Humboldt House Rehabilitation and Nursing Center
October 29, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.25(l):DIALYSIS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed 10/29/18, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan for one (Resident #27) of one resident reviewed for [MEDICAL TREATMENT]. Specifically, the [MEDICAL TREATMENT] bandage was not removed after [MEDICAL TREATMENT] per the physician's orders [REDACTED]. The finding is: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 8/6/18 documented the resident was cognitively intact, was understood and understands. Further review of the MDS revealed the resident was receiving [MEDICAL TREATMENT] services. During an observation on 10/26/18 at 8:15 AM, the resident lifted his right arm and showed the surveyor his access site for [MEDICAL TREATMENT]. The AVF (arteriovenous fistula, a tube or device surgically implanted to create an artificial connection between an artery and a vein) access site was observed to have a dressing/ bandage on it. The resident stated, No one had removed my bandage yesterday after [MEDICAL TREATMENT]. Maybe they will remove it today. Review of the Medication Review Report dated 10/26/18 revealed orders for [MEDICAL TREATMENT] on Monday, Tuesday, Thursday, and Saturday. Additionally, monitor right upper extremity AVF for brut (whooshing sound of blood flow) and thrill (a buzzing vibration felt by palpation) and signs and symptoms of infection, every shift. Remove dressing four hours post- [MEDICAL TREATMENT] treatment, one time a day on Monday, Tuesday, Thursday and Saturday. Review of the Comprehensive Care Plan with initiated date of 9/6/17 revealed the resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION] and was to attend [MEDICAL TREATMENT] Monday, Tuesday, Thursday, and Saturday. Interventions included to check and change dressing as ordered at access site. Review of the Medication Administration Record [REDACTED]. Review of a nursing Progress Note dated 10/25/18 revealed there was no notation regarding the removal of the bandage at the right arm AVF site. During an observation/interview on 10/26/18 at 8:26 AM, LPN #4 stated, That is the bandage from [MEDICAL TREATMENT]. The bandage should have been taken off yesterday about five hours post [MEDICAL TREATMENT]. The evening shift should have removed it. It is even in the TARs that it is to be removed so many hours after [MEDICAL TREATMENT]. During an interview on 10/26/18 at 9:04 AM, Registered Nurse (RN) #5 stated, There is an order to remove the bandage from the AVF site four hours post [MEDICAL TREATMENT]. I cannot say for sure if the bandage was removed or not. The nurse at night documented that she removed it, but there are no notes having to re-bandage it due to bleeding. I cannot say for sure the bandage was not removed. During an interview on 10/26/18 at 9:35 AM, LPN #4 stated that was the [MEDICAL TREATMENT] bandage, as it was thicker than the facilities bandages. During an interview on 10/26/18 9:51 AM, LPN #3 stated, I did not remove the bandage from the AVF site last night. I signed off in the MAR before I removed it and I got distracted with another resident and forgot to go back and remove the dressing. During an interview on 10/26/18 at 11:03 AM, the Director of Nursing (DON) stated, The orders read to remove dressing four hours post [MEDICAL TREATMENT] treatment. My expectation would be for the bandages to be removed as ordered. They should have removed it. During an interview on 10/26/18 at 11:22 AM, the Medical Director stated, I expect them to remove the bandage as ordered, four hours post [MEDICAL TREATMENT]. 415.12

Plan of Correction: ApprovedDecember 3, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #27 had the [MEDICAL TREATMENT] bandage changed the next day upon discovery. The resident was assessed by the Assistant Director of Nursing there was no negative outcome to resident.

All [MEDICAL TREATMENT] residents were immediately checked for proper and timely dressing changes upon return from [MEDICAL TREATMENT] with no issues noted.

All nurses will be educated as to the need to remove shunt dressings 4 hours post [MEDICAL TREATMENT] treatments as ordered by the physcian.
Director-of-Nursing or designee

The ADON will audit all [MEDICAL TREATMENT] residents weekly x 8 weeks to ensure shunt dressings are removed timely as ordered and forward audit findings to the DON.
A QAPI review will be completed monthly for 3 months.
The results of all audits and reports will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Director-of-Nursing will oversee the completion of this P(NAME) in its entirety.

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

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 10/29/18, the facility did not ensure residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions, and behavioral interventions, unless contraindicated, in an effort to discontinue these drugs. One (Resident #59) of five residents reviewed for unnecessary medications had issues involving the lack adequate indication and behavior documentation to support the use of [MEDICATION NAME] (antipsychotic medication). Additionally, the lack of non-pharmalogical interventions prior to the initiation of an antipsychotic medication. The finding is: Review of the policy and procedure entitled Antipsychotic Medication Use dated 12/2016 revealed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environment causes of behavioral symptoms have been identified and addressed. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to others. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Antipsychotic medications shall generally be used for the following conditions as documented in the record: Mood disorders; delusional disorder; [MEDICAL CONDITION] in the absence of Dementia. In addition, will only be considered if the behavioral symptoms present a danger to the resident and or others; the symptoms are identified as due [MEDICAL CONDITIONS]; behavioral interventions have been attempted and included in the plan of care. 1. Resident #59 was admitted to the facility 5/24/18 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 8/23/18 documented the resident had severe cognitive impairment. The MDS also documented the resident exhibited no behavioral symptoms during the assessment period. The Comprehensive Care Plan (CCP) dated 6/13/18 documented the resident had little interest or pleasure in doing things, appearing down or depressed at times. It was documented the resident was treated with [MEDICAL CONDITION] medications for depression and included the following planned interventions: psych evaluation as needed; monitor for any declines in mood status; social work to provide supportive visits to offer emotional support. The hospital Discharge Summary dated 5/24/18 documented to give [MEDICATION NAME] 50 mg (milligrams) at bedtime. Review of a Note to Attending Physician/Prescriber dated 5/25/18 documented the resident was recently admitted on [MEDICATION NAME] 50 mg for depression. CMS (Centers for Medicare & Medicaid Services) regulations require that antipsychotic agents be used only if symptoms or behaviors present a danger to the resident and or others. If continued as is, please document a benefit versus risk assessment. The Physician/Prescriber response was checked agreed and signed by the Medical Director on 5/31/18. Review of a Physician's History and Physical dated 5/26/18 revealed there was no documented evidence of behaviors. In addition, a Physician's Progress Note dated 6/14/18 revealed there was no documented evidence of behaviors. The resident had depression and dementia. Review of the Nurses Notes dated 5/24/18 through 6/12/18 revealed there was no documented evidence of behaviors. Review of the twenty-four-hour reports (daily nursing reports) dated 5/24/18 through 6/30/18 revealed they were missing. A physician's orders [REDACTED]. A Social Work Progress Note dated 6/8/18 documented the resident was always happy, in a positive state and had adjusted well to this environment. A Nurses Note dated 6/13/18 documented the resident's mood had changed and that she used to look forward to outings and activities. The resident now appeared very depressed and asked to be taken off the lists for activities. She had medication changes 5/29/18 which might be contributing to the change in her mood. Review of the CCP dated 6/14/18 revealed the use of [MEDICATION NAME] for depression. Interventions included to administer medications as ordered; discuss with MD (medical doctor) and family the ongoing need for the use of the medication; review behaviors/ interventions, alternate therapies attempted and their effectiveness; monitor any adverse reactions. An unsigned Pharmacy Consultant Note to Attending Physician/ Prescriber dated 6/14/18 documented the resident's medications were reviewed at the BMARC (Behavior Monitoring and Recommendation Committee) meeting on 6/14/18. A dramatic change in mood had been noted after medication changes. The resident used to look forward to outings and activities, but now appeared very depressed and asked to be taken off the lists for activities. physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. During intermittent observations from 10/22/18 through 10/24/18 between 9:50 AM and 2:15 PM revealed the resident was often in a darkened room with the curtains closed, lying in bed, sleeping in a fetal position and dressed in a hospital gown. During interview on 10/24/18 at 2:06 PM, Certified Nurse Aide (CNA) #4 stated that occasionally on the second shift, the resident would come to the lounge area but otherwise would remain in her room and wanted to be left alone. the CNA did not recall any specific behaviors. During an interview on 10/24/18 at 11:22 AM, the Director of Activities stated the resident preferred to be alone. Occasionally 1:1 (one to one) visits were provided but had no accountability for the visits. During an interview on 10/24/18 at 1:48 PM, the Physician stated Registered Nurse (RN #1) had notified him of behaviors but could not recall what type of behaviors. He gave an order to restart the [MEDICATION NAME] 50 mg because of the resident's history of depression and that she had been admitted with the medication from the hospital. The Physician stated he did not think to order any medical workup prior to restarting the medication. The recent change in medication may have caused her increased depression thus the [MEDICATION NAME] was restarted. During an interview on 10/25/18 at 10:08 AM, RN # 1 stated that when the resident came to the facility she would participate in activities. Then she suddenly stopped attending and would not come out of her room. Resident #59 had also requested to be taken off the list of all activities. RN #1 stated that she notified the physician, and the physician reordered the [MEDICATION NAME] for depression. During an interview on 10/26/18 at 10:51 AM, the Pharmacist Consultant stated she reviewed the [MEDICATION NAME] on her first review. Felt the [MEDICATION NAME] was inappropriate and recommended it to be discontinued. She was notified the resident had a change in mood and was not attending activities and seemed very depressed because of this the Interdisciplinary Team requested the [MEDICATION NAME] to be restarted. The consultant further stated, the nurses were upset I had recommended to discontinue the [MEDICATION NAME], and now had such a dramatic change, I felt responsible. During an interview on 10/29/18 at 8:00 AM, the Director of Nurses (DON) stated the expectation was that staff to interview the resident to determine if medical workup is necessary and review the need for non-pharmacological interventions prior to the start of the medication. The DON then stated the resident should have been on the 24 hour-report, documentation in the nurses' notes of unusual behaviors to validate the proper justification and the need of the [MEDICATION NAME]. 415.12(1)(l)

Plan of Correction: ApprovedDecember 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 59 was placed on 24 hr report to monitor mood and behavior.
The IDT /physician will meet to conduct a review of the resident and appropriateness of [MEDICATION NAME].
All residents will be reviewed to ensure that non-pharmacological interventions are initially employed and that adequate indication and behavior documentation are in place to support the use of [MEDICAL CONDITION].
What measures will the facility take to ensure that the problem does not recur.
1. All nurses, social workers, and the pharmacy consultant to be educated on the requirements for use of non-pharmacological interventions and to adequate indication prior to initiating a [MEDICAL CONDITION].
Director-of-Nursing or designee
2. Nurses and social workers educated for the need to place the resident on 24hour report to monitor and document behaviors to ensure non-pharmcological interventions are employed prior to initiation of [MEDICAL CONDITION] medications.
Director-of-Nursing or designee
3. DON, upon reviewing the pharmacy consultant recommendation, will ensure that residents are placed on the 24hr report to monitor behavior and use of non-pharmocological interventions prior to restarting medication.
4. The IDT will begin using of a PCC psychoactive assessment tool to monitor appropriate use of [MEDICAL CONDITION] including gradual dose reductions and use of non-pharmcological interventions.

The monthly pharmacy report will be reviewed at QAPI for correct [DIAGNOSES REDACTED].

The results of all audits and reports will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Director-of-Nursing will oversee the completion of this P(NAME) in its entirety.

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: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 10/29/18, the facility did not ensure that each resident receives adequate supervision to prevent accidents as is possible for one (Resident #75) of four residents reviewed for mobility. Specifically, the lack of providing staff assistance for a resident ambulating independently that required extensive assist of one person for ambulation. The finding is: 1. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 9/6/18 documented the resident had long and short-term memory problems, usually understands, was usually understood. The undated Certified Nurse Aide (CNA) Visual/Bedside Kardex Report (guide used by staff to deliver care) identified as current documented the resident required extensive assist of one person for ambulation. The undated Comprehensive Care Plan identified as current documented the resident had limited physical mobility and was an extensive assist of one person for ambulation with no assistive devices. The Therapy Fall Consults dated 4/18/18 through 10/22/18 documented the resident was an extensive assist of one for ambulation with no changes or updates to the care plan. During intermittent observations between 10/22/18 and 10/25/18 revealed the following: - 10/22/18 at 8:36 AM, the resident walked independently from her room into the lounge by herself wearing a hospital gown. The resident was leaning forward while walking. - 10/22/18 at 12:18 PM, the resident was walking independently throughout the unit. She was leaning forward and was holding up her pants with one hand. - 10/24/18 10:20 AM, the resident was ambulating independently through the dining room. The resident appeared to be slightly off balance while standing still, wavering back and forth, slightly bent forward at the waist. The resident then continued to ambulate independently to the other side of the dining room. - 10/25/18 10:24 AM, the resident ambulated alone down the West Wing of the unit independently, again in a leaning forward position. - 10/25/18 11:21 AM, the resident ambulated with the Director of Rehabilitation from lounge into her room. The resident buckled near the bed and the Director caught her, stabilized her, and got her to lay on her bed. During an interview on 10/24/18 at 2:01 PM, the Director of Rehabilitation stated that an extensive assist with ambulation means using a gait belt around the resident, regardless of distance, and there is partial weight bearing with the resident. During an interview on 10/25/18 at 8:58 AM, CNA #2 stated the resident is independent with ambulation. During an interview on 10/25/18 at 9:18 AM, CNA #3 stated, oh yeah she will walk real good for you by herself. During an interview on 10/25/18 at 10:59 AM, the Physical Therapist stated he would expect staff to walk with her because of an unsteady gait and safety awareness issues. During an interview on 10/25/18 at 11:21 AM, the Director of Rehabilitation stated the resident should stay an extensive assist and she needs someone to walk with her or at least have a hand on her or be next to her. During an interview on 10/25/18 at 11:22 AM, Range of Motion (ROM) Aide #1 stated she holds the resident's hand when she ambulates with the resident. The resident gets agitated if you put a gait belt on her. She also stated the resident walks around the unit independently. The only time she has seen staff walk with her was when the resident was agitated about something. During an interview on 10/25/18 at 1:02 PM, Registered Nurse (RN) #1 Resident Care Coordinator stated that she expects her staff to the look at the resident's Kardex to what their ambulation status is and to follow that status. During an interview on 10/26/18 at 10:00 AM, the Physical Therapist stated that he finished an evaluation on the resident and the resident will be put on a program for strengthening. During an interview on 10/29/18 at 7:47 AM, the Director of Nursing (DON) stated that she expects her staff to put a referral for Physical Therapy for the resident if the resident was having problems or the staff were unable to follow the residents plan of care. 415.12(h)(2)

Plan of Correction: ApprovedDecember 2, 2018

Resident #75 was re-evaluated by Physical Therapy and changed from extensive assist x 1 to a limited assist x 1.
Resident #75 was picked up on a therapy program for strengthening and balance.
Resident #75 will be moved to a room closer to the nurse station.
The Interdisciplinary team will meet and review the resident?s current care-plan, history of falls, safety interventions, and therapy recommendations.
All fall therapy consults completed in the past 60 days will be reviewed and compared to the resident?s current care-pan to ensure accuracy.
Director-of-Therapy or designee
All residents on the dementia unit that have an extensive/limited assist x 1 for ambulation will be reviewed to ensure the following; the residents current care-plan and current therapy recommendations are compared for accuracy, and the appropriate assistance is being provided to the resident according to care-plan.
Director-of-Therapy or designee
What measures will the facility take to ensure the problems do not recur
1. All full/part-time licensed/certified nursing personnel will be rein-serviced on following the resident?s care-plan and timely reporting of any deviations to the care-plan.
Director-of-Nursing or designee

2. Weekly audits will be conducted for the next 6 weeks on 8 random residents care-planned with ext/limited assistance x 1 for ambulation to ensure the following; the residents current care-plan and current therapy recommendations are compared for accuracy, and the appropriate assistance is being provided to the resident according to care-plan.
Director-of-Therapy or deisgnee
The results of all audits will be reviewed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Director-of-Therapy will oversee the completion of this P(NAME) in its entirety.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint # NY 930) during the Standard survey completed on 10/29/18, the facility did not ensure that all alleged violations of abuse, exploitation or mistreatment, were thoroughly investigated. One (Resident #80) of four residents reviewed for abuse did not have a complete and thorough investigation conducted for misappropriation of resident property. The finding is: Review of the facility's policy entitled Personal Property with the revised date of (MONTH) 2012, documented that a representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room. Resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. Furthermore, that the facility will promptly investigate any complaints of misappropriation or mistreatment of [REDACTED]. 1. Resident #80 was admitted to the facility on [DATE] had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated revealed the resident had severe cognitive impairment, usually understands and is usually understood. The Misappropriation of Resident Property Report dated 9/26/18 documented that it was reported to the Social Worker the resident had several missing personal items. The report did not give a description of the missing items, but instead documented to see attached receipts. Attached to the report were photo copies of eight receipts for mulitple various personal items that included toiletries, and several clothing items. The Social Worker documented that she checked with the family, social services, nursing, and activities departments. The Social Worker personally checked with laundry and the missing items were not located. The documented resolution was that the items cannot be verified that they were purchased for resident. The Administrator signed and dated the report on 10/1/18. Review of a facility document entitled Clothing/ Items for Labeling/ Delivery, provided by the Director of Laundry on 10/26/18 at 10:30 AM revealed all the items listed on the document reconciled with the photocopy receipts provide by the family. During an interview on 10/25/18 1:08 PM, the Director of Laundry stated when a family member brings in clothing it all gets labeled, washed and every article is documented on the Clothing/ Items for Labeling/ Delivery Sheet before the clothing gets delivered to the unit. During an interview on 10/26/18 at 10:08 AM, the Administrator stated the process for missing resident property, is that the Nursing Supervisor gets notified and we start a search for the missing items. He also stated that we do have a missing report that gets filled out and we try to find the items. If we can't find them and it is a credible loss I replace the items. Additionally, when interviewed regarding credible the Administrator stated, if they have receipts and or it was checked in through the laundry department I reimburse the resident. During an interview on 10/26/18 at 10:16 AM, Social Worker (SW#2), stated when a patient gets admitted and has valuables the nursing staff bring them to me. I hold on to them until the resident can lock them up, if they have a lockable drawer or until the family can take them home. She then stated, we do have a Misappropriation of Resident Property Report that I usually fill out. She was aware the resident had missing personal items, as the resident's sister came in and a report out was filed. The SW took the family member to the laundry room and they looked for the items, and they were unable to locate any of the items. The SW further stated, I asked her to bring in receipts for the items, but the receipts that she brought in all reflected socks, underwear and boys uniform pants. I told her that I could not accept these receipts because they did not reflect items for a man. 415.4(b)(3)

Plan of Correction: ApprovedDecember 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #80- An investigation was completed by the Administrator and the Social Worker and the resident has been reimbursed and made whole for missing personal items.
A 100% audit was completed of grievances regarding misappropriation or mistreatment of [REDACTED].
The Director of Quality Assurance will review with the Administrator and with the Director of Social Work the Facility?s policy ?Personal Property?.
A review of the Facility?s policy and procedure for identifying, labeling and inventory of personal items will be completed.
The Director of Quality Assurance to review the last 60 days of misappropriation grievances.
The Director of Quality Assurance will review all misappropriation grievances for 3 months.
All misappropriation grievances will be reviewed by the Director of Social Work monthly at QAPI on an ongoing basis.
The Director of Social Work will oversee the implementation of the P(NAME) in its entirety.

FF11 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed 10/29/18, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Three (Unit 2, 3 and 4) of three units and one of one kitchen were observed to have little black flies flying around in the hallways, rooms and main kitchen. Residents A, B and C were involved. The findings are: Review of the policy entitled Pest Control dated (MONTH) 2008 revealed the facility shall maintain an effective pest control. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. a) Intermittent observations on Unit 2 were as follows: - 10/22/18 at 11:55 AM, in the main dining room during meal observations, there were multiple little black flies flying around. - 10/23/18 at 10:15 AM, in the activities room during a group interview, there were several little black flies flying around. - 10/26/18 at 8:12 AM, the Unit 2 nurses station had little black flies flying around the desk area. During an observation and interview on 10/22/18 at 11:14 AM, Resident B stated, Those little flies bother me. They are always in here. I think they may be coming from the bathroom drain. The interview took place in the resident's room on Unit 2. During the interview several little black flies were observed flying around the room. During an observation and interview on 10/22/18 at 11:45 AM, Resident A stated, There are a bunch of little flies in my room all the time. It does bother me, they are a nuisance. The interview took place in the resident's room on Unit 2. During the interview several little black flies were observed flying around the room, and into the surveyor's face. During an observation and interview on 10/26/18 at 8:22 AM, Resident C stated, Those little flies are always flying around in my room and they bother me. The interview took place in the resident's room on Unit 2. During the interview several little black flies were observed flying around the room while the resident was eating his breakfast. b) Intermittent observations on Unit 3 were as follows: - 10/25/18 at 8:45 AM, there were multiple little black flies flying around unit 3 during breakfast. - 10/26/18 at 12:15 PM, there were multiple little black flies were scattered around the unit and in the dining area during lunch. c) Intermittent observations on Unit 4 are as follows: - 10/24/18 at 2:34 PM, little black flies were flying in the hallway near the nourishment room. - 10/25/18 at 8:52 AM, little black flies were flying in the hallway of room [ROOM NUMBER]. - 10/25/18 at 8:57 AM, little black flies were flying in the hallway near the elevator. d) During an observation of the main kitchen, on 10/24/18 at 10:06 AM, there were little black flies flying around the food prep area during the preparation of the puree foods. The Food Service Director stated the flies usually fly around inside the kitchen and that they come and go depending on the weather. They facility does have pest control come in, but maintenance handles that. e) During a tray line observation in the main kitchen on 10/25/18 between 11:30 AM and 12:53 PM there were multiple observations of little black flies flying around. Review of Pest Control Inspection and Service Reports dated from 11/24/17 through 10/22/18 revealed pest control services were provided for fruit flies. All drains were treated with special attention to breakroom and kitchen noted. During an interview on 10/25/18 at 4:05 PM, the Director of Maintenance stated they have had the fruit flies for several months and they have been treating them. The Pest Control Company said it is because trays have being left out and the presence of the flies depends on the weather. These flies tend to die down when it is hot out and then when it is cooler they come back. They are everywhere in the facility. They are in the kitchen, nourishment rooms, dining rooms, hallways and residents' rooms. The treatment they recommend does work, but it is not done on a regular basis. Treatments are done when they start appearing again. 415.29(j)(5)

Plan of Correction: ApprovedDecember 2, 2018

Pest Control Company contacted by facility to address black flies noted in the following areas: main dining areas on all units, activity room, common areas on all units, resident rooms, nourishment rooms and food service kitchen areas.
What measures will the facility take or the systems it will alter to ensure that the problem does not occur?
Administrator and Maintenance Supervisor to meet with pest control company to develop a written plan for the facility which addresses the prevalence of black flies.
The pest control company will add an additional day of monitoring at the facility to address and eliminate presence of black flies.
All full/part-time environmental, dietary and nursing staff to be rein-serviced on timely removal of uncovered foods and perishable items located in the main dining areas, activity room, common areas, resident rooms, nourishment rooms, and food service kitchen areas.
The inservice will be provided by the Maintenance Director
How will the facility monitor its performance to make sure that solutions are sustained?
Weekly audits will be conducted x 8 weeks on random areas in the facility for the prevalence of black flies and timely removal of uncovered foods and perishable items.
The Administrator of the facility will review pest control reports to ensure appropriate monitoring.
The results of all audits and reports will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Maintenance Director will oversee the implementation of the P(NAME) in its entirety.

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: Pattern
Severity: Potential to cause minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 10/29/18, the facility did not ensure that Office of the State Long Term Care Ombudsman was notified of the transfer/ discharge of each discharged resident. This was evident for three (Residents #34, 122, 241) of four residents reviewed for admission, transfer, discharge notice requirements. Specifically, the facility did not send a copy of the discharge notice to the Office of the State Long Term Care (LTC) Ombudsman. The findings are: The Transfer/Discharge Notice instructions form dated 3/18, documented to email a copy of the discharge/ transfer notice to the regional Long Term Care Ombudsman's Office with the name of the facility in the subject line. For emergency transfers only, the facility may send a list of the residents transferred to the acute care hospital on a monthly basis. 1. Resident #122 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 10/1/18 documented the resident was cognitively intact. Review of the Nursing Home to Hospital Transfer Forms dated 7/25/18 and 8/30/18 revealed the resident was transferred to the hospital. A nurse's Progress Note dated 7/25/18 and 8/30/18 documented the resident was admitted to the hospital for evaluation and treatment of [REDACTED]. The Progress Notes dated 7/25/18 through 10/18/18 revealed there was no documented evidence a copy of the discharge notice dated 7/25/18 or 8/30/18 was sent to the Office of the State Long-Term Care Ombudsman. During an interview on 10/26/18 at 10:32 AM, the Social Worker (SW) #1 stated she was not aware that she was supposed to notify the ombudsman's office about discharges to the hospital. During an interview on 10/26/18 at 11:20 AM, a representative from the Ombudsman program stated they had not received discharge notices for Resident #122 for the dates of 7/25/18 or 8/30/18. During an interview on 10/29/18 at 9:23 AM, the Director of Nursing (DON) stated the Ombudsman should have been receiving information of the resident's transfer/ discharge to the hospital, but the process was dropped because of a change of department directors. 2. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, was understood and understands. Review of the MDS accepted into the database included a Discharge assessment dated [DATE]. The Physician's Re-Admission note dated 2/15/18 documented the resident was admitted to the hospital from 2/11/18 to 2/14/18. Review of the entire medical record revealed there was no documented evidence the Ombudsman office was notified of the hospitalization on [DATE]. During an interview on 10/25/18 at 9:40 AM, Social Worker #3 stated, I have not sent out notifications to the Ombudsman Office. I have received some information about it via e-mail, but I really have not looked into what I am to be doing. I was never told to send out these notifications. During an interview on 10/25/18 at 9:51 AM, the Director of Social Work stated, We have just started to send notification to the Ombudsman Office about two months ago. Each Social Worker is to be sending them for their residents they are assigned to. I have spoken to the other Social Workers and have sent out e-mails regarding this, informing them that they needed to start doing them. I did not have them sign a copy of the in-service/ instructions that they needed to be doing this. I have not done any QA (quality assurance) on this as I just recently started sending notification to the Ombudsman Office. I do not know if the facility has a policy. During an interview on 10/25/18 at 11:09 AM, the Ombudsman Program Director stated, It has been a hit and miss with receiving the notifications from this facility. We are not getting the volume to match the facility. We have received some, but very few in the months of January, (MONTH) and May. The facility did reach out to me on 10/22/18 regarding the notifications and that were sending them to the wrong Ombudsman Office in New York City. 3. Resident #241 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, was understood and understands. The nursing Progress Note dated 2/19/18 documented the resident was admitted to the hospital with [REDACTED]. Review of the MDS accepted into the database included a Discharge assessment dated [DATE]. Review of the entire medical record revealed there was no documented evidence the Ombudsman office was notified of the hospitalization on [DATE]. During an interview on 10/25/18 at 2:03 PM, the Ombudsman Area Program Director stated, We have only received a total of 15 notifications since the new regulations have been put in place from this facility. Out of the fifteen, Resident #34 and Resident #241 were not any of them. 415.3(h)(1)(iv)(a-e)

Plan of Correction: ApprovedDecember 2, 2018

Resident # 122- The Ombudsman was notified of the discharges that occurred on 7/25/18 and 8/30/18.
Resident #34- The Ombudsman was notified of the discharge that occurred on 2/11/18.
Resident #241- The Ombudsman was notified of the hospitalization of 2/11/18. Resident has been discharged from the Facility.

A thorough review of all transfers and discharges was completed for the past 30 days and notification to be sent to the State Long Term Care Ombudsman.
What measures will the facility take to ensure that the problems do not recur.
1.Social Workers to be educated on the facility policy of their responsibility to notify the Ombudsman on all transfers/discharges.
Regional QA nurse
2. The Director of Social Work will audit all Transfers/discharged to ensure notification to the Ombudsman is complete.

3. The Director of Social Work will contact the State Long Term Care Ombudsman monthly to ensure receipt of monthly notifications.
RN supervisors to be educated on acute transfers and need to complete transfer-discharge documentation.
The results of all audits and reports will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Director-of-Social Work will oversee this P(NAME) for completion in its entirety.

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Actual harm has occurred
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY 034) completed during the Standard survey on 10/29/18, the facility did not ensure that each resident received treatment and care based on the comprehensive assessment of the resident that is in accordance with professional standards of practice for one (Resident #241) nine residents reviewed for diabetic management. Specifically, the incorrect transcription of medication orders resulted in the administration of insulin (used to decrease glucose (blood sugar) levels in the blood). The administration insulin and the lack of monitoring glucose levels led to critically low blood glucose levels, and subsequently hospitalization . This resulted in actual harm that is not immediate jeopardy. The findings are: The policy entitled Nursing Care of the Resident with Diabetes Mellitus dated (MONTH) (YEAR) documented the purpose of the guideline was to review the most common and serious conditions and complications associated with diabetes, help the resident control his/ her diabetes with diet, exercise, and insulin (as ordered), and to prevent recurrent [MEDICAL CONDITION]/ [DIAGNOSES REDACTED]. The management of individuals with diabetes mellitus should follow relevant protocols and guidelines. The physician will order the frequency of glucose monitoring. Additionally, residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on the situation. The survey team requested a policy on readmission/ admission procedures on 10/29/18 at 11:00 AM and none was provided by the facility. 1. Resident #241 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 2/19/18 documented the resident was cognitively intact, was understood and understands. The MDS also documented the resident received insulin injections. The current Comprehensive Care Plan with an initiated date of 1/24/18 had no documented plan for the use of insulin and glucose monitoring. A Change of Condition Progress Note dated 2/4/18 at 4:43 PM by Licensed Practical Nurse (LPN #2) documented around 8:00 AM, the resident was found unresponsive, had pursed lip breathing with clear mucous coming from their mouth. Several attempts were made to arouse the resident without success. A blood glucose level was obtained and documented as 33 (normal 70-130). The resident was administered [MEDICATION NAME] (medication used to raise concentration of glucose in bloodstream) IM (intramuscular- injection directly into the muscle) per the physician's orders [REDACTED]. The resident became more alert and responsive after the administration of [MEDICATION NAME]. Repeated blood glucose levels during this time were obtained and documented as 55 and 104. The doctor (MD) was updated on resident's condition and orders were obtained for STAT (now) blood work which included a CBC/ CMB (complete blood count/ comprehensive metabolic panel), reduce [MEDICATION NAME] (insulin) to 10 ml (milliliters) at HS (hour of sleep) and to notify the MD for blood glucose levels below 60 or greater than 300. laboratory results dated [DATE] documented a glucose level of 71 L (low), with a reference range of 74-100 mg/dl (milligram/ deciliter). A nursing Progress Note dated 2/5/18 documented the following: - 4:15 AM, Registered Nurse Supervisor (RN #6) documented the resident was found unresponsive, except to a sternal rub with fixed and dilated pupils. The resident's skin was cold and clammy, the bed linens and the resident's gown were wet. The following vital signs were documented, pulse ox (PO2, amount of oxygen in the blood) 91 % (percent, normal 95-100 %), and pulse rate of 104 (normal 60-100). A new order was obtained to administer 1 mg (milligram) of [MEDICATION NAME], discontinue the HS [MEDICATION NAME] and to increase oxygen (O2) to 4L (liters) for comfort till responsiveness returned. After the administration of [MEDICATION NAME], the resident became responsive to verbal commands, and was able to eat and drink. The BSFS (blood sugar fingerstick) slowly increased to 89 by 4:45 AM. The note did not include a blood glucose level but documented will continue to monitor for [DIAGNOSES REDACTED]. - 7:48 AM, Licensed Practical Nurse (LPN #7) documented she was called to the resident's room by a CNA (certified nurse aide, unidentified), the resident was cold, clammy and unresponsive. The Supervisor was notified. The following glucometer readings (blood glucose levels) were documented: 4:00 AM the FS was 34, 5:00 AM the FS was 89, and at 6:30 AM the FS was 93. The resident was verbally responsive at this time, skin warm and dry to touch. - 9:16 AM, LPN #7 documented that she was called to the resident's room by a CNA (unidentified). The resident was found with cold and clammy skin, and the resident was diaphoretic (sweating heavily). The LPN obtained a fingerstick (blood glucose level) of 38. The Supervisor was called to the unit. The resident's BP (blood pressure) was 170/90 (normal 120/80). A second fingerstick was obtained after orange juice and sugar was given, and the blood glucose was up to 58. A nursing Progress Note dated 2/6/18 at 1:00 AM, RN Supervisor #6 documented the resident was admitted to the hospital with [REDACTED]. A hospital Discharge Summary dated 2/13/18 for a discharge date of [DATE] documented discharge [DIAGNOSES REDACTED]. The discharge summary documented to PLEASE AVOID GIVING THIS PATIENT INSULIN (LONG OR SHORT ACTING). Patient has had multiple admissions for [DIAGNOSES REDACTED], transiently high blood sugars are preferred to low blood glucose. The summary also documented the PATIENT NO LONGER REQUIRES INSULIN and was at high risk for [DIAGNOSES REDACTED]. Additionally, included instructions to STOP TAKING THESE MEDICATIONS - Insulin [MEDICATION NAME] ([MEDICATION NAME], long-acting insulin to help control blood sugar level) 10 units sub-Q (subcutaneous- beneath the skin) injection, daily at bedtime. A Nursing Admit/ Readmit Screen dated and signed by RN Supervisor #6 on 2/16/18 documented admitting [DIAGNOSES REDACTED]. A Medication Review Report signed by physician on 2/17/18 documented orders for Insulin [MEDICATION NAME] Solution Pen-injector 100 unit/ ml (milliliters)- inject 10 unit subcutaneously at bedtime for DM with start date of 2/16/18. There were no orders or instructions to monitor the residents blood glucose levels. A Physician's Comprehensive Nursing Home Visit- Admission History & Physical dated and signed on 2/17/18 documented [DIAGNOSES REDACTED]. The resident was receiving rehabilitation at the facility when she was transferred back to the hospital on 2/7/18 for [DIAGNOSES REDACTED] and altered mental status. The physician's documented Assessment/ Plan included: Altered Mental Status secondary to [DIAGNOSES REDACTED], resolved, monitor glucose and DM on [MEDICATION NAME]. The Medication Administration Record [REDACTED]. There was no documented evidence of glucose monitoring. Review of the Progress Notes dated 2/16/18 through 2/18/18 revealed there was no documented evidence of glucose monitoring. Review of a document entitled Weights and Vitals Summary for blood sugar results revealed there was no glucose testing documented for the month of (MONTH) (YEAR), except for the result of 222 on 2/19/18. A nursing Progress Note dated 2/19/18 documented: - 1:28 AM, LPN #2 documented the resident was alert with some confusion. PO2 was 95% with O2 on as ordered. The resident was able to participate in ADL's (activities of daily living), and could self-propelled wheel chair. Meds were given as ordered and her appetite was good. - 9:00 AM, the former Assistant Director of Nursing (ADON) documented a change of condition, the resident was lethargic and slumped over in bed. At 9:05 AM, IM [MEDICATION NAME] was given for a fingerstick (blood glucose) of 37. The resident became more alert after the administration of [MEDICATION NAME] and was given juice with sugar. The MD was updated on the hypoglycemic event. - 10:52 AM, an RN #7 RCC (Resident Care Coordinator) documented there was good effect from [MEDICATION NAME] administration, a FS was retaken and the result was 222. Ambulance was called by a 4th party per EMT (emergency medical technician). Resident refused to go out to hospital, and stated she was not having any chest pain. EMT did encourage resident to go for evaluation and she agreed. The resident was transferred to hospital for evaluation. - 8:58 PM, RN Supervisor #6 documented the resident was admitted to the hospital at 2:59 PM with [DIAGNOSES REDACTED]. A hospital Discharge Summary dated 3/1/18 documented an admitting [DIAGNOSES REDACTED]. The patient was given [MEDICATION NAME] and sent to hospital. Upon arrival to the hospital the glucose had normalized and appropriately responded to treatment. Subsequently while in the ED (emergency department) the patient had an alteration in mental status and was found to have a fingerstick glucose of 21. The patient was given 1 amp (25 grams) of D50 ([MEDICATION NAME] in 50 ml (milliliters) - fluids given intravenously to help raise blood sugar level) and was subsequently admitted for refractory [DIAGNOSES REDACTED] (unmanageable). The summary also documented [DIAGNOSES REDACTED]- acute metabolic [MEDICAL CONDITION] mostly likely due to low blood sugars. Additionally, avoid any long acting insulin agents in patient as this is second or third hospitalization for [DIAGNOSES REDACTED]. During an interview on 10/26/18 at 11:22 AM, the Medical Director stated, I would say that 100% of the time I will always go by what the hospital discharge summary would recommend for a resident readmitted into the facility. I have 48 hours to see the resident when they come back from the hospital. The nurses/ supervisors would be the one reading the discharge summary recommended medications to me to order. I go by what the nurses tell me and trust the nurses as to what the discharge summary recommends regarding the medications and other recommendations on it. I do not know why the insulin was ordered if the discharge summary had to stop it, the nurse may have miss-read the orders to me. I usually try to read the discharge summaries from the hospital when I come in and see the resident. I do not know why I did not address the recommendations in my history and physical on 2/17/18 or discontinue the insulin. When a diabetic is admitted or readmitted back to the facility they should have their glucose level be monitored and that is standard for every diabetic. The facility should be monitoring the resident's glucose for the first seven days, four times a day regardless. If the resident becomes stable they should be monitored at least 1 to 2 times a week regardless. As to why the glucose levels would have been discontinued on 1/31/18, I would have to think someone mistakenly clicked something and caused it to be deleted from the system. She should have been having the glucose levels done. The Physician further stated because she has a [DIAGNOSES REDACTED]. I would say this caused harm for such a brittle diabetic. During an interview on 10/26/18 at 12:53 PM, the ADON stated, When a resident is readmitted back into the facility from the hospital, you would use the discharge summary from the hospital and read from that to the physician to confirm the orders. Just the RN's would do this for admits and re-admits. During a telephone interview on 10/26/18 at 1:15 PM, former RN Supervisor #6 Supervisor stated, she would read the discharge summary medications to the physician, get the medications approved by the physician, and place them in name of computer system. The RN stated she did not recall if she read to stop the insulin to the MD but stated, I usually read off the whole discharge summary. If it said to stop the insulin, I am not quite sure why I had the MD order it. Additionally, stated, when a resident comes back on insulin and is a diabetic I would usually ask the Physician if they would like fingerstick levels. During an interview on 10/26/18 at 2:36 PM, the Director of Nursing (DON) stated, the process for taking orders off (transcribing) when a resident is admitted or readmitted to the facility is that the RN would read off the discharge summary to the physician what was recommended, and the nurse would then confirm the orders with the physician and put them in the computer. By reading these orders from Resident #241's discharge summary, I would say the resident should not have been getting the insulin as it says to stop. The error is on the person who took the orders off. In addition, the DON stated, At that time the RN may or may not have asked the MD for glucose levels it would depend on the resident's situation. We would not have necessarily monitored the glucose because she was on [MEDICATION NAME]. During an interview on 10/26/18 at 2:49 PM, the Administrator stated, The DON or myself would do a review of negative outcomes. There is a process for reviewing outcomes. I do not know if we did a review on this issue. The RN Supervisor who took the orders was not released (terminated) because of this situation, she resigned. When asked if this chart was reviewed for the negative outcome of this resident it was stated well we really need to look at the chart to see what is going on. During an interview on 10/26/18 at 3:44 PM, the RN, Regional Director of Quality Assurance stated, When any resident comes back to the facility from the hospital it should be reviewed. It should be reviewed by the nurses and the DON. I would absolutely encourage the physician to do blood glucose monitoring on any diabetic coming back on insulin. The best practice would encourage the MD to monitor the glucose levels, but ultimately the decision is up to physician. During an interview on 10/29/18 at 8:50 AM, the following were present RN/ Administrator, Director of Strategic Planning; RN Regional Director of Quality Assurance; DON; Administrator and Assist Administrator from the facility. The following was stated by the RN/ Administrator, Director of Strategic Planning, The DON had completed an entire chart review with an investigation completed back in (MONTH) (YEAR) when the incident had occurred. A 100% audit of the entire building for all residents with diabetes mellitus was completed in (MONTH) and in-services were done with all the nurses at the time. It was stated that they had signatures from all the nurses from this in-service. The audit was for six weeks, where they found some residents were without fingerstick orders, therefore it was corrected by receiving orders for the fingerstick to be done. The RN Supervisor who transcribed the order incorrectly was disciplined. There was a Quality Improvement Tool completed, so therefore the DON did identify the issue in (MONTH) and corrective actions were taken. The entire building this past weekend was re-educated again regarding glucose monitoring. When asked what they felt went wrong, The DON stated, I think the nurse read the orders on the discharge summary wrong to the doctor. The doctor should have looked at the discharge summary. It is expected the doctors read the discharge summary. The RN/ Administrator, Director of Strategic Planning stated, The nurse must not have seen the discharge summary state do not give the insulin. The doctor should have acknowledged that he reviewed the discharge summary either by signing the copy or writing it in his note on 2/17/18. Review of the facilities investigation revealed on 2/21/18 the DON initiated an investigation secondary to a QI (Quality Improvement) review. The investigation documented that all nurses were educated on the need to monitor blood sugars on any resident admitted to the facility with a [DIAGNOSES REDACTED]. The nurse transcribing the orders was educated and disciplined. A full house review was initiated on all residents with [DIAGNOSES REDACTED]. Review of the In-service Sign in Sheets dated (MONTH) 22, (YEAR) revealed three nurses were educated in February, two nurses in March, five in April, one in (MONTH) and one in September. The in-service addressed the monitoring of residents with a [DIAGNOSES REDACTED]. During an interview on 10/29/18 at 10:01 AM, the RN/ Administrator, Director of Strategic Planning stated, No we did not implement anything for Quality Assurance regarding the doctors reviewing hospital discharge summaries. We do not have any medication errors for the month of (MONTH) (YEAR). We only have two since (MONTH) (YEAR), one in (MONTH) (YEAR) and one in (MONTH) (YEAR). 415.12

Plan of Correction: ApprovedDecember 3, 2018

Resident #241- chart was reviewed there were no discrepancies noted between discharge summary, comprehensive care plan, and the medical administration record. The resident discharged successfully to the community.
Director-of-Nursing
At the time of occurrence, Feb (YEAR), a 100% audit of all residents with diabetes mellitus was completed and continued for 6 weeks to ensure residents receiving antihyperglycemic agents had proper blood glucose monitoring orders.
All nurses were educated to same.
Nursing supervisor was educated and disciplined.
Director-of-Nursing or designee
The entire building was re-auditied the weekend of (MONTH) 26 and 27 for all residents with diabetes mellitus to ensure residents receiving antihyperglycemic agents had proper blood glucose monitoring and nurses were again re-educated to same regarding glucose monitoring.
Director-of-Nursing or designee
100% audit was conducted on all current residents with diabetes mellitus to ensure there were no discrepancies with the discharge summary, comprehensive care-plan, and the medication administration record.
Director-of-Nursing or designee
What measures will the facility take to ensure the problem does not recur.
1. All nurses to be educated regarding the need to monitor blood glucose levels for residents receiving antihyperglycemic agents, requirements for med error completion, proper transcription of orders and review of the discharge summary.
Director-of-Nursing or designee
2. All nurses to be educated regarding the need to monitor blood glucose levels for residents receiving antihyperglycemic agents, requirements for med error completion, proper transcription of orders and review of the discharge summary.
Director-of-Nursing or designee

3. The Director of Strategic Planning and the Administrator met with the Medical Director to review the deficient practice and review expectation for reviewing all discharge summaries with initial review.
All current diabetics to be audited to ensure accurate transcription of orders and blood glucose monitoring.

4. A new admission checklist tool to be utilized x 12 weeks to ensure accuracy of transcribed orders and proper blood glucose monitoring orders by the RN and forwarded to the DON.
The DON to review the admission checklists monthly for 3 months at QAPI.
The results of all audits and reports will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Director-of-Nursing will oversee the completion of this P(NAME) in its entirety.

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 10/29/18, it was determined that the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Two (Units 3, 4) of three resident units observed for sanitary and comfortable environment had issues involving foul odors; unlabeled personal care items in a resident bathroom; soiled call light cords; soiled/sticky floors in resident rooms; and a leaking sink pipe. The findings are: Review of facility policy and procedures (P&Ps) revealed the following: - Bathrooms dated 4/06- Bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. - Floors dated 12/09 - Floors shall be maintained in a clean, safe, and sanitary manner. - Daily Resident Room Cleaning dated 1/18 - All residents' rooms must be cleaned using the standard room cleaning procedure. - Maintenance Service dated 12/09 - Maintenance service shall be provided to all areas of the building, grounds, and equipment. Observations of Unit 4 on 10/22/18 revealed the following: - 9:45 AM - Resident room [ROOM NUMBER] W - The bathroom call light had spots of brown debris on the button and cord. There were multiple brown debris spots on the bathroom floor approximately one centimeter (cm) in diameter. The floor was sticky and the room had a stale urine smell. - 10:47 AM - The bathroom located next to Resident room [ROOM NUMBER] (4 bed room) contained 19 stacked wash basins that were not labeled and one unlabeled fracture bedpan on the floor underneath the sinks. There were two overfilled soiled linens bins in the bathroom. - 11:20 AM - Resident room [ROOM NUMBER] P - The inside of the toilet bowl in the resident's bathroom had dark brown and black stains; the toilet seat had brown debris on it; and there was brown debris on the bathroom call light cord and button. - 12:02 PM - Resident room [ROOM NUMBER] 2 - The floor was sticky with areas with dirt and dust debris including used gloves under the bed; the blanket on the resident's bed had a hole approximately one cm in diameter with multiple snags and threads hanging loose. There were two toilets seats in the bathroom with rusty hinges and the bathroom floor was dirty. - 2:51 PM - Resident room [ROOM NUMBER] - The floor was sticky and the room had a stale, musty smell. There was dust and dirt on the floor under the bed including a used glove. Interview with the resident's sister at the time of the observation revealed she sprayed deodorizer because the room stinks so bad. Observation of Units 3 and 4 on 10/23/18 revealed the following: - 8:36 AM - Resident room [ROOM NUMBER] D - There was a stale urine smell in the room and the floor was sticky. - 9:07 AM - Resident room [ROOM NUMBER] 3 - The bathroom sink was leaking water and there was a grey basin underneath to catch the water. Additional observations of Units 3 and 4 revealed the following: - 10/24/18 at 2:25 PM - Resident room [ROOM NUMBER] 2 - The room floor was sticky with dirt, dust and bandaid wrappers it. The floor mat next to the resident's bed was dusty with footprints on it and had multiple white spots one millimeter (mm) in diameter. - 10/24/18 at 2:38 PM - Resident room [ROOM NUMBER] - The floor was sticky with multiple, small spots of brown debris. The toilet in the resident's bathroom had brown debris on the sides. - 10/25/18 at 8:35 AM - Resident room [ROOM NUMBER] - There was a stale urine smell in the room. The bathroom call light had spots of brown debris on the button and cord. There were numerous spots of brown debris on the bathroom floor that were approximately one cm in diameter. 10/25/18 at 8:33 AM - Resident room [ROOM NUMBER] P - The inside of the toilet bowl in the resident's bathroom had dark brown and black stains. The toilet seat had brown debris and there was brown debris on the bathroom call light cord and button. - 10/26/18 at 9:36 AM - Resident room [ROOM NUMBER] - The bathroom sink was leaking water and there was a grey basin underneath to catch the water. Further observation on 10/26/18 at 10:40 AM revealed the bathroom located next to Resident room [ROOM NUMBER] (4 bed room) still contained 19 stacked wash basins that were not labeled and one unlabeled fracture bedpan on the floor underneath the sinks. Two overfilled soiled linens bins remained in the bathroom. During an interview on 10/26/18 at 10:41 AM, the Director of Housekeeping stated he expects his staff to clean the residents' rooms every day including the call light cords. The day shift housekeeping staff should be cleaning the toilets and the afternoon shift should be spot checking the toilets for cleanliness. During an interview on 10/26/18 at 10:43 AM, a Certified Nurse Aide (CNA #1) stated that staff are supposed to put resident care equipment labeled with their room number into the residents' nightstand drawers. Review of the Maintenance Report Log dated 10/1/18 to 10/29/18 revealed there was no notation of the leaking bathroom sink in Resident room [ROOM NUMBER]. During an interview on 10/29/18 at 7:39 AM, a Licensed Practical Nurse (LPN #6) stated if there was a maintenance issue with a resident's room or bathroom, she would expect the staff to write the issue in the Maintenance Log. She would expect staff to label wash basins and bed pans with the resident's room number and those items should be stored in the resident's drawers. LPN #6 stated she did not see Resident room [ROOM NUMBER] in the Maintenance Log and she would put it in the log right away. During an interview on 10/29/18 at 7:47 AM, the Director of Nursing (DON) stated she expects her staff to label and store personal care items properly. She expects her staff to put maintenance items in the Maintenance Log so it can be addressed. When interviewed on 10/29/18 at 7:59 AM, the Director of Maintenance stated that he expects staff to put any maintenance issues in the Maintenance Log so we can fix it. 415.5(h)(2)

Plan of Correction: ApprovedNovember 24, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** room [ROOM NUMBER]W- the room was deep cleaned removing urine odors, debris from call light and floors. The floor was cleaned removing debris and sticky substances. Housekeeping/Laundry Supervisor
All wash basins and bedpans were removed from bathroom next to resident room [ROOM NUMBER] and discarded. The soiled linens bins were removed from the bathroom.
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]p- the inside of the toilet bowl and toilet seat was cleaned removing dark brown and black stains. The bathroom call light was cleaned removing brown debris on the call light cord and button.
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]-2- The room and bathroom was deep cleaned removing sticky substance from floors, dirt, debris and used gloves under bed. The blanket was replaced. The toilet seats were replaced.
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]- The room was deep cleaned removing sticky substance off the floor and eliminating odors. The used glove was removed from under the bed.
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]d- The room was deep cleaned removing sticky substance off the floor and eliminating odors.
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]-3- The bathroom sink was repaired
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]-2- The room was deep cleaned removing sticky substances from floors, dirt, dust and band-aide wrappers. The floor-mat was replaced.
Housekeeping and Laundry Supervisor
room [ROOM NUMBER]- The room was deep cleaned removing sticky substances from floors, spots, and brown debris. The toilet in the bathroom was cleaned removing brown debris on the sides.
Housekeeping and Laundry Supervisor
100 percent audit will be conducted on all resident rooms to ensure proper housekeeping and maintenance services are provided to maintain a sanitary, orderly, and comfortable interior.

100 percent audit will be conducted on all resident rooms to ensure resident care equipment is properly labeled
Director of Environmental Services will be starting on 11/27/2018 and the sod will be reviewed.
Proficiency audits will be conducted on all full/part-time housekeeping employees immediately, upon-hire, and annually.
.
All full/part-time housekeepers and environmental employees will be rein-serviced on homelike environment and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. To include: daily cleaning of rooms and bathrooms, removal of all debris, removal of all sticky substance on floors, proper working equipment and cleaning of resident?s call lights.
All full/part-time environmental and nursing employees will be rein-serviced on correct procedure and expectation of Maintenance Logs.
10 rooms per week will be audited x 8 weeks by the Adm/asst. admin then 100% monthly by the director-of-environmental services, Adm/Asst Adm to ensure proper housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. To include daily cleaning of rooms and bathrooms, removal of all debris, removal of all sticky substance on floors, proper working equipment, labeling of personal items, and cleaning of resident?s call lights.
The maintenance logs will be reviewed monthly by the Administrator or Assistant Administrator.
The results of these audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
This P(NAME) will be overseen by the Environmental Service Director to ensure completion in its entirety.

FF11 483.40(b)(3):TREATMENT/SERVICE FOR DEMENTIA

REGULATION: §483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Standard Survey completed 10/29/18, the facility did not ensure a resident who displays or is diagnosed with [REDACTED].#59) of three residents reviewed for dementia care. Specifically, the facility did not revise the resident's plan of care to provide ongoing meaningful activities to meet the resident's interests when the resident experienced a change in behavior and involvement. The finding is: 1. Resident #59 was admitted to the facility 5/24/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set -MDS (resident assessment tool) dated 8/23/18 revealed the resident had severe cognitive impairment, was understood and understands. The admission MDS dated [DATE] documented it was very important to have books, newspapers, magazines to read; listen to music; be around animals such as pets; keep up with the news; do things with groups of people; go outside to get fresh air when the weather is good; and participate in religious services or practices. Review of the Comprehensive Care Plan revised 8/24/18 revealed a focus area of self chosen activities and required gentle reminders from staff to foster a sense of involvement in pro-social group engagement related to choosing to stay in personal space. Planned interventions included to provide the resident with a monthly calendar; invite resident daily, and escort to activities. Although she chooses not to participate preferred activities are: movies; outside experiences, bingo, music entertainment, bingo, 1:1 (one to one) visits by staff with similar interests/hobbies. Review of a Physician's History & Physical dated 5/26/18 revealed supportive care for dementia. A Nurses Note dated 6/13/18 documented the resident's mood had changed and that she used to look forward to outings and activities. The resident now appeared very depressed and asked to be taken off the lists for activities. An unsigned Pharmacy Consultant Note to Attending Physician/ Prescriber dated 6/14/18 documented the resident's medications were reviewed at the BMARC (Behavior Monitoring and Recommendation Committee) meeting on 6/14/18. A dramatic change in mood had been noted after medication changes. The resident used to look forward to outings and activities, but now appeared very depressed and asked to be taken off the lists for activities. The Activity Attendance Logs from 5/1/18 through 10/15/18 documented that 1:1 visits were provided once on 10/15/18. During intermittent observations on 10/22/18 through 10/24/18 between 9:50 AM and 2:15 PM Resident #59 was observed to stay in her room, lying/sleeping in bed in a fetal position. The room was dark and the curtains were closed. There was no television, magazines, books or radio in the room. During an interview on 10/24/18 at 11:22 AM, the Director of Activities stated due to the high turnover rate in the activities staff, the department was lacking in documentation. She has had difficulty inputting documentation into computer program and has no accountability for who attended activities. The Director of Activities stated she provides 1:1 visits and then stated, When a resident chooses to be left alone, typically we leave them alone. the Director of Activities also stated they should have provided and offered the resident with in room activities to meet the resident's interests. During interview on 10/24/18 at 2:38 PM, CNA #4 stated, occasionally on the second shift the resident will come to the lounge area, but otherwise will remain in her room and wants to be left alone, so will leave her alone. CNA #4 then stated she does not recall if she had in-servicing on caring for residents with dementia. During an interview on 10/25/18 at 10:08 AM, RN #1 stated that when the resident came to the facility she would participate in activities. Then she suddenly stopped attending and would not come out of her room. Resident #59 had also requested to be taken off the list of all activities. Review of the Facility Survey Report revealed Dementia Care was not on the list of in-service topics presented to the nurse aides since the last survey. During an interview on 10/29/18 at 7:55 AM, the Director of Nurses (DON) stated she has provided Behavior training to the staff on the units and is on a case by case basis, but otherwise there was no dementia training in place. During an interview on 10/29/18 at 8:00 AM, the Administrator stated he had identified that the staff needed Dementia/Alzheimer's training and will be working with name of company to provide the training. The Administrator stated that no staff has had training in dementia care since he started in the facility in (MONTH) of (YEAR) and was unable to provide any in-service training logs. 415.12

Plan of Correction: ApprovedDecember 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The interdisciplinary team will meet to review and revise resident #59 current activities care-pan to ensure there are meaningful activities that meet the resident?s interest. Resident #59 will have a quarterly assessment completed for activities.
Resident #59 will be referred to psychological services for evaluation.
100 percent audit will be conducted on all current residents? with a [DIAGNOSES REDACTED].?s interests.
What measures will the facility take to ensure that the problem does not recur.
1. All staff will receive education on dementia care immediately, upon-hire, and annually.
Administrator or Designee
2. All full/part-time activity staff will be rein-serviced on daily attendance documentation of residents.
Director-of-Activities
3. The current Activities Director will receive training and education on activity assessments and care-planning, MDS, and attendance documentation by experienced Director from sister facility.
4. The Activities Director will review attendance logs for completion on a daily basis for 60 days.
5. The Assistant Administrator will review attendance logs for activities weekly x 8 weeks for completion.
3 care-plans per week for 8 weeks will be audited on current residents who have a [DIAGNOSES REDACTED].?s interests ( asst admin)
The results of all audits and reports will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
This P(NAME) will be overseen by the Assistant Administrator for completion in its entirety.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 10, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 10/29/18, structural components of the building were not properly protected from fire. Issues included, unprotected structural steel beams and structural steel trusses, located above a non-fire rated ceiling assembly, that were not protected to meet the minimum fire rating of building construction type II (222). This affected Four (First, Second, Third, and Fourth Floors) of four resident use floors. The finding is: 1. Intermittent observations on 10/22/18 between 8:20 AM and 3:55 PM revealed that this facility is a fully sprinklered four-story building and each of the floors had areas of the ceilings that were comprised of lay-in style ceiling assemblies. a) Observation on the Fourth Floor, on the 10/23/18 at 8:40 AM, revealed unprotected steel trusses were observed through numerous penetrations in the solid ceiling located above the lay-in style ceiling assembly at the nurse's station. b) Observation on the Third Floor, on the 10/23/18 at 8:53 AM, revealed unprotected steel trusses were observed through numerous penetrations in the solid ceiling located above the lay-in style ceiling assembly at the nurse's station. c) Observation on the Second Floor, on the 10/23/18 at 9:02 AM, revealed unprotected steel trusses were observed through numerous penetrations in the solid ceiling located above the lay-in style ceiling assembly at the nurse's station. d) Observation on the First Floor, on 10/23/18 at 9:10 AM, revealed unprotected steel beams were observed above the lay-in style ceiling assembly in the First-Floor corridor near the service elevator. e) Observation on the First Floor, on 10/23/18 at 9:26 AM, revealed unprotected steel beams were observed above the lay-in style ceiling assembly in the First-Floor front lobby and corridor near the passenger elevator. Observations on 10/23/18 from approximately 8:40 AM until 9:40 AM revealed unprotected steel beams were observed above the lay-in style ceiling assemblies on the First Floor and unprotected steel trusses were observed above the lay-in style ceiling assemblies on the First, Second, Third, and Fourth Floors. The observations revealed the lay-in style ceiling assembly's tiles were not labeled with a fire resistance rating, the ceiling tiles were not clipped in place, and the grid work for the ceiling tiles and the metal wiring that the grid work was hung from lacked any labeling of their fire resistance ratings. During an interview on 10/25/18 at 11:40 AM, the Maintenance Director stated the facility had not made any changes to the lay-in style ceiling assemblies on the First, Second, Third, and Fourth Floors, or the unprotected steel beams on the First Floor and the unprotected steel trusses on the First, Second, Third, and Fourth Floors. The minimum acceptable construction type for this four-story building is type II (222) per the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. This construction type requires that structural components are protected with at least a two-hour fire resistive rating, either by a physical two-hour fire rated protective covering on the structural components or by maintaining a two-hour fire rated ceiling assembly 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 8.2, 8.2.1, 8.2.1.1, 8.2.1.2, 19.1.6, 19.1.6.1, 19.3.5, 19.3.5.1 2012 NFPA 220 Standard on Types of Building Construction: 4.1, 4.1.1

Plan of Correction: ApprovedDecember 4, 2018

The facility will continue collaboration with
an outside agency to assure compliance
with the 2012 edition of the Life Safety
Code while under Time limited Waiver.
The maintenance staff and QA committee
will be educated on the requirements of the
FSES by the Administrator. In-service
education to include, but not limited to the
FSES review and conditions and milestones of the Time-Limited Waiver.
The time limited waiver 172W069 with an expiration of 7/27/20 has been approved by CMS
The Director of Environmental Services will review the
FSES annually to assure that conditions of
The Time Limited Waiver and ensure that
any milestones of the Time-Limited Waiver
are met.
Any changes to the building that would
affect the continuation of the FSES will be
brought to the QA Committee for review
and further recommendations.
The P(NAME) will be overseen by the Director-of-Environmental Services to ensure its completed in its entirety.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 10/29/18, electrical equipment was not properly maintained. Issues included: in-use power strips were daisy chained (plugged together) to extension cords or other power strips, an extension cord was in-use, and an unapproved power strip was being used to supply power to a medical device in a resident room. This affected two (First and Third Floors) of four resident use floors. The findings are: 1 a. Observation on the First Floor, on 10/22/18 at 10:51 AM, revealed a power strip that was daisy chained to an extension cord was supplying power to an air conditioner installed in a widow behind the reception area in the Front lobby. During the observation, the Maintenance Director stated he was not aware the power strip was plugged into the extension cord and staff knew they were not to use extension cords. b. Observation on the First Floor, on 10/22/18 at 11:10 AM, revealed a power strip was daisy chained to another power strip that was supplying power to a television and two digital video disc (DVD) players on a cart in the in-service room. During the observation, the Maintenance Director stated he was not aware the power strips were plugged together. c. Observation in the First Floor service corridor, on 10/22/18 at 10:51 AM, revealed a power strip was daisy chained to an extension cord that was supplying power to a computer, a computer monitor and a computer tower, in the central supply storage room. During the observation, the Maintenance Director stated he was not aware the power strip was plugged into the extension cord and staff knew they were not to use extension cords. 2. Observation on the First Floor, on 10/22/18 at 10:57 AM, revealed an extension cord was being used to supply power to a vending machine located in the resident lounge. During the observation, the Maintenance Director stated he was not aware the extension cord was being used to supply power to the vending machine and the vending machine had been installed in the resident lounge four to five months ago. The Maintenance Director further stated he had told the vending company that they were not to use extension cords. 3. Observation on the Third Floor, on 10/24/18 at 1:03 PM, revealed a power strip, that was not approved to be used with medical devices, was supplying power to an oxygen concentrator in resident room [ROOM NUMBER]. During the observation the Maintenance Director stated the staff knew medical equipment had to be plugged into electrical outlets that were hard-wired into the wall. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 2.1, 2.2, 10.2.3.6(5), 10.2.4.1, 10.2.4.2, 10.2.4.2.1, 2011 NFPA 70: 110.3(A)(1), 110.3(A)(7), 110.3(A)(8), 400.3, 400.8(1), 590.3(B)

Plan of Correction: ApprovedNovember 24, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The extension cord was immediately removed from the reception area.
The power strips were immediately removed from the in-service room.
The extension cord was immediately removed from the central supply storeroom.
The extension cord was immediately removed from the resident's dining room area.
The power strip was immediately removed from the resident's room [ROOM NUMBER].
A 100 percent audit was conducted facility-wide to ensure there were no further extension cords, non approved power strips, or daisy-chaining within the facility.
All full/part-time staff will be rein-serviced by the maintenance department on the regulations of power strip usage, extension cords and daisy-chaining of power-strips and extension cords.
Random weekly audits will be conducted x 8 weeks in non-patient and patient care areas to ensure compliance with power strip usage, extension cords, and daisy chaining of power-strips/extension cords.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Environmental Director will oversee this P(NAME) for completion in its entirety.

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: October 29, 2018
Corrected date: December 19, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 10/29/18, the building's emergency generator was not properly maintained. Issues included, a fuel quality test was not performed at least annually, on the diesel fuel used to power the emergency generator. This affected one of one emergency generator. The finding is: 1. Observation on 10/22/18 revealed the fuel for the emergency generator was located in an exterior underground tank located behind the West side of the building. During an interview on 10/24/18 at 10:09 AM, the Maintenance Director stated the diesel fuel for the emergency generator was located in an underground tank located behind the building. The Maintenance Director further stated the fuel for the emergency generator had not been tested in four to five years. Per the 2010 edition of National Fire Protection Association (NFPA) 110: Standard for Emergency and Standby Power Systems, a fuel quality test shall be performed at least annually. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.5, 6.5.4.1.1.2, 6.4.4.1.1.3 2010 NFPA 110: 8.3.8

Plan of Correction: ApprovedDecember 3, 2018

The vendor was contacted and the fuel quality test is scheduled to be performed in Dec. (YEAR).
The fuel quality test will be completed by compliance date.
A one hundred percent audit was conducted on the emergency generator reports to ensure the facility's generator was properly maintained.
The facility Administrator rein-serviced the maintenance director on the 2010 NFPA fuel quality test requirements.
The facility's generator reports will be audited every month x 5 months to ensure all required testing and maintenance is performed according to NFPA regulations.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
This P(NAME) will be overseen by the Environmental Director of the facility to ensure completion in its entirety.

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: October 29, 2018
Corrected date: December 7, 2018

Citation Details

Based on observation, interview, and record review during the Life Safety Code survey completed on 10/29/18, the building's emergency generator was not properly maintained. Issues included, the facility's emergency generator was not connected to a remote alarm annunciator that operated in a location readily observed by operating personnel at regular work stations. This affected one of one emergency generator. The finding is: 1. Intermittent observations on 10/22/18 between 8:20 AM and 3:55 PM revealed a remote annunciator for the emergency generator was not located inside the building. Observations on the First Floor, on 10/22/18 at 11:40 AM revealed the emergency generator was installed in a room on the service corridor. During an interview on 10/24/18 at 10:10 AM, the Maintenance Director stated the building's emergency generator was not equipped with a remote annunciator. During an interview on 10/25/18 at 1:05 PM, the Administrator stated the facility had a proposal for the installation of a remote annunciator for the emergency generator that was dated 9/18/17 and the facility did not have a definite date for the installation of the remote annunciator. Review of a proposal to install a remote annunciator, from an outside contractor, dated 9/18/17, revealed it contained no documentation for an installation date of the remote annunciator. Per the 2012 edition of the National Fire Protection Association (NFPA) 99: Health Care Facilities Code, a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.4, 6.4.1.1.17

Plan of Correction: ApprovedDecember 3, 2018

The Maintenance Director has reached out to contractors for new quotes on installing the remote annunciator.
The facility is in the process of procuring an eight-month time-limited waiver to complete installation of the emergency generator annunciator panel. The waiver request will be submitted 12/5/2018.
The estimated time-limited waiver will expire 8/19/2019
Humboldt House will submit documentation upon completion of the emergency generator annunciator panel.
All full/part-time maintenance staff will be in-serviced on completing visual inspections of the emergency generator three times per day to ensure the emergency or auxiliary power source is operating to supply power to load.
The maintenance staff and QA committee will be educated on the requirements of the installation of the remote annunciator in the next QAPI meeting to include updates for the time-limited waiver.
This P(NAME) will be overseen by the Director-of-Environmental Services for completion in its entirety.


K307 NFPA 101:EXIT SIGNAGE

REGULATION: Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 10/29/18, exit signs were not properly maintained. Issues included exit signs were not illuminated. This affected three (First, Second, and Fourth Floors) of four resident use floors. The findings are: 1) a. Observation on the Fourth Floor, on 10/22/18 at 9:12 AM, revealed the exit sign located above the Dining room stairway exit door was not illuminated. During the observation, the Maintenance Supervisor stated he was not aware the exit sign was not illuminated. b. Observation on the Second Floor, on 10/22/18 at 10:06 AM, revealed the exit sign located above the corridor door of the therapy kitchen was not illuminated. During the observation, the Maintenance Supervisor stated he was not aware the exit sign was not illuminated. c. Observation on the Second Floor, on 10/22/18 at 10:08 AM, revealed the exit sign located above the doorway between the therapy room and the therapy kitchen was not illuminated. During the observation, the Maintenance Supervisor stated he was not aware the exit sign was not illuminated. d. Observation on the landing between the First and Second Floor of the Dining room stairway, on 10/22/18 at 10:08 AM, revealed the exit sign located above the stairway exit door to the exterior of the building was not illuminated. During the observation, the Maintenance Supervisor stated he was not aware the exit sign was not illuminated. e. Observation on the First Floor, in the service corridor, on 10/22/18 at 12:04 PM, revealed the exit sign located above the corridor door to the laundry dryer/ folding room was not illuminated. During the observation, the Maintenance Supervisor stated he was not aware the exit sign was not illuminated. During an interview on 10/25/18 at 11:43 AM, the Maintenance Director stated he checks the building's exit signs and if a bulb is out he replaces it. The Maintenance Director further stated he had no documentation to verify how often the signs were checked. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.10.1, 7.10, 7.10.1.2.1, 7.10.1.2.2, 7.10.5.1, 7.10.5.2.1

Plan of Correction: ApprovedNovember 22, 2018

The fourth floor exit sign above the dining room stairway exit door, bulbs were replaced. The exit sign illuminates.
The second floor exit sign above the corridor of the therapy kitchen, bulbs were replaced. The exit sign illuminates.
The second floor exit sign above the doorway between the therapy room and the therapy kitchen, bulbs were replaced. The exit sign illuminates.
The exit sign located between the first and second floor of the dining room stairway, bulbs were replaced. The exit sign illuminates.
The exit sign located above the corridor door on the first floor, bulbs were replaced. The exit sign illuminates.
A 100 percent audit was conducted on all exit signs within the facility to ensure continuous illumination.
The maintenance supervisor was rein-serviced by the facility administrator to ensure regular monitoring of all exit signs for continuous illumination.
Weekly audits will be conducted x 9 weeks on all exit signs to ensure continuous illumination.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The environmental director will ensure the plan of correction is completed in its entirety.

K307 NFPA 101:FIRE ALARM SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 10/29/18, all areas of the building were not protected by the fire alarm system. Issues included a smoke detector was not installed at the top of a stairway. This affected one (Auditorium Stairway) of five stairways. The finding is: Observation on the Second Floor, on 10/22/18 at 9:50 AM, revealed a smoke detector was not installed at the top of the Auditorium stairway. Further observation at this time revealed the stairway served as a path of egress to the exterior of the building from the First and Second Floors. During the observation, the Maintenance Director stated he was not aware a smoke detector was not installed at the top of this stairway. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.6, 9.6.1.3 2010 NFPA 72: 17.5.3, 17.5.3.1

Plan of Correction: ApprovedDecember 3, 2018

The smoke detector will be installed before compliance date 12/13/2018
100 percent audit was conducted to ensure all areas are protected by the fire-alarm system, including stairways.
The Maintenance Director was rein-serviced by the Administrator to ensure all areas are protected by the fire-alarm system including stairwells.
A weekly audit x 5 weeks will be performed by the maintenance director to ensure smoke detectors remain installed in the 5 stairways.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The overall completion of this P(NAME) will be overseen by the Director-of-Environmental Services.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 10/29/18, the building's fire alarm system was not properly maintained. Issues included, a smoke detector was covered with a plastic installation cap and tape. This affected one (Fourth Floor) four resident use floors. The finding is: Observation on the Fourth Floor, on 10/22/18 at 8:45 AM, revealed a smoke detector located in the soiled utility room near Resident room [ROOM NUMBER] was covered with an orange colored plastic cap and gray tape. During the observation, the Maintenance Director stated an outside contractor was working on the Fourth Floor removing wall paper, sanding and then painting the walls. The Maintenance Director further stated he had told the contractor that the covers on the smoke detectors had to be removed each day after they finished working. The last time the contractor had been working in this utility room was on Saturday 10/20/18. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.6.1.3, 4.5.8, 4.6.12.2 2010 NFPA 72: 14.3.1, 14.3.4, 14.5.1

Plan of Correction: ApprovedNovember 24, 2018

The orange colored plastic cap and the gray tape was immediately removed from the smoke detector.
The contractor had concluded painting the walls on the fourth floor.
One hundred percent audit was conducted on the fourth floor to ensure no plastic caps or gray tape covered any other smoke detectors.
All full time and part-time maintenance staff were rein-serviced to ensure appropriate follow-up when contractors are performing work in the building.
A weekly audit x 8 weeks will be conducted on 6 random smoke detectors to ensure nothing is covering or impeding them from functioning.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
This P(NAME) will be overseen by the Director-of-Environmental Services for completion in its entirety.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 10/29/18, oxygen cylinders were not properly restrained. This affected one (Third Floor) of four resident use floors and one of one oxygen shed. The findings are: 1 a. Observation in the oxygen storage shed, located at the exterior of the building, on 10/22/18 at 12:08 PM, revealed four, H/K size oxygen cylinders were stored standing upright and in a single row. These cylinders were improperly restrained by a single metal chain that was loosely hung around the four cylinders. Further observation revealed two additional H/K size oxygen cylinders were also stored standing upright and were improperly restrained by a single metal chain that was loosely hung around the two cylinders. Continued observation at this time revealed the shed contained:11 H/K-size oxygen cylinders, 60 E-size oxygen cylinders, seven D-size oxygen cylinders and two C-size oxygen cylinders During an interview, at the time of these observations, the Maintenance Director stated he was not sure why the oxygen cylinders were not individually secured. The Maintenance Director further stated the delivery person for the oxygen supply company knew the cylinders had to be individually secured. During an interview on 10/26/18 at 12:50 PM, the Maintenance Director stated he had contacted the oxygen supply company and was informed that someone other than the facility's usual delivery person had made the last delivery to the facility. b. Observation on the Third Floor, on 10/23/18 at 8:53 AM, revealed one E-size oxygen cylinder was stored free standing and unsecured in the room located behind the nurse's station. Further observation, at this time, revealed five E-sized oxygen cylinders were stored in a metal rack inside the room. Continued observation revealed the metal rack was designed to hold six oxygen cylinders and had room to store one more oxygen cylinder. During the observation, the Maintenance Director stated the staff knew oxygen cylinders had to be properly stored in a cart or rack. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 11.3.2, 11.3.2.6, 11.6.2.3, 11.6.2.3(1), 11.6.2.3(11)

Plan of Correction: ApprovedNovember 24, 2018

The 6 H/K size oxygen cylinders were immediately secured individually according to regulations.
The maintenance director placed a call to the oxygen company to ensure all drivers are aware that oxygen cylinders need to be individually secured.
The e-size oxygen cylinder was immediately placed in the metal rack.
A one-hundred percent audit was conducted to ensure proper storage of oxygen cylinders within the facility.
All full/part-time nursing staff will be rein-serviced by the maintenance department on rules and regulations on oxygen storage.
Random weekly audits will be conducted x 8 weeks to ensure proper storage of oxygen cylinders and ensuring H/K cylinders are individually secured.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
This P(NAME) will be overseen by the Director-of-Environmental Services for completion in its entirety.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 13, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Life Safety Code survey completed on 10/29/18, hazardous areas were not properly maintained. Issues included hazardous area doors would not self-close and latch into their door frames and were obstructed from closing. This affected three (First, Third, and Fourth Floors) of four resident use floors. The findings are: 1) a. Observation on the Fourth Floor, on 10/22/18 at 8:58 AM, revealed the corridor door of the clean linen storage room located near Resident room [ROOM NUMBER] would not self-close and latch into its frame. Further observation at this time revealed the room was greater than 50 square feet in size and was being used to store three, six-foot tall by five-foot long by two-foot wide racks full of sheets, towels, bed pads, and packages of disposable briefs. During the observation, the Maintenance Director stated the building's doors had recently been checked and he was not aware of any issues with the doors. b. Observation on the Third Floor, on 10/22/18 at 9:35 AM, revealed the corridor door of the clean linen storage room located near Resident room [ROOM NUMBER] would not self-close and latch into its frame. Further observation at this time revealed the room was greater than 50 square feet in size and was being used to store two, six-foot tall by five-foot long by two-foot wide racks full of sheets, towels, bed pads, packages of disposable briefs, and mechanical lift slings. c. Observation on the First Floor, in the service corridor, on 10/22/18 at 12:00 PM, revealed the corridor door to the laundry dryer/ folding room would not self-close and latch into its frame. Further observations revealed the room was greater than 50 square feet in size and contained six clothing dryers, seven, six-foot tall by five-foot long by two-foot wide racks and three, six-foot tall by three-foot long by two-foot wide racks that contained sheets, blankets, bed pads, towels, gowns, table cloths, shirts, pants, pillows and privacy curtains. 2. Observation on the First Floor, in the service corridor, on 10/22/18 at 11:53 AM revealed the corridor door to the housekeeping supply room, located next to the power washing room, was in a fully open position. Further observation at this time revealed a wire hanger was wrapped around the door's handle and attached to a hook installed on the wall behind the door. Continued observation revealed the room was greater than 50 square feet in size and was being used to store the following: - four cardboard boxes containing paper towel dispensers - one cardboard box containing rolls of paper towels - ten cardboard boxes containing plastic can liners - three cardboard boxes containing 20-inch floor stripping pads - two cardboard boxes containing one-gallon plastic containers of glass cleaner During the observation, the Maintenance Director stated the staff knew doors were not to be held open by hangers. During an interview on 10/25/18 at 11:29 AM, the Maintenance Director stated the building's corridor doors, including hazardous area and stairway doors, were checked on a monthly basis and the facility had documentation of the checks. Review of monthly door check logs revealed the building's corridor doors, including hazardous area and stairway doors, were being checked on a monthly basis and the last time they were checked was on 9/15/18. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.1

Plan of Correction: ApprovedNovember 22, 2018

The clean linen storage corridor door on the fourth floor was immediately repaired, allowing the door to self-close and latch into its frame.
The clean linen storage corridor door on the third floor was immediately repaired, allowing the door to self-close and latch into its frame.
The corridor door to the laundry dryer/folding room located on the first floor was immediately repaired, allowing the door to self-close and latch into its frame.
The wire-hanger was immediately removed from the housekeeping supply room, allowing the door to self-close and latch into its frame.
A 100 percent audit was conducted on all hazardous areas- enclosure to ensure they were self-closing, free from obstruction, and latched into its frame.
The maintenance supervisor was rein-serviced by the facility administrator to ensure regular monitoring of all hazardous areas- to verify doors are self-closing, free from obstruction, and latch into their frame.
All full/part-time environmental staff will be rein-serviced on hazardous areas- enclosure to include self-closing expectations, and ensuring no barriers or objects prevent doors from closing.
A weekly audit x 9 weeks will be conducted on 5 hazardous areas- enclosure to verify doors are self-closing, free from obstruction, and latch into their frame.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
This plan of correction will be overseen by the Director of Environmental Services for completion in its entirety.

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 29, 2018
Corrected date: December 11, 2018

Citation Details

Based on observation, interview, and record review during the Life Safety Code survey completed on 10/29/18, the building's automatic sprinkler system was not properly maintained. Issues included, the fire pump was not run under emergency power conditions. This affected four (First, Second, Third, and Fourth Floors) of four resident use floors. The finding is: Observation on the First Floor, on 10/22/18 at 11:38 AM, revealed there was an electric fire pump installed in a room on the service corridor. On 10/22/18, a review of Fire Pump inspection reports dated 6/7/17 and 6/14/18 revealed the reports contained no documentation that the facility's fire pump had been run under emergency power conditions. Further review of the repots revealed; on page #1 of the 6/14/18 report: Power failure simulation not performed. Continued review of the reports revealed; on page #8 of the 6/7/17 report: Please note: Periodic tests of transfer switches and emergency generators may be necessary in accordance with National Fire Protection Association NFPA 110 Standard for Emergency and Standby Power Systems but are not part of this inspection. During an interview on 10/25/18 at 11:02 AM, the Maintenance Director stated the fire pump was part of the facility's automatic sprinkler system, the facility's emergency generator supplied emergency power to the fire pump, and the building's electrical system had an automatic transfer switch. The Maintenance Director further stated the outside contractor that inspected and tested the building's fire pump was not running the fire pump under emergency power. Per the 2011 edition National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Chapter 8 - Fire Pumps: 8.3.3.4, For installations having an automatic transfer switch, the following test shall be performed to ensure that the overcurrent protective devices (i.e., fuses or circuit breakers) do not open: (1) Simulate a power failure condition while the pump is operating at peak load (2) Verify that the transfer switch transfers power to the alternate power source (3) Verify that the pump continues to perform at peak load (4) Remove the power failure condition and verify that, after a time delay, the pump is reconnected to the normal power source. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5 2011 NFPA 25: 8.3.3.4, 8.3.4.1, 8.3.4.2 2010 NFPA 110

Plan of Correction: ApprovedDecember 3, 2018

The maintenance director has contacted the company and the testing of the fire-pump will be run under emergency power conditions by 12/13/2018.
A 100 percent audit was conducted on automatic sprinkler system reports to ensure compliance according to NFPA.
The Administrator rein-serviced the Maintenance Director on ensuring the automatic sprinkler system was properly maintained.
Monthly audits will be conducted x 5 months to ensure automatic sprinkler system reports are in compliance according to NFPA.
The results of all audits will be discussed at the monthly QAPI meeting to demonstrate the success of the plan or the need to provide additional education or ongoing auditing as warranted.
The Environmental Director will ensure the completion of this P(NAME) in its entirety.