findings and recommend any further instructions or education that needs to be conducted in order to ensure compliance with International Fire Code (YEAR) Edition Section 915 Carbon Monoxide Detection.

Completion Date: 4/28/19

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure written notice was provided to the resident and/or the resident's representative of the bed hold and return policy for 4 (Resident #'s 190, 191,197 and #220) of 5 residents reviewed for hospitalization . Specifically, the facility did not ensure there was documented evidence the resident and the resident's representative received written notice of the bed hold policy when the resident was admitted to the hospital. This evidenced by: Review of the policy titled Bed Hold Policy dated 6/2018, documented that each resident be given a notice of this policy upon each leave of absence from the facility. It did not include documentation that it must be given in writing. Review of the facility letter used for Bed hold and for hospital transfer/discharge by the social worker is labeled Bed Hold. The letter includes bed hold information along with an attachment of the Bed Reservation Policy Notice that is provided upon emergency transfer. Resident #190: The resident was admitted to facility on 12/24/18 at 12:51 PM for rehabilitation post hospitalization . [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident makes self-understood, and can understand others. Nursing progress notes dated 12/25/18 at 2:41 AM, documented the residents decline in health status, notification to the physician with an order to transfer the resident to the emergency room (ER) and notification to the first contact about resident's condition. Ambulance arrived, resident left at 1:50 AM. Nursing progress notes dated 12/25/18 at 12:38 PM, documented the resident was admitted to the hospital. Review of the medical record did not include documentation that the notice of Bed Hold Policy was provided. During an interview on 02/27/19 at 03:19 PM, the Director of Social Work (SW) #2 stated she fills out the Bed Hold letter and mails it. The SW stated there is no proof that written documentation was provided to the resident and/or the residents representative. Resident #197 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition and was able to make himself understand and understand others. A nursing progress note dated 1/101/9 documented the resident was transferred to the emergency room . A Social Work nursing progress note dated 1/11/19 documented the resident was sent to the emergency room and admitted on [DATE]. Bed will be reserved. A review of the medical record did not include a copy of a Notice of Bed Hold. During an interview on 02/27/19 at 03:19 PM, the Director of SW #2 stated she fills out the Bed Hold letter and mails it. The SW stated there is no proof that written documentation was provide to the resident and/or the residents representative. Resident #191: The resident was admitted to facility on 3/20/17 and re-entered on 12/28/18 after a hospitalization for a fall, with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was understood and could sometimes understand others. A Brief Interview of Mental Status (BIMS) assessed the resident to have a score of 3/15 which indicated a severe cognitive impairment for daily decision making. Nursing progress notes dated 12/25/18 at 12:00 AM, documented the residents was sent out to the hospital to be evaluated after falling at the facility. The physician had been contacted and agreed the resident needed to be sent out by ambulance for further evaluation. Nursing progress notes dated 12/25/18 at 7:05 AM, documented the resident was admitted to the hospital. Review of the medical record did not include documentation that a bed hold notification had been provided to the resident or the residents representative when the resident was transferred to the hospital on [DATE]. During an interview on 02/28/19 at 11:35 AM, SW #2 stated she did not have proof that a written notice of the bed hold was given to the resident/or representative. 10NYCRR415.3(h)(4)(i)(a)

Plan of Correction: ApprovedMarch 18, 2019

F 625 ? Notice of Bed Hold Policy Before/Upon Transfer:

1. All residents identified in the sample have returned to the facility. To identify other residents who may have the potential to be affected by the same deficient practice:
a. The Director of Social Services will identify residents that have been transferred within the past 30 days and provide them with written information regarding the facility bed hold policy.
Completion Date: 3/28/2019
2. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Director of Nursing and Director of Social Services will review the policy and procedure for Notification of Bed Hold Policy. The policies will be revised as needed.
b. The Director of Nursing will provide inservice training to all nursing staff on the policy and procedure regarding notification of bed hold policy and procedure.
c. The Director of Nursing will monitor compliance with the policy and procedure for notification of bed hold. The Director of Nursing, or her designee, will conduct weekly audits to ensure residents have been provided with notification of the facility bed hold policy. Immediate corrective action will be taken if indicated.
Completion Date: 4/28/2019
3. To ensure the deficient practice will not recur, the following measures will be incorporated into the facility?s Quality Assurance and Performance Improvement Program:
a. The Director of Social Service and Director of Nursing, or her designee, will audit 25% of transfers weekly to ensure the resident and representative was provided with notification of the bed hold policy.
b. The Director of Social Service and Director of Nursing will review the audit findings weekly. Audit findings will be presented to the Corporate Compliance Committee monthly and the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measure implemented if necessary.
Completion Date: 4/28/2019
4. The Director of Social Service and Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.
Completion Date: 4/28/2019

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure 4 (Resident #'s 190, 191,197 and #220) of 5 residents reviewed for hospitalization received written notice of transfer/discharge and the reasons for the transfer in a language and manner they understand. Specifically, the facility did not ensure that there was documented evidence that written notification of transfer/discharge was provided to the resident and/or the resident's representative(s). This was evidenced by: Review of the policy titled Emergency Transfer dated 7/2018, did not include documentation regarding notice of transfer/discharge to the resident and/or resident's representative. Review of the policy titled Discharge Planning dated 12/2015, did not include documentation for notification of hospital transfer/discharge. Review of the facility letter used for transfer/discharge to the hospital by the social worker is labeled Bed Hold. The letter includes bed hold information along with a sentence that states - you are receiving this letter because your loved one has recently been admitted to the hospital. The letters title did not include notice of hospital transfer/discharge. It did not include the content required regarding transfer discharge notice. Resident #190: The resident was admitted to facility on 12/24/18 at 12:51 PM for rehabilitation post hospitalization with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident can make self-understood, and can understand others. Nursing progress notes dated 12/25/18 at 2:41 AM, documented the residents decline in health status, notification to the physician with an order to transfer the resident to the emergency room (ER) and notification to the first contact about resident's condition. Ambulance arrived, resident left at 1:50 AM. Nursing progress notes dated 12/25/18 at 12:38 PM, documented the resident was admitted to the hospital. Review of the medical record did not include documentation that the notice of hospital transfer/discharge was provided. Resident #197: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition and was able to make himself understand and understand others. A nursing progress note dated 1/101/9 documented the resident was transferred to the emergency room . A Social Work nursing progress note dated 1/11/19 documented the resident was sent to the emergency room and admitted on [DATE]. Bed will be reserved. A review of the medical record did not include a copy of a transfer discharge notice. Resident #191: The resident was admitted to facility on 3/20/17 and reentered on 12/28/18 after a hospitalization for a fall, with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was understood and could sometimes understand others. A Brief Interview of Mental Status (BIMS) assessed the resident to have a score of 3/15 which indicated a severe cognitive impairment for daily decision making. Nursing progress notes dated 12/25/18 at 12:00 AM, documented the resident was sent out to the hospital to be evaluated after falling at the facility. The physician had been contacted and agreed the resident needed to be sent out by ambulance for further evaluation. Nursing progress notes dated 12/25/18 at 7:05 AM, documented the resident was admitted to the hospital. Review of the medical record did not include documentation that a notice of a hospital transfer/discharge was provided to the resident or the residents representative when the resident was transferred to the hospital on [DATE]. During an interview on 02/28/19 at 11:35 AM, the SW #2 stated she did not have proof of a written notice of transfer discharge to the hospital for this resident. During an interview on 02/27/19 at 03:19 PM, the Director of Social Work (SW) #2 stated she does not have a transfer/discharge notice for hospitalization s. SW stated she fills out the Bed Hold letter and mails it. The SW stated there is no proof that written documentation was provided to the resident and/or the residents representative NYCRR 415.3(H)(1)(iii)(a-c)

Plan of Correction: ApprovedMarch 18, 2019

F 623 ? Notice Requirements Before Transfer/Discharge
1. All residents identified in the sample have returned to the facility. To identify other residents who may have the potential to be affected by the same deficient practice:
a. The Director of Social Services will identity residents that have been transferred or discharged within the past 30 days and provide them with written notice of such transfer/discharge.
Completion Date: 3/28/19
2. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Director of Nursing and Director of Social Services will review the policy and procedures for Transfer and Discharge Notice. The policies will be revised as needed.
b. The Director of Social Services will provide inservice training to all social service staff on the policy and procedure regarding transfer and discharge notice requirements.
c. The Director of Social Services will monitor compliance with the policy and procedures for transfer and discharge notice. The Director of Social Services, or her designee, will conduct weekly audits to ensure residents have been provided with a transfer or discharge notice. Immediate corrective action will be taken if indicated.
Completion Date: 4/28/2019
3. To ensure the deficient practice will not recur, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Social Services, or her designee, will audit 25% of transfers and discharges weekly to ensure written notice was provided.
b. The Director of Social Services will review the audit findings weekly. Audit findings will be presented to the Corporate Compliance Committee monthly and the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measure implemented if necessary.
Completion Date: 4/28/2019
4. The Director of Social Services will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.

Completion Date: 4/28/2019

FF11 483.60(i)(3):PERSONAL FOOD POLICY

REGULATION: §483.60(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 28, 2019
Corrected date: April 28, 2019

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure it had 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. Specifically, the facility did not provide information for family and visitors on safe food preparation and handling practices. This is evidenced as follows: Review of the facility's policy on Food Brought to Residents from the Outside on 02/26/19 at 10:00 AM, revealed the policy did not include procedures for families and visitors to be educated on the safe preparation, handling, or storage of foods brought in for residents. During an interview with Dietitians #4 and #5 on 2/26/19 at 11:40 AM, the Dieticiians stated they did not provide any instruction to families regarding the safe and sanitary home preparation, handling and storage of food to be brought in for residents. They thought the Food Service Manager might provide instructions. During an interview with the Food Service Manager (FSM) at 11:49 AM on 2/26/19, the FSM stated instruction regarding safe and sanitary home preparation and handling and storage of food was not provided to families. The Registered Dietitian and the Food Service Manager have talked about providing education, but it was not currently being done. 10 NYCRR 415.14(h)

Plan of Correction: ApprovedMarch 18, 2019

F 813 ? Personal Food Policy

1. There was no specific resident identified in the sample, however all residents have potential to be affected by the same deficient practice. The following measures will be put into place to prevent current residents from being affected by the same deficient practice:
a. The Administrator, Food Service Director and Director of Nursing will review the personal food policy and procedures. The policy and procedures will be revised as needed to ensure family and visitors are educated on safe food preparation, handling and storage practices.
b. A family newsletter will be distributed to all resident representatives regarding the policy and procedure for safe and sanitary food preparation, handling and storage.
Completion Date: 4/28/2019
2. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Food Service Director and Director of Nursing will review the personal food policy and procedures. The policy and procedures will be revised as needed to ensure family and visitors are educated on safe food preparation, handling and storage practices.
b. An informative guideline of safe and sanitary food preparation, handling and storage will be added to the facility admission packet, and provided to family members of residents upon admission, to ensure adequate education is provided.

3. To ensure the deficient practice will not recur, the following measures will be incorporated into the facility?s Quality Assurance and Performance Improvement Program:
a. The Administrator and Director of Food Service, or designee, will audit 25% of admission packets weekly to ensure the resident and representative was provided with the facility?s personal food policy.
b. The Director of Food Service and Administrator will review the audit findings weekly. Audit findings will be presented to the Corporate Compliance Committee monthly and the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measure implemented if necessary.
Completion Date: 4/28/2019
4. The Director of Food Service and the Administrator will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice.

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity 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. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

Based on observation, record review and interviews during the recertification survey the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for residents on 3 of 7 units. Specifically, for Unit's 1, 2, and 4, the facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room, did not ensure that resident's meals were not interrupted by the need for other resident's to enter or exit the dining room, did not ensure that medications were not administered while residents were eating, and did not ensure that residents' seated at the same table received their meals at the same time. This was evidenced by: Unit 1: Finding #1 The facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room. During an observation on 02/24/19 at 4:35 PM, the dining area consisted of two rooms, an open front room with 1 long table which had the only access to the rear dining room. The rear dining room consisted of 4 square four-top tables, and 2 rectangle eight-top tables. There were 19 Residents in wheelchairs and geri chairs. A Certified Nursing Assistant (CNA) was observed trying to place a resident in a geri chair between the table and the wall, and had to pull on the geri chair sideways to fit it into place. A resident sitting at a square four-top table had the back of her wheelchair touching the back of the wheelchair of another resident sitting at another table. A resident sitting at the rectangular table had to be moved away from the table to fit another resident at the other side of the same table. During an observation on 2/26/19 at 4:35 PM, in the rear dining room, one resident was sitting at a square table and their wheelchair had to be moved away from the table to allow another resident in a geri chair to get to the table in the back of the room. A resident in a wheelchair was trying to leave the rear dining room could not leave until a resident sitting at a square table was moved out of the way. During an interview on 2/24/19 at 5:49 PM, CNA #3 stated the dining room is crowded, if a resident wanted to leave the dining room we would have to move other residents out of the way. We try not to toilet people during the meals, we will ask them to wait until after the meal. During an interview on 2/27/19 at 9:11 AM, CNA #16 stated the dining area is very cramped. They try to fill the back of the dining area first. If someone is not done eating in the front area, and someone in back wants to get out, we will ask them to wait. If someone has to go to the bathroom we tell them they have to wait. We often have to move residents already seated in the dining area to get other residents in. During an interview on 02/27/19 at 02:17 PM, CNA #2 stated the staff will refrain from moving residents from the dining area during the meal. If a resident needed to be moved we would have to move at least one resident or more to get a resident out. Finding #2 The facility did not ensure that did not ensure that residents' seated at the same table received their meals at the same time. During an observation on 02/24/19 at 5:26 PM in the open front room, there were four residents sitting at a long table. Two residents were served their trays and began eating. The remaining two residents at the table did not receive their trays until 5:49 PM. During an interview on 02/27/19 at 1:01 PM, Registered Nurse (RN) #14 stated that all residents at a table should be served at the same time. As a rule all residents at one table are set-up with their meals before starting another table. The dining room can be crowded, the staff usually toilet the residents before the meals. If a resident needed to come out of the dining room during a meal the staff would have to move other residents. Unit 2: Finding #1 The facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room. During observation on 2/26/19 at 4:35 PM, Resident #132 was sitting at the table and had to be moved to bring another resident into the room, who was then transferred to a straight back chair, and Resident #116 had to be moved to get the wheel chair out of the room. During observation on 2/27/19 at 9:09 AM, the main pathway through the dining room did not allow a clear passage for residents who wanted to leave the dining room. During an interview on 2/27/19 at 9:11 AM, CNA #16 stated the dining room was very cramped. They try to fill the back of the DR first. If someone was eating in the front of the dining room and someone in the back wanted to get out, they moved the front residents out if they were done eating. If a resident had to go to the bathroom, we tell them they had to wait. They sometimes had to move residents already seated to get others in. Unit 4: Finding #1 The facility did not ensure that medications were not administered while residents were eating. During observation on 2/24/19 at 5:09 PM, Licensed Practical Nurse (LPN) #9 was passing medication in the main dining room on Unit #4. Three residents were seated at a square table with their food in front of them. One resident at the four-person table was given her medication as a resident at the same table had started to eat her dinner. The resident was moved back from the table, interrupting her meal, as LPN #9 turned the resident in a Barco recliner around to give her medication. During observation on 2/24/19 at 5:15 PM, the LPN #9 on Unit #4 continued to pass medications to 3 Residents during the evening meal after 10 residents had received their food and begun eating. During interview on 2/24/19 at 5:30 PM, LPN #9 on Unit #4 stated she tried to get medications passed so she wouldn't get behind. She stops when she must help with feeding the resident. She shouldn't have moved the resident that was eating to reach the resident she gave medication to. She didn't think the resident minded but she didn't ask her. During interview on 2/24/19 at 6:00 PM, the 3-11 Supervising Registered Nurse (RN) # 6 for Unit #4 stated there should be no medications passed in the dining room once the trays are being started. The LPN was new and maybe wasn't familiar with what was expected and would need to be reeducated. Finding #2 The facility did not ensure that one resident did not receive her tray over 30 minutes after other residents at her table received their trays. This resident was served last. During observation on 2/24/19 at 5:38 PM, on unit 4 during the evening meal a resident sitting at a table with 3 other residents had not received food. Approximately 30 minutes after the other 3 residents were served and had begun eating the resident became verbally anxious. While sitting in a Barco chair the resident began to push herself away from the table while the other residents continued to eat. She was asking for food and the Certified Nursing Assistant (CNA) # 4, told the resident she would bring her food in a minute. The resident received her tray at 5:38 PM after the last tray was past and all other residents in the dining room had begun eating. During an interview on 2/24/19 at 5:45 PM, CNA #4 on Unit #4 stated they bring everyone into the dining room before they ring the bell to start passing trays. The resident is frequently restless and attempts to get out of the Barco. They wait until last to give her a tray because she needs assistance and makes a mess if food is left in front of her. It's more disruptive to others when she makes a mess at the table. During interview on 2/24/19 at 6:00 PM, the 3-11 Supervising RN #6 unit stated everyone, except a few residents who eat in their rooms, eat dinner in this main dining/activity room. Some residents must wait if they need help to eat. They do their best to make sure everyone receives their tray in a timely manner. It just isn't always possible for the residents with behaviors to get served at the same time. She realized the resident was disruptive and someone should have given her something when the other residents at the same table were served. Finding #3 The facility did not ensure that residents were not moved during their meal to accommodate for residents who were entering or exiting the dining room. During observation on 2/24/19 at 5:54 PM, residents in wheelchairs and Barco's needed to be moved away from their places at their tables to facilitate resident's exiting the dining room. Eight residents seated at the middle and back tables in the dining room were moved to allow other residents exit from the dining room. Two CNA's left resident's they were feeding to assist making a clear path for resident's who were attemptiing to exit. During interview on 2/24/19 at 6:35 PM, CNA #4 stated the room is crowded because residents' do not go down to the main dining room on the first floor for dinner. They bring residents' into the Unit dining room early and try to position the residents' the best they can. When the food cart is brought in it gets cramped. They have frequently move resident's when someone wants to leave, especially if they are in the middle or back of the room and need toileting. During interview on 2/24/19 at 6:00 PM, the 3-11 Supervising RN #6 stated everyone, except a few residents who eat in their rooms, eat dinner in this dining during evening meal. It is a bit crowded and if someone comes into the dining room late or needs to leave the dining room, they do have to pull some of the residents away from the table while they are eating. 10NYCRR415.5(a)

Plan of Correction: ApprovedMarch 18, 2019

F 550 ? Resident Rights/Exercise of Rights

1. The following corrective action was taken for the residents identified in the sample:
a. The nursing staff directly responsible for the care of the residents identified in the sample were educated by Nursing Administration on the facility policies and procedures regarding preparing resident for, serving, assisting and monitoring of resident meals to promote a dignified dining experience.
b. Dining areas will be reviewed and rearranged to allow ample space for residents to mobilize without interrupting others.
Completion Date: 3/28/2019
2. To identify other residents who have the potential to be affected by the same deficient practice:
a. Nursing Administration will assess the dining atmosphere and staff practices on all residential units to ensure residents are offered a dignified dining experience without unnecessary interruption.
b. Further staff education will be provided to nursing staff as necessary regarding the facility policies and procedures regarding preparing resident for, serving, assisting and monitoring of resident meals to promote a dignified dining experience.
Completion Date: 4/28/2019
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator and Director of Nursing will review the policy and procedures for preparing resident for dignified dining experience. The policies will be revised as needed.
b. The Director of Nursing will provide inservice training to all nursing staff regarding the facility policies and procedures regarding preparing resident for, serving, assisting and monitoring of resident meals to promote a dignified dining experience.
c. The Director of Nursing will monitor compliance with the policy and procedures regarding dignified dining. The Director of Nursing, or her designee, will conduct random weekly meal audits. Immediate corrective action will be taken if indicated.
Completion Date: 4/28/2019
4. To ensure the deficient practice will not recur, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Plan:
a. The Director of Nursing, or her designee, will audit 10% of resident meals weekly to ensure dignified dining experience is offered.
b. The Director of Nursing will review the meal audit findings weekly. Audit findings will be evaluated, and additional corrective actions will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audit findings will be presented to the Dining Committee monthly and the Quarterly Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measures implemented if necessary.
Completion Date: 4/28/2019
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice. The Corporate Compliance Committee will review and monitor the SOD & Plan of Corrections on a monthly basis.
Completion Date: 4/28/2019

FF11 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- §483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 28, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey the facility did not provide proper treatment and assistive devices to maintain vision for 1 (Resident #177) of 5 residents reviewed for visual impairment. Specifically, the facility did not ensure that Resident #177 was provided assistance locating her glasses and that the resident's plan of care included a plan for vision and devices. This is evidenced by: Resident #177: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident used corrective lenses and had adequate vision. The resident had the ability to be understood and usually understood others. The MDS dated [DATE] & 1/30/19, documented the resident did not use corrective lenses, had impaired vision with the ability to see large print, was understood and understands and continued mild cognitive impairment. During an interview on 02/25/19 at 2:09 PM, the resident stated she had glasses when she entered the facility and they are now missing. The resident stated that facility staff was made aware that her glasses were missing. The resident was told that she did not have glasses on admission to the facility During an interview on 2/27/19 at 9:20 AM, Registered Nurse #1 stated she does not recall the resident having glasses, and a list of belongings was not obtained at the time of admission. RN #1 stated the resident did not have a care plan for impaired vision. During an interview on 2/27/19 at 9:25 AM, Social Worker (SW) #15 stated the resident did not have glasses while a resident at the facility. SW #15 stated that the resident's son was contacted when the resident reported missing her eyeglasses. The resident's son stated that he had the eyeglasses because the resident refused to wear them. SW #15 did not recall when this occurred or the name of the person she spoke with. The SW stated that she did not ask the resident's son to bring the resident's glasses into the facility. The SW could not recall informing the resident that her son had her glasses. During an interview on 2/28/19 at 11:17 AM, the resident stated she reported on several occasions that her glasses were missing, as she enjoys reading and stated she had several magazines she wished to read and was unable to do so without glasses. During an interview on 2/27/19 at 1:15 PM, Minimum Data Set Coordinator (MDSC) #14 stated she completed the Hearing, Speech and Vision section of the MDS for the resident dated 8/2/18 and 9/6/18. MDSC #14 confirmed the resident had glasses present on during the MDS dated [DATE] and was able to read regular print. MDSC #14 stated the resident did not have glasses present during the MDS dated [DATE] and the resident was only able to read large print. During an interview on 2/28/19 at 12:20 PM, the Director of Nursing stated the expectation is that if a resident has a visual deficit, a CCP would be developed and implemented. The DON stated the expectation is that staff would follow-up if a decline to a resident's visual ability was identified. The DON stated the resident has had an increase in her cognitive ability and functioning over the past six months. 10NYCRR415.12(3)(b)

Plan of Correction: ApprovedMarch 18, 2019

F 685 ? Treatment/Devices to Maintain Hearing/Vision

1. The following corrective action was taken for the resident identified in the sample:
a. An ophthalmology exam has been scheduled for the resident identified in the sample.
b. The nursing staff directed responsible for the resident identified in the sample were inserviced by the Director of Nursing on the policy and procedures for maintaining appropriate treatment plans to meet the resident?s visual or hearing needs.
Completion Date: 4/28/2019
2. To identify other residents who may have the potential to be affected by the same deficient practice:
a. Nursing Administration will identity other residents with visual or hearing impairments to ensure appropriate treatment plans and devices are in place. Additional interventions will be implemented to meet each resident?s needs.
b. Nursing Administration will provide further education to nursing staff as necessary.
Completion Date: 4/28/2019
3. The following measures will be put into place to prevent future residents from being affected by the same deficient practice:
a. The Administrator, Medical Director and Director of Nursing will review the policy and procedure for maintaining treatment plans that meet the residents visual and hearing needs. The policies will be revised as needed.
b. The Director of Nursing will provide inservice training to all nursing staff on the policy and procedure of providing and maintaining adequate treatment and devices for visual and hearing needs.
c. The Director of Nursing will monitor compliance of maintaining treatment plans to meet resident visual and hearing needs by conducting weekly audits of resident visual and hearing needs. Corrective action will be taken if indicated.
Completion Date: 4/28/2019
4. To ensure the deficient practice will not recur, the following measures will be incorporated into the facility?s Quality Assurance Performance Improvement Program:
a. The Director of Nursing, or her designee, will audit 5% of all residents weekly to ensure treatment plans and devices are adequate to maintain vision and hearing abilities.
b. The Director of Nursing will review the vision and hearing treatment plan audit findings weekly. Audits findings will be evaluated, and additional corrective actions will be implemented if indicated.
c. A monthly summary of the audit findings will be reported to the Administrator. Summaries of the audit findings will be presented to the Quality Assurance Performance Improvement Committee at least quarterly, where they will be reviewed, and additional corrective measures implemented if necessary.
Completion Date: 4/28/2019
5. The Director of Nursing will be responsible for the compliance of the policies and procedures and ensure corrective action is taken to prevent recurrence of the deficient practice. The Corporate Compliance Committee will review the P(NAME)'s on a monthly basis to ensure compliance and record findings.
Corrective Date: 4/28/2019

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 28, 2019
Corrected date: April 29, 2019

Citation Details

Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that PCREE is tested and inspected prior to being placed in service and is maintained with consideration of the owner's manual. Specifically, PCREE was not maintained as prescribed in the owner's manual. This is evidenced as follows. Observations 02/27/2019 at 8:30 AM revealed that oxygen concentrators having inventory numbers 122, 224, 229, 238, 240, 244, 261, 376, and 378 were in use in resident rooms and situated directly next to walls, curtains, or furniture. Review of the oxygen concentrators owner's manuals on 02/27/2019 revealed that while in use, the concentrator is to be situated at least 3-inches to 12-inches from walls, curtains, and furniture. Observations on 02/27/2019 at 8:30 AM revealed that nebulizers located in resident rooms and having inventory numbers 214, 218, 233, 250, 260, 287, 288, 367, and 375 were plugged into electrical outlets. Review of each nebulizer owner's manual 02/27/2019 revealed that each unit is to be unplugged immediately after use. Observations on 02/27/2019 at 8:30 AM revealed that suction machines located in dining rooms and having inventory numbers 205, 206, 235, 236, 252, 256, 257, and 360 did not have bacteria filters installed between the collection canister and pump. Bacterial filters were not found with the suction machines. Review of the user manuals for the suction machines on 02/27/2019 revealed that the setup procedure requires in installation of a bacteria filter between the collection canister and pump. The Assistant Director of Nursing stated in an interview conducted on 02/27/2019 at 2:55 PM that staff have not been provided education on the safe use of PCREE as outlined in the owner's manuals. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedMarch 20, 2019

K921
I. The following actions were accomplished for the areas identified in the SOD:
The Director of Engineering and Assistant Director of Nursing (Facility Infection Preventionist) identified the oxygen concentrators, nebulizers and suctioning machines that were not operating properly according to the owner?s manuals.
Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering and Assistant Director of Nursing (Facility Infection Preventionist) will conduct a facility wide inventory of patient care-related electrical equipment (PCREE) to ensure all PCREE are being maintained and operated as per the equipment?s owner?s manual

Completion Date: 4/1/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
1. The Administrator, Director of Engineering and Assistant Director of Nursing will conduct Education, inservice training and audits on the proper usage of PCREE as per NFPA 101 Electrical Equipment ? Testing and Maintenance.
2. The Infection Control and Safety Committees will audit proper usage of the equipment cited. Audit findings will be followed up with on-going education through the facility?s QAPI program.


Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
1. The Administrator, Director of Engineering and Assistant Director of Nursing will be held responsible for continual compliance of the proper maintenance and usage of PCREE. The Safety Committee and Infection Control committee will audit 5% of all equipment on a monthly basis to ensure compliance.

2. Education and non-compliance will be followed up on in the monthly nursing meetings. Audit results and findings will be reported to the facility?s quarterly QAPI committee.

3. The Corporate Compliance Committee will review audit findings and recommend any further instructions or education that needs to be conducted in order to ensure compliance with NFPA 101 Electrical Equipment. Additional corrective action will be implemented
as necessary.

Completion Date: 5/1/19

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 29, 2019

Citation Details

Based on staff interview and record review during post survey review, the facility did not maintain the emergency generator as required by adopted regulations. NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.8 requires that a fuel quality test shall be performed at least annually using tests approved by ASTM standards. Specifically, no fuel quality tests were performed within the past year. This is evidenced as follows. The emergency generator inspection and maintenance records were reviewed on 02/27/2019. The inspection report dated 02/13/2018, did not include a fuel quality test. There were no other records available for review that documented a fuel quality test was performed on the emergency generator fuel reserve. The Director of Engineering stated in an interview on 02/27/2019 at 3:40 PM, that the facility did not conduct tests on the emergency generator fuel. 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.3.8

Plan of Correction: ApprovedMarch 20, 2019

K918
The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The Director of Engineering identified the deficient practice of not having the Generator/Electric System Testing with no fuel quality tests that were performed with the past year.

Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering contacted the facility?s generator maintenance vendor and requested that they conduct a test, document and provide a fuel quality report on the Generator at their next inspection visit. The tests must be approved by ASTM standards.

Completion Date: 3/1/19


III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Engineering will be responsible to ensure the facility is in compliance annually with NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.8. Copies of the report will be submitted to the Administrator.
Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
The Administrator and Director of Engineering will be held responsible for continual compliance of the proper maintenance of the generator and all its operations in compliance with NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.8. A quality assurance audit will be conducted by the facility?s Safety Committee and findings reported to the facility?s quarterly QAPI Program. Additional corrective action will be implemented as necessary.

Completion Date: 5/1/19

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 29, 2019

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide emergency power as required by adopted regulations. NFPA 99 Health Care Facilities Code 2012 edition section 6.4.1.1.17 requires that the emergency power source (emergency generator) is to include a remote annunciator that is storage battery powered and shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. Specifically, the emergency generator remote annunciator is not located in a readily observable location in a regular work station. This is evidenced as follows. Observations on 02/27/2019 at 2:40 PM, revealed that the emergency generator remote annunciator is located in the north exit stairwell from the center building. The Director of Engineering stated in an interview conducted on 02/27/2019 at 2:40 PM, that he will have the remote annunciator relocated to a regular work station. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1.1.15

Plan of Correction: ApprovedMarch 20, 2019

K916
The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD
The Director of Engineering identified the deficient practice of not having the Generator/ Electric System Remote Annunciator and Alarm in a location readily observed by operating personnel.

Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering removed and re-installed the Generator/Electric System Remote Annunciator at the First Floor (Birch Lane) Nursing Station to ensure it can be monitored and observed by operating personnel 24 hours a day. This location is a regular work station. All other Annunciator panels for all other essential electricity system alarms have been audited and are correctly installed at the nursing stations and vestibules.

Completion Date: 3/15/19



III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Engineering will be responsible to ensure the newly re-located annunciator panel is functioning properly. All other annunciator panels will be inspected on a regular basis to ensure they are in compliance with NFPA 99 SECTION 6.4.1.17,17.5.

Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
The Administrator and Director of Engineering will be held responsible for continual compliance of the proper maintenance of all annunciator panels. A quality assurance audit will be conducted by the facility?s Safety Committee and findings reported to the facility?s quarterly QAPI Program. Additional corrective action will be implemented as necessary.

Completion Date: 5/1/19

MAINTENANCE, INSPECTION & TESTING - DOORS

REGULATION: Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 29, 2019

Citation Details

Based on record review staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.3.1 requires that door assemblies in exit enclosures be tested not less than annually in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition (NFPA 80). NFPA 80 section 5.1.5 requires that repairs shall be made, and defects that could interfere with operation shall be corrected without delay. Specifically, defects were not corrected to 13 fire-rated door assemblies and not all fire rated doors were inspected annually. This is evidenced as follows. The (YEAR) fire-rated door inspection report was reviewed on 02/27/2019. The report listed 13 doors that were unsatisfactory and were not repaired or replaced. The fire rated doors separating the 1974 construction from the 1987 construction were not listed as inspected on the (YEAR) fire-rated door inspection report. The Director of Engineering stated in an interview on 02/28/2019 at 9:05AM that he was unaware that the 13 doors identified with defects on the (YEAR) door inspection report have not been repaired and he will insure that all fire rated doors are inspected annually. 42 CFR 483.70 (a)(1); 2012 NFPA 101 8.3.3.1; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedMarch 20, 2019

K 761

The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified the area of concern for the deficient practice of inspecting and testing Fire Doors annually in accordance with NFPA 80 for the 13 fire rated doors where defects were noted on the facility?s inspection report.
Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering will conduct a full and complete inspection of all Fire doors within the building to identify any additional defects not observed by the surveyor that fail to meet the requirement of having been maintained in accordance with NFPA 80. The Director will correct, fix and replace all defective fire doors within the facility.

Completion Date: 5/1/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Engineering will ensure that all Fire Doors are placed on annual preventative maintenance and inspection schedule and record evidence of work performed to ensure they meet the requirement of being maintained in accordance with NFPA 80 Standard for Fire Doors and Other Operating Protectives.
Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
Upon completion of the facility wide inspection of all Fire Doors and ensuring that they all meet NFPA 80, the Administrator and Director of Engineering will be held responsible for continual compliance. A quality assurance audit will be conducted by the facility?s Safety Committee and findings reported through the facility?s QAPI Program. Additional corrective action will be implemented as necessary.
Completion Date: 5/1/19

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires sprinkler heads be free of foreign materials, such as dust. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows. An assessment of the sprinkler system was conducted on 02/27/2019 at 10:15 AM. Two sprinkler heads in resident rooms #259 and #119, two sprinkler heads in the laundry room, one sprinkler head in resident room [ROOM NUMBER], one sprinkler head in the 2nd floor nursing station, one sprinkler head in the 3rd floor bathing room, one sprinkler head in the 3rd floor nursing station and one sprinkler head in the 2nd floor nursing station were found with a coating of dust. The Administrator stated in an interview on 02/27/2019 at 4:15 PM, that he was unaware that the sprinkler heads were dusty and that he will have the housekeeping staff remove the dust. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedMarch 20, 2019

K 353

The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified and cleaned those sprinkler head?s that were covered with dust that were Observed by the surveyor that failed to meet the requirement of being maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering will conduct a full and complete inspection of all areas within the building to identify any additional sprinkler heads not observed by the surveyor that fail to meet the requirement of having been maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. During this audit, any additional uncleaned sprinkler heads found to be dusty and out of compliance will be cleaned.
Completion Date: 4/1/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Engineering will ensure that all sprinkler heads are placed on a preventative maintenance/cleaning schedule and record evidence of work performed to ensure they meet the requirement of being maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.

Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
Upon completion of the cleaning of all sprinkler heads and ensuring that they all meet NFPA 25 Standards, the Administrator and Director of Engineering will be held responsible for continual compliance. A quality assurance audit will be conducted by the facility?s Safety Committee and findings reported to the facility?s QAPI program. Additional corrective action will be implemented as necessary.
Completion Date: 5/1/19

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 28, 2019
Corrected date: April 29, 2019

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 4th floor resident unit south smoke barrier wall (wall) was inspected on 02/27/2019 at 10:20 AM. One metal electrical box each in resident rooms #405, #406, #411, and #412 measured greater than sixteen square inches (6 inches by 6 inches) were not fire protected. The Director of Engineering stated in an interview on 02/28/2019 at 10:00 AM, that the electrical boxes were not fired sealed and he will seal the electrical boxes in the smoke walls. 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: ApprovedMarch 20, 2019

K372
The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified and corrected the electrical metal boxes in the resident rooms in need of Fire protection in room #405, #406, #411, and #412 that were observed by the surveyor that failed to meet the requirement of maintaining smoke barriers in accordance with adopted
regulations NFPA 101 Life Safety Code 2012 edition section 8.3.5.6.3.

Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering will conduct a full and complete inspection of all areas within the building to identify any smoke barrier walls that failed to meet the requirement of maintaining smoke barriers in accordance with adopted regulations NFPA 101 Life Safety Code 2012 edition section 8.3.5.6.3. Any additional metal electrical boxes found to be out of compliance will be sealed and fire protected according to NFPA 101.

Completion Date: 4/1/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
Through a preventative maintenance and audit schedule, the Administrator and Director of Engineering will ensure that all smoke barrier wall areas within the building meet the requirement of maintaining smoke barriers in accordance with adopted regulations NFPA 101 Life Safety Code 2012 edition section 8.3.5.6.3.



Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
The Administrator and Director of Engineering will be held responsible for continual compliance of the proper maintenance of all smoke barrier walls. A quality assurance audit will be conducted by the facility?s Safety Committee and findings reported through the facility?s QAPI Program. Additional corrective action will be implemented as necessary.

Completion Date: 5/1/

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 29, 2019

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain equipment using gas or related gas piping in accordance with adopted regulations. NFPA 54, National Fuel Gas Code 2011 Edition Section 9.3 requires that Type II gas dryers specifically provide outside air for fuel combustion (make-up air). Specifically, adequate make-up air was not provided for gas dryers. This is evidenced as follows. Record review of the clothes dryer installation manual on 02/27/2019 revealed that a total of 195 squared inches of free openings for make-up air be provided for fuel combustion for each unit. Observations of the laundry room on 02/27/2019 at 9:35 AM, revealed 5 fuel fired gas clothes dryers and two ducts for make-up air approximately 12-inches by 12-inches each, a total of 288 square inches of free ducting area. This room is missing 637 square inches of free openings to provide the required amount of make-up air. The Director of Engineering stated in an interview on 02/29/2019 at 3:56 PM, that he thought that the room was engineered to provide the required amount of make-up air and did not realize the current vents are undersized. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.1, 9.1.2; 2011 NFPA 54 9.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 54

Plan of Correction: ApprovedMarch 20, 2019

K 511

I. The following actions were accomplished for the areas identified in the SOD:
The facility identified the area of concern for the deficient practice of operating gas clothes dryers that were deficient for adequate make-up air as per NFPA 54 National Fuel Gas Code 2011 Edition Section 9.3.

Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering installed a new vented window to comply with NFPA 54 National Fuel Gas Code 2011 Edition Section 9.3. ensuring there is now sufficient make-up air or air for fuel combustion to properly operate the facility?s Type II gas dryers.


Completion Date: 3/14/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Director of Engineering will be responsible to ensure the new vented window is operating effectively on an on-going basis in order to comply with NFPA 54 National Fuel Gas Code 2011 Edition Section 9.3. that there is sufficient make-up air or air for fuel combustion to properly operate the facility?s Type II gas dryers.

Completion Date: 5/1/19
IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
a. The Director of Engineering and Administrator will conduct monthly audits on the air make-up for the clothes dryers operations portion of the facility.
b. The Safety Committee will conduct audits of the facility?s practice and report the findings to the Quarterly QAPI Program.
c.The Director of Engineering will be held responsible for ensuring that the deficiency cited is corrected and in compliance with NFPA.

Completion Date: 5/1/19

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 28, 2019
Corrected date: April 29, 2019

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 maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be continuous. Specifically, rated ceilings in resident rooms and the west mechanical room were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations on 02/27/2019 at 10:20 AM of the fire rated ceiling assemblies revealed in resident room [ROOM NUMBER] one 6-inch, one 4-inch, one two-inch, and one 1-inch unsealed penetrations around piping; and in resident room [ROOM NUMBER] one 4-inch unsealed penetration around piping. The Director of Engineering stated in an interview on 02/28/2019 at 8:30 AM, that the piping penetrating the fire rated ceiling assemblies have not been fired sealed and he will seal the holes. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3

Plan of Correction: ApprovedMarch 20, 2019

The following Life Safety Code Plan of Corrections are submitted in accordance with applicable law and regulation for continued Medicare/Medicaid certification.
K 311
I. The following actions were accomplished for the areas identified in the SOD:
The Director of Engineering identified the penetrations within the resident rooms with unsealed penetrations around piping and ceiling assemblies that were observed by the surveyor within the building that failed to meet the requirement of proper fire resistance within vertical openings.
Completion Date: 3/1/19
II. The following corrective actions will be implemented to identify any additional areas of the facility that may be affected by the same practice:

The Director of Engineering will conduct a full and complete inspection of all areas within resident rooms to identify any additional vertical openings and ceiling assemblies that fail to meet the requirement of having unacceptable obstruction.

Completion Date: 4/1/19
III. The following system changes will be implemented to assure continuing compliance with regulations:
The Administrator and Director of Engineering will ensure that all resident rooms, piping, ceiling assemblies, unsealed openings and other vertical openings are enclosed with UL Approved fire stopping systems all in compliance to meet the requirement of NFPA 101 Life Safety Code 2012.

Completion Date: 5/1/19

IV. The facility?s compliance will be monitored utilizing the following continuous quality improvement system:
Upon completion of the project to ensure that vertical opening penetrations and ceiling assemblies are enclosed with UL Approved Fire- Stopping systems and protected to ensure that they all meet NFPA 101 Life Safety Code 2012 edition section 8.6.1 and 8.5 have a 1-hour fire resistance rating, the Administrator and Director of Engineering will be held responsible for continual compliance. A quality assurance audit will be conducted by the facility?s Safety Committee and findings reported through the facility?s QAPI Program. Additional corrective action will be implemented as necessary.
Completion Date: 5/1/19