Nathan Littauer Hospital Nursing Home
August 21, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure the care plan was evaluated for effectiveness and revised to include the changing goals and needs for three (3) (Resident #'s 8, #57, and #73) of eighteen (18) residents reviewed for care plans. Specifically, for Resident #57 and #73, the Care Plan for at Risk for Falls was not revised after the residents had an actual fall, for Resident #57, the resident had an attempted elopement and there were no short-term or long-term goals assessed, and the effectiveness of the wander guard was not evaluated and for Resident #8, who had a change in ambulation status, the facility did not change the resident's ambulation status on the care plan. This is evidenced by: Resident #57: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Sett (MDS) of 7/3/2018, documented the resident could understand and was understood, had a Brief Interview of Mental Status (BIMS) of 12/15 with moderate impairment for daily decision making. During record review the falls risk care plan dated 4/1918 documented the resident was at risk for falls, with short-term and long-term goals as follows: Resident will not have any injuries due to falls through next review in 90 days. Intervention/approach plan documented as follows: Procedures to be followed to avoid any injuries due to falls, 1. Call light within reach. 2. Personal items within reach. 3. Keep environment well lit. 4. Ensure safety with transfers include stable locked transfer surface. 5. Non-skid pad in chair. A record review documented the resident had a fall on 5/19/18. The existing at Risk for Falls Comprehensive Care Plan (CCP) dated 4/19/18, documented new concerns as follows: 5/19/18 at 11:45 AM, the resident was found on the floor sitting on her bottom, wheelchair was in the bedroom. The care plan did not include the documentation of new goals or interventions on the at Risk for Falls CCP. A record review documented the resident had a fall on 5/19/18. The existing at Risk for Falls CCP dated 4/19/18, documented new concerns as follows: On 6/7/18, the resident attempted to exit through door. The at Risk for Falls CCP dated 6/7/19, documented a new intervention for placement of a wander guard on the resident's ankle. The care plan did not include documentation that short or long-term goals were assessed. It did not include documentation that of a responsible discipline or date of reevaluation. During interview 8//20/18 at 11:30 AM, the Registered Nurse Unit Manager (RNUM) stated the care plan was initially for falls risk, no new care plan had been done - no new interventions had been added. A fall had occurred after the falls risk care plan had been put in place and new goals and interventions should have been placed on the care plan. During interview on 8/20/18 at 11:48 AM, the Director of Physical Therapy stated the resident should have been evaluated after a fall and assessed for new interventions to prevent further falls. It would be nursing's responsibility to add any new intervention and the date to reevaluate the effectiveness to the residents CCP. During interview on 8/21/18 at 2:00 PM, the Director of Nursing (DON) stated the CCP for the residents were the responsibility of the Registered Nurses on the units. They should be updated with goals and interventions whenever a resident needs changed. A fall would be a reason to update goals and interventions to make sure everything is being done to prevent another fall and protect the resident from an unavoidable injury. Resident #73: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/24/2018, documented the resident was understood and could usually understand, and was severely impaired for daily decision making. During record review the falls risk care plan dated 5/4/18, documented the resident was at risk for falls, with short-term and long-term goals: Resident will not have any injuries due to falls through next review in 90 days. Intervention/approach plan documented: Procedures to be followed to avoid any injuries due to falls, 1. Call light within reach. 2. Personal items within reach. 3. Keep environment well lit. 4. Ensure safety with transfers include stable locked transfer surface. 5. Non-skid pad in chair. A record review included documentation that the resident had a fall from bed on 7/23/18. The resident hit her head and required neuro checks. The existing care plan detailed the residents fall from bed on 7/23/18. The at Risk for Falls CCP did not include documentation of new goals. A scoot chair was added as a new intervention after the residents fall from bed. The CCP did not include documentation of a monitoring plan or a reevaluation date to assess the effectiveness of the scoot chair. During interview 8//20/18 at 11:30 AM, the Registered Nurse Unit Manager (RNUM) stated the care plan was initially for falls risk, but a scoot chair had been added after the fall of 7/23/18 to prevent falls from a chair. No new interventions had been done to directly address the fall from her bed. She stated she understood now that a fall had occurred that new interventions should have been assessed on the care plan. The MDS of 7/24/18 reflected the fall and new interventions or a new care plan should have been completed. Resident #8: The resident was admitted to the nursing home on 2/27/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The Comprehensive Care Plans (CCP) for Requires Assist with Ambulation and Requires Assist with Transfers dated 2/28/18, documented that on 4/30/18, the resident was changed from a 2 person assist to a 1 person assist with a wheeled walker and gaitbelt to and from the bathroom. It was last re-evaluated on 8/1/18. The CCP for Assist with Transfers dated 2/28/18, documented that on 4/30/18, the resident was changed to a 1 assist with a wheeled walker and gaitbelt to and from the bathroom. It was last re-evaluated on 8/1/18. During an interview on 08/16/18 10:10 AM, Certified Nursing Assistant (CNA) #3 stated that she had noticed a decline in the resident's transfer status since using the scoot chair. They need 2 people to get him up because his legs are not so stiff. She had reported this to nursing and PT (physicial therapy). During an interview on 08/20/18 at 10:29 AM, the Physical Therapy Director (PTD) stated that he did recall staff reporting an increased difficulty with transfers and thought he changed the status to a 2 assist. When he checked, while the surveyor was present, he stated it was not changed and it may have been PTs mistake. If it gets reported that the status has changed he will change the care plan. During an interview on 08/21/18 at 09:22 AM, Registered Nurse #2 stated that PT decides what residents get unit ambulation and which ones are ambulated in PT. CNA's have come to her and complained that the residents were harder to transfer and ambulate and thinks staff have come to her with concerns about this resident's transfer decline.

Plan of Correction: ApprovedSeptember 14, 2018

Resident #57's attempt at elopement on (MONTH) 07, (YEAR) has been added to the wandering care plan.
Fall care plan developed for resident #73 to reflect fall of (MONTH) 23, (YEAR). Fall care plan for resident #73 updated for one additional fall.
The Rehabilitation Manager notifies Nursing by email, during morning report and rehab staff changes care plan.
Verbal communication to staff indicating a change in mobility are noted on the 24 hour report sheet and Nursing updates the CNA kardex of the changes.
Audits to ensure changes in mobility are noted on the care plan and the CNA kardex will be conducted.
10 Status changes per month will be audited for 3 months to ensure compliance.
The audits will be submitted to the Quality Assurance Committee and the need for further audits will be decided by the Committee.
The Rehabilitation Manager will be responsible for compliance.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during a recertification survey the facility did not ensure the development and implementation of comprehensive, person centered care plans for one (Resident #8) of eighteen residents reviewed. Specifically: the facility did not ensure that the resident had a care plan in place to address the resident's diarrhea and to address changing the resident's Foley bag to a leg bag during the day and putting the Foley bag back on at night. This is evidenced by: Resident #8: The resident was admitted to the nursing home on 2/27/18, with [DIAGNOSES REDACTED]. The resident uses a leg bag during the day and a Foley bag at night. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Finding #1: The CCP titled Indwelling Foley Catheter dated 2/28/18, and Certified Nursing Assistant (CNA) Kardex did not include instructions to put a leg bag on during the day and change to a Foley bag at night and the CNA Kardex did not instruct staff to perform catheter care every shift. A Progress Note dated 6/4/18 at 7:35 am, documented that at 6:50 am, the resident complained of lower abdomen pressure and was found with leg bag (usually hold 600- 1000 cubic centimeters (cc)) very full. It drained a total of 2100 cc urine. During an interview on 08/20/18 at 03:04 PM, Certified Nursing Assistant (CNA) #9 stated that the resident got a Foley bag at night and a leg bag in am, but it was not on the CNA Kardex. There was also no special care to the catheter, just wash around it, and this also was not on the Kardex. During an interview on 08/20/18 at 12:04 PM, Registered Nurse Manager (RNM) #1 stated, that changing the bag to a leg bag during the day could be in the CNA guide, but usually, new CNAs will do rounds with a seasoned CNA and if they have questions they can/will ask the CNA; routine catheter care is something they are trained to do which does not need to be on Kardex; it is a given, that it is done once a shift. During an interview on 08/20/18 at 03:36 PM, the Director of Nursing (DON) stated that the residents care plan and CNA Kardex should address the use of a leg bag during day and catheter care. Finding #2: A review of the Resident's Bowel Record and 24-hour reports from 7/10/18 - 7/25/18 the resident had twenty-nine large loose and one medium loose bowel movements. A Progress Note dated 7/23/18, documented that the resident had been having loose stool for the past three to four days. A Progress Note dated 7/25/18, documented that the review of the bowel record noted that for the last 2-3 weeks the resident had a notable change in bowel habits. The resident previously had 1-2 soft BM's daily. The last 2-3 weeks the resident has had multiple loose BM's daily. The resident does not receive bowel medications. The Comprehensive Care Plan did not include a care plan to address the resident's diarrhea. During an interview on 08/20/18 at 12:04 PM, RNM #1 stated that the bowel and bladder care plan is inaccurate. The RNM did not know why it was there or why she had been re-evaluating the careplan without any changes since admission. The CCP should have reflected the resident's bowel incontinence and diarrhea. On 08/20/18 at 03:35 PM, the DON stated the issues with the diarrhea should be care planned. NYCRR10 483.21(b)(1)

Plan of Correction: ApprovedSeptember 14, 2018

Resident #8 no longer used leg bag as of (MONTH) 26, (YEAR).
No residents currently are using leg bags.
All residents using a leg bag will have it noted on their care plan and on the CNA kardex.
Foley catheter care every shift has been added to resident #8 care plan and the CNA kardex.
All residents with a foley catheter have had catheter care every shift added to their care plan and the CNA kardex.
Audits to ensure catheter care every shift is on the care plan and the CNA kardex will be done weekly for 4 weeks and then monthly for 2 months.
Results of the audits will be reported to the Quality Assurance Committee. The need for additional audits will be determined by the Quality Assurance Committee.
Director of Nursing will be responsible for compliance.
Resident #8's diarrhea was addressed by provider on (MONTH) 26, (YEAR).
No residents are currently experiencing diarrhea.
Any new onset of diarrhea will be added to the resident care plan and provider notified.
Audits will be performed weekly for 4 weeks and then monthly for 2 months to ensure any resident experiencing diarrhea is added to the residents care plan.
Results of the audits will be reported to the Quality Assurance Committee. The Quality Assurance Committee will determine need for further audits.
The Director of Nursing is responsible for compliance.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the garbage dumpster was not insect and rodent proof. This is evidenced as follows: The facility's garbage disposal area was inspected on 08/13/2018 at 11:55 AM. Trash was disposed of in a container with two large 4-feet x 8-inch openings, the lid was left open, and insect activity was observed. The Food Service Director stated in an interview conducted on 08/13/2018 at 12:15 PM, that garbage should not have been disposed in the container with large openings, and staff will be reminded to discard garbage in the trash compacter and to close the lids of outside trash containers after use. The Director of Environmental Services stated in an interview conducted on 08/13/2018 at 12:25 PM, that the container with large openings is designated for recyclables. Garbage from the kitchen must be disposed in the trash compactor and the lids must be closed on the dumpster after use. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.150 (c)

Plan of Correction: ApprovedSeptember 21, 2018

The dumpster referenced in the finding was removed on (MONTH) 10, (YEAR).
Environmental and Nutrition Staff will be trained and documented on the use of the recycling and trash compactors by (MONTH) 16, (YEAR).
A new waste vendor is starting on (MONTH) 01, (YEAR) and offers single stream recycling of cardboard, paper, aluminum and plastic in a closed compactor.

FF11 483.45(c)(1)(2)(4)(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically: there were no time frames established for all the steps in the MRR (medication regimen review) process and there were no steps the pharmacist needed to take when he/she identified an irregularity that required urgent action to protect the resident. This is evidenced by: The Facility Resident Care Policy and Procedure Manual for Pharmacy Medication Review dated 8/18 documented: 1. All provider orders for medications will be sent to the(NAME)Littauer hospital Pharmacy when ordered. 2. Pharmacist shall review all orders and profile them in the Meditech EMAR (electronic medication administration record) system when received. 3. Review shall include clinical appropriateness, drug interactions, allergies [REDACTED]. 4. Pharmacist shall dispense an appropriate quantity of medication to the Nursing Home to cover until the next cart exchange. 5. On a monthly basis, the Pharmacist shall review each resident's medication profile and make any appropriate communication to the Provider and Director of Nursing. During interview on 08/21/18 at 10:04 AM, the Director of Nursing (DON) reported the facility reviews physician orders [REDACTED]. All new orders are faxed to the pharmacy which are then entered into the electronic Medication Administration Record [REDACTED]. The DON stated time frames and steps are not in the current MRR process but will be added. During interview on 08/21/18 at 10:52 am, the Administrator stated she spoke with the Director of Pharmacy and it was decided that at the next meeting with pharmacy and therapeutics, time frames will be established. 10NYCRR415.18 (c)(2)

Plan of Correction: ApprovedOctober 5, 2018

Policy and procedure for Pharmacy Medication Review was revised on (MONTH) 10, (YEAR) to include Pharmacist will immediately notify provider of any irregularity that requires urgent action.
The Pharmacists will be re-educated on the revised policy and procedure.
The pharmacy logs any irregularities and communication with the provider.
The logs will be audited monthly for compliance with our policy and procedure and the results forwarded to our Quality Assurance Committee for three months. The Quality Assurance Committee will determine if further audits are required.
All provider orders for medications will be sent to the(NAME)Littauer Hospital Pharmacy immediately when ordered.
On a monthly basis, the Pharmacist shall review each resident's medication profile and make any appropriate communication to the Provider and Director of Nursing. Response from Provider is expected within 7 days.
The Pharmacist will review all Provider orders for any urgen irregularity and notify the Provider immediately prior to dispensing medications.
The Director of Pharmacy is responsible for compliance.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Food preparation, serving areas are to be kept in good repair and equipment is to be kept clean. Specifically, plumbing was not in good repair, food and non-food contract surfaces were not kept clean. This is evidenced as follows: The main kitchen and unit kitchenettes were inspected on 08/13/2018 at 9:39 AM. In the main kitchen under the food preparation countertop there was an open drain line that was not plumbed properly to contain waste gas from entering the kitchen. The spray hose in the West Unit kitchenette was resting below the drain line creating a possible back siphonage (a condition that could contaminated the portable water supply). In the main kitchen the meat slicer, can opener, cutting board and drawer gaskets on the sandwich making station; the bottom shelf of the sliding door standup refrigerator unit; the exhaust fan guards in the walk-in cooler; the floor tiles by the cook line in the main kitchen and in the West Unit kitchenette, and the steam table food covers were soiled with dust, grease or food particles. The floor tiles in the main kitchen by the cook line and the gasket on the standup cooler unit in the west end kitchenette were in disrepair. The Food Service Director stated in an interview conducted on 08/13/2018 at 12:15 PM, that the maintenance department will be contacted to plug the drain line and adjust the spray hose; the floor tiles will be replaced; and he will recommit staff to more thoroughly clean the can opener, slicer, and all the non-food contact surfaces. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.150 (c) 14-1.170.

Plan of Correction: ApprovedSeptember 21, 2018

The drain line was properly covered on (MONTH) 22, (YEAR).
The drain line has been added to the monthly audits.
Staff will be trained on the new audit tool.
The spring on the spray hose in the West Dining Room Kitchenette was replaced on (MONTH) 22, (YEAR).
The items noted were cleaned and to be free of dust, grease or food particles.
Staff was trained and documented on the cleaning procedure and schedule on (MONTH) 26, (YEAR).
Floor tiles and gaskets are on order and will be replaced.
The cleanliness and spray hose will be audited monthly for three months and reported to the Quality Assurance Committee. The Committee will determine need for further audits.
The Director of Nutritional Services will be responsible for compliance.

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessments be updated annually, and Section 4-2.4 requires that by (MONTH) 1, (YEAR), a potable water system Legionella culture sampling and management plan (SMP) be adopted and implemented. Specifically, the facility did not adopt and implement a SMP and did not maintain a current Legionella Environmental Assessment Form (EAF) as required by New York State regulation. This is evidenced by the following. Record review on 08/14/2018, revealed that a SMP was not available for survey review, and the EAF was dated 08/30/2016. The Director of Engineering stated in an interview conducted on 08/14/2018 at 3:15 PM that he did not know an EAF needed to be updated annually and though Legionella water sampling is conducted, a comprehensive potable water sampling plan has not been but will be developed. 415.19(a)

Plan of Correction: ApprovedSeptember 21, 2018

Engineering and infection control will develop a more comprehensive sampling management plan. The Legionella Assessment Plan will be revised to include the sampling plan and the need for annual review.
The Environment Assessment Form will be reviewed for (YEAR) and annually thereafter.
The EAF will be reported to the Safety Committee annually.
The sampling plan and annual review will be reported to the Safety Committee for one year.
The Safety Office will be responsible for compliance.

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

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not maintain an infection control program (IPCP) to help prevent the development and transmission of communicable diseases and infection on 2 of 2 units for two (2) (Resident #'s 57 and #65) of 2 dressing changes observed, and for one (1) (Resident #8) of one (1) resident observed for catheter care. Specifically: For Resident #'s 57 and #65, the facility did not maintain infection control during dressing changes. For Resident #8, the facility did not ensure catheter care was done in a manner that prevented infection. This is evidenced by: A Policy and Procedure titled Aseptic Dressing Change dated 6/2013, documented the following: 1. Gather equipment 2. Wash hands 3. Place barrier 4. Place dressing supplies on barrier. 5. Open dressings using aseptic technique 6. Don gloves 7. Remove soiled dressing 8. Remove gloves, Cleanse hands with alcohol gel or wash hands per policy. 9. Don new pair of gloves. 10. Follow order. 11. Apply clean dressing 12. Place barrier and paper refuse in disposable bag 13. Remove gloves, wash hands Resident #57: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/3/2018, documented the resident could understand and was understood, and was moderately impaired for daily decision making. A physician's orders [REDACTED]. Wrap with Kling. Change BID (2 times a day) and PRN (as needed). A treatment flow sheet documented: Clean right heel with saf-cleans, apply [MEDICATION NAME] ointment to area, cover with 4 x 4 gauze and ABD (dressing). Wrap with Kling. Change BID (2 times a day) and PRN (as needed). During observation on 8/16/17 at 9:59 AM, Registered Nurse #3 performed wound care to the resident's right heel. She opened and placed dressing supplies on the table, washed her hands for 10 seconds in the bathroom and turned off the faucet with her hand. The RN then donned gloves, removed the old dressing, removed gloves and without washing her hands donned new gloves and cleaned the heel wound. While cleaning the wound, the RN held the resident right ankle that had been resting on the leg of the chair with her gloved hand. RN #3 removed her gloves and without washing her hands or applying new gloves, placed the clean dressing on the residents' heel, and wrapped it with kling. After the dressing change was complete, she gathered her supplies, discarded them in the trash and left the room without washing her hands. During interview on 8/16/18 at 10:30 AM, RN #3 stated she knew she had contaminated her hands after washing them before starting the procedure. She stated she should have used a paper towel to turn of the water instead of her hand and should have rewashed her hands. She also acknowledged she should have washed her hands before applying new gloves after removing the old dressing. She stated she had her annual competencies, but had not reviewed the dressing change policy and procedure in a while. During an interview on 8/21/18 at 10:30 AM, the Infection Control Registered Nurse (IFCRN) stated that when performing wound care, the nurse should clean the surface to be used, wash hands, place a barrier down and open the supplies on the barrier. Hands should be washed before application of the gloves and when gloves are removed in between removing the old dressing, cleaning the wound, and before applying the new dressing. The nurses are taught to always wash their hands between glove change to prevent cross contamination. Resident #65: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. A physician's orders [REDACTED]. Apply [MEDICATION NAME] (a dressing which absorbs drainage and maintains a moist wound-healing environment) border and change every 3 to 5 days and as needed. During observation on 8/16/18 at 11:01 am, Registered Nurse (RN) #3 opened and placed dressing supplies on the table. RN #3 unwrapped the old dressing. RN #4 held the resident's leg while RN #3 held a mirror with gloved hands to get a better look at the wound behind the resident's lower leg. RN #4 set the resident's uncovered foot on the pedal of the wheelchair. RN #3 proceeded with the dressing change without removing her gloves, washing her hands and donning a new pair of gloves after holding the mirror. During an interview on 08/16/18 at 11:18 AM, the RN #3 stated she now realized she should have changed her gloves after holding the mirror and did not realize the resident's uncovered foot was resting on the wheelchair foot rest as the RN #4 had been holding it in the air. During an interview on 08/16/18 at 11:18 AM, RNM #4 stated there probably should have been a barrier under the resident's foot. After the new dressing was applied she stated there absolutely should have been a barrier in place on the pedal. The nurses are inserviced yearly on clean dressing change technique. Resident #8: The resident was admitted to the nursing home on 2/27/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The resident had an indwelling foley catheter (foley) (a tube inserted into the bladder and hooked to a drainage system to drain urine from the bladder). During observation of care on 08/20/18 at 9:52 AM, two CNAs stood the resident, who had been incontinent of loose stool from the toilet. When providing peri care, the CNA washed the residents buttocks and then with the same washcloth wiped his urinary meatus (opening in the tip of the penis, to place catheter) and foley tubing. The CNA repeated this with 2 other wash clothes that were soiled by the time she was cleaning the foley. The CNA then used a towel and dried the resident from back to front. There was visible stool on the towel and the CNA dried the resident's urinaty meatus and foley tubing with the soiled towel. During an interview on 08/20/18 at 10:08 AM, CNA #3 stated she did not realize she used the same soiled washcloth and towel she had used to do peri care. During an interview on 08/20/18 10:11 AM, RN #2 stated that once the linens were soiled they should not have been used to do care around the catheter. The resident just had a UTI. During an interview on 08/20/18 at 12:04 pm, RNM #1 stated that doing pericare in that manner could cause a UTI. During an interview on 8/21/18 at 10:30 AM, IFCRN stated when performing catheter care, staff should wash hands and put on gloves. Only a clean wash cloth should be used to wipe around the catheter. If there is any remenant of stool on a towel or wash cloth it should not be used. Contamination with stool by the opening of the meatus can allow e-coli (a bacteria in stool) to enter the bladder and cause a urinary tract infection [MEDICAL CONDITION]. Also, if the staff's gloves become contaminated with stool, hands should be washed and clean gloves should be put on before final cleaning of the catheter. The staff are taught to always wash their hands between glove change to prevent cross contamination. 10NYCRR415.19(a)(1-3)

Plan of Correction: ApprovedSeptember 14, 2018

CNA received counseling on (MONTH) 12, (YEAR) on proper perineal care and catheter care.
All CNA's will be re-inserviced on our perineal care policy and procedure and our catheter care policy and procedure.
RN#3 was counseled on (MONTH) 13, (YEAR) on proper hand hygiene, length of time to wash hands and the infection control steps for proper dressing changes.
RN#3 was given the policy on aseptic dressing changes and hand hygiene.
RN#3 was counseled on (MONTH) 13, (YEAR) on proper dressing changes and hand hygiene.
RN#4 was informed on (MONTH) 13, (YEAR) that a barrier should have been under residents foot on pedal.
All Nurses will be re-inserviced on aseptic dressing change
policy and procedure.
All Nurses will be re-inserviced on proper hand hygiene.
Audits for aseptic dressing change compliance will be done weekly for 4 weeks and then monthly for 2 months.
Audits for compliance with hand washing during dressing changes will be done weekly for 4 weeks and then monthly for 2 months.
Results from audits will be reported to the Quality Assurance Committee meeting for compliance. Committee will determine need for further audits.
Director of Nursing will be responsible for compliance.

FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

Based on medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who were discharged from the facility were not provided with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS- . This was evident for one (1) out of three (3) sampled residents reviewed for Beneficiary Protection Notification (Resident #132). This is evidenced as follows: Review of the medical records for Resident #132 on 08/15/2018, revealed that the resident was not provided the (NOMNC), form CMS- to inform the resident of their right to an expedited review of a service termination. The Administrator stated in an interview conducted on 08/16/2018 at 12:54 PM, that she did not think a NOMNC had to be issued when a resident cooperated and agreed with their planned discharge. 10 NYCRR 415.3 (g)

Plan of Correction: ApprovedSeptember 14, 2018

Resident #132 was discharged home on (MONTH) 20, (YEAR).
The Notice of Medicare Non-Coverage will be initiated for all Medicare recipients when services are being terminated as outlined in the Instructions for the Notice of Medicare Non-Coverage.
Staff responsible for initiating the notice will be educated on the procedure.
All Medicare recipients will be audited for three months to ensure the proper notice was initiated.
The results of the audits will be reported to the Quality Assurance Committee. The Committee will determine if further audits are required.
The Patient Account Manager will be responsible for compliance.

FF11 483.12(a)(3)(4):NOT EMPLOY/ENGAGE STAFF W/ ADVERSE ACTIONS

REGULATION: §483.12(a) The facility must- §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, the facility did not conduct the minimum required background checks on new employees. Facilities may not employ individuals with a finding entered into the State Nurse Aide Registry (NAR) concerning abuse, neglect, mistreatment of [REDACTED]. Specifically, the facility hired 1 of 5 new employees reviewed without knowledge of the result of all required State Nurse Aide Registry and professional background checks. This is evidenced as follows: The personnel files for Speech Language Pathologist (SLP) #1 were reviewed on 08/14/2018. This record review revealed that SLP #1 was hired on 07/09/2018, and the facility did not conduct an NAR for this individual until 08/14/2018, thirty-six days after hiring. The Human Resources Manager stated in an interview conducted on 08/15/2018 at 9:44 AM, that she does not know why the NAR check was not conducted for SLP #1 prior to hiring and that it was likely an oversight. 10 NYCRR 483.12(a)(3)(4)

Plan of Correction: ApprovedSeptember 21, 2018

As of (MONTH) 06, (YEAR), all employees to-date have had the required New York State Nurse Aide Registry checks and have had not found as the inquiry status.
The Speech Language Pathologist was verified through the Nurse Aide Registry on (MONTH) 14, (YEAR) with nothing found.
All potential employees will be verified through the New York State Nurse Aide Registry to ensure we do not employ an individual who has been found guilty of abusing, neglecting, exploiting or mistreating individuals by a court of law as our policy indicates.
The Human Resource staff will be re-inserviced on this policy and procedure.
All new hires will be audited for the next three months to ensure employees were submitted to the Nurse Aide Registry.
The results of the audits will be reviewed at the Quality Assurance Committee Meetings and the Committee will determine if further audits are needed.
The Human Resources Manager is responsible for compliance.

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure they immediately consulted with the resident's physician when there was a significant change in condition for one (Resident #8) of one resident reviewed for significant changes. Specifically, for Resident #8, the facility did not notify the physician (MD) that the resident had diarrhea. This is evidenced by: Resident #8: The resident was admitted to the nursing home on 2/27/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A review of the Resident's Bowel Record and 24-hour reports from 7/10/18 - 7/25/18 documented the resident had twenty-nine large loose and one medium loose bowel movements. A Progress Note dated 7/23/18, documented that the resident had been having loose stool for the past three to four days. A Progress Note dated 7/25/18, documented that a review of the resident's bowel record noted that for the last 2-3 weeks the resident had a notable change in bowel habits. He previously had 1-2 soft BMs daily, but for the last 2-3 wks he has had multiple loose BMs daily and was not on bowel meds. During an interview on 08/21/18 at 09:11 AM, Registered Nurse #2 stated that they did have a bowel protocol if someone did not move their bowels. She does not look at the bowel book unless someone complains. It should have been looked at prior and the MD should have been called about diarrhea. During an interview on 08/21/18 02:09 PM, Registered Nurse Unit Manager #1 stated she did not check the bowel list. The Licensed Practical Nurses do that. If the resident had diarrhea they should have reported it to the charge nurse. The physician should have been notified prior to 7/26/18. 10NYCRR415.3(e)(2)(ii)(b)

Plan of Correction: ApprovedSeptember 14, 2018

Provider was notified of resident #8's diarrhea on (MONTH) 26, (YEAR).
All resident's bowel records have been monitored for any period of diarrhea.
Bowel Documentation policy and procedure was revised on (MONTH) 11, (YEAR).
New Bowel Protocol policy and procedure was developed on (MONTH) 11, (YEAR).
All Nursing Staff will be in-serviced on the new Bowel policy and procedure and revised Bowel Documentation policy and procedure.
Audits of the bowel documentation will be done weekly for 4 weeks then monthly for 2 months for compliance with the policies.
Results of the audits will be reported to the Quality Assurance Committee. The Quality Assurance Committee will determine the need for further audits.
Director of Nursing will be responsible for compliance.

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews during a recertification survey, the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents on two of two units. Specifically, the facility did not insure that there was enough staff to ambulate Resident #'s 8, 57 and #73, per their Comprehensive Care Plan (CCP) and Nursing Rehabilitation Physical Therapy in house ambulation program. This is evident by: Finding #1: Resident #57: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 7/3/2018, documented the resident could understand and was understood, with a Brief Interview of Mental Status (BIMS) of 12/15 and was moderately impaired for daily decision making. The CCP and Nursing Rehabilitation Ambulation Sheet documented that the resident was to receive ambulation training under 1 assist with a wheeled walker and gait belt for 120 feet, to maintain optimal mobility status. Nursing Rehabilitation Ambulation Sheets from 6/1/18 - 8/17/18, documented that out of seventy-eight opportunities to ambulate, the resident was ambulated thirty-five times. During an interview on 8/21/17 at 2:00 PM, the Certified Nursing Assistant (CNA) #2 stated that Physical Therapy (PT) is supposed to be her daily assigned area to assist with the Residents mobility program. Frequently the staffing has been less than adequate and the CNA's designated to do ROM and walk residents are placed as staff on the unit to provide care. Even with pulling from the rehabilitation program often there are only 3 CNA's on each unit on days, and 2 to 3 CNA's on each unit on 3 to 11 shifts. When this occurs, the residents are not ambulated per the care plans. During an interview on 8/20/18 at 11:30 AM, the Registered Nurse Unit Manager (RNUM) #4 stated they have had to pull from the Nursing Rehabilitation Program to provide care to the residents on the unit. When this occurs ambulation for the residents is not guaranteed. If the residents are ambulated it isn't every day. Shortage in staff is a common problem and causes delays in care as well. Finding #2 Resident #73: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/24/2018, documented the resident was understood and could usually understand, and was severely impaired for daily decision making. The Comprehensive Care Plan and Nursing Rehabilitation Ambulation Sheet documented that the resident was to receive ambulation training under 1 assist with a wheeled walker and gait belt for 120 feet, to maintain optimal mobility status. Nursing Rehabilitation Ambulation Sheets from 6/1/18 - 8/17/18, documented that out of seventy-eight opportunities to ambulate, the resident was ambulated thirty-five times. During interview on 8/20/18 at 11:48 AM, the Director of Physical Therapy (DPT) stated all the resident are placed on the Nursing Rehabilitation Program for either ambulation or Range of Motion (ROM) to promote mobility. Since (MONTH) (YEAR), the ability to see the residents on a regular basis has suffered because there has not been enough staff to provide care on the units. Staffing creates missed visits, this is the first place they pull from if staffing is short. When a residents nursing rehabilitation documentation sheet has a blank or is circled that means there has been no ambulation or ROM completed for that resident. During an interview on 08/20/18 at 11:55 AM, CNA #7 stated that they had problems with staffing; when the information for a day is blank for the Nursing Rehabilitation Ambulation Sheet or the initials are circled, there was no staff to ambulate the resident. During an interview on 08/21/18 02:00 PM, the Director of Nursing (DON) was asked for staffing sheets. Upon providing this writer with the required daily sheets she stated, honestly the staffing sheets do not reflect the call ins or correct numbers on the unit. We have been understaffed on all the days where there are holes in the nursing rehabilitation schedule. Due to insufficient staff and low numbers on the unit we have had to pull the 2 CNA's on the nursing rehabilitation to supplement the numbers on the unit. The call ins have been horrible, and we have not been able to cover even with agencies on weekends and evenings since June. Finding #3: Resident #8: The resident was admitted to the nursing home on 2/27/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. The Comprehensive Care Plan and Nursing Rehabilitation Ambulation Sheet documented that the resident was to receive ambulation training under 1 assist with a wheeled walker and gait belt for a distance of 120 feet, in order to maintain optimal mobility status. Nursing Rehabilitation Ambulation Sheets from 6/1/18 - 8/17/18, documented that out of seventy-eight opportunities to ambulate, the resident was ambulated twenty-one times. A weekly CNA Rehabilitation note dated 8/15/18, documented the resident does well when we have staffing. During an interview on 08/16/18 10:10 AM, CNA #3 stated that she had noticed a decline in his transfer status since using the scoot chair. They need 2 people to get him up because his legs are not so stiff. She had reported this to nursing and PT. During an interview on 08/20/18 at 10:29 AM, the Physical Therapy Director (PTD) stated that the resident gets ambulated 7 times a week in therapy to keep up his ambulation status. He did recall staff reporting an increased difficulty with transfers and thought he changed the status to a 2 assist . When he checked with the surveyor present, he stated it was not changed and it may have been PTs mistake. If it gets reported status changes he will change the care plan. He stated that they have had an issue with PT CNA staffing so people have not been ambulated. During an interview on 08/20/18 at 11:55 AM, CNA #7 stated that they had problems with staffing; when the information for a particular day is blank for the Nursing Rehabilitation Ambulation Sheet or the initials circled, there was no staff to ambulate the resident. During an interview on 08/21/18 at 09:22 AM, Registered Nurse #2 stated that PT decides who is on unit and who is on PT ambulation. She was aware that people were not getting ambulated because of staffing and it has been going on for quite a while. 10NYCRR415.13(a)(1)(i-iii)

Plan of Correction: ApprovedSeptember 14, 2018

Resident #57 has been ambulated in Nursing Rehab 11 out of 13 days in September.
Resident #73 has been ambulated 10 out of 13 days (1 refusal) in September.
Resident #8's health is declining rapidly on (MONTH) 22, (YEAR). Resident no longer able to transfer with 2 assist and was changed to a mechanical lift and discharged from Nursing Rehab program. On (MONTH) 13, (YEAR), he was admitted to the Hospice House.
Director of Nursing actively pursuing hiring new CNA's. Two new CNA's started on (MONTH) 20, (YEAR). One new CNA hired to start on (MONTH) 24, (YEAR). Two individuals are being sent for sponsorship into a CNA class.
A full time CNA returned from a leave of absence and has been assigned to Nursing Rehabilitation as of (MONTH) 30, (YEAR).
Audits of the Nursing Rehabilitation ambulation of residents will be done weekly for 4 weeks; then bi-weekly for 4 weeks and then monthly for 3 months.
Results of the audits will be reported to the Quality Assurance Committee. The need for further audits will be determined by the Quality Assurance Committee.
The Director of Nursing will be responsible for compliance.

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: August 21, 2018
Corrected date: October 16, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure comprehensive person-centered care plans reflected individualized, person-centered approaches with measurable goals, timetables and specific interventions for two (2) (Residents 24 and #28) of four (4) residents reviewed. Specifically, for Resident #'s 24 and #28, the facility did not document specific interventions for residents with dementia for use by staff based on their effectiveness. This is evidenced by: A Policy and Procedure for Dementia Care with effective date of 8/2014, documented non-pharmacological approaches to dementia care must be trialed before any initiation of [MEDICAL CONDITION] medication. Resident #24 This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The resident understands others and is able to be understood. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Nurse Progress Note dated 7/30/18 at 6:29 am, documented increased agitation. Resident became verbally and physically aggressive. He followed the medication nurse and attempted to enter rooms with her. He became very verbally aggressive when told he had to stay in the hall. He went to the kitchenette area and pulled the drawer with crackers completely out and it crashed to the floor. He attempted to yank folding bathroom door off its hinges when he stood to pull up his attends and pants. He stated he is not going to be told what to do. A Nurse Progress Note dated 8/03/18 at 4:39 PM, documented resident was verbally abusive to staff, kicked the medication cart and tried to take things from the medication cart. A Nurse Progress Note dated 8/03/18 at 5:25 PM, documented the resident was behind the nurses station and was very agitated picking up the phone and computer mouse, motioning as if he was going to throw them at the staff. He told the staff this is mine and you need to get out, using foul abusive language. Resident stated he was calling the police to get all of them out of here as this was his place. Swinging arms at staff and other residents telling female staff he wished they were a boy and making a punching gesture at them. Continuously trying to take phones off the desk stating they are his. A Nurse Progress Note dated 8/04/18 at 6:05 am, documented the resident had been up all night going from one refrigerator to another. He has been in an argumentative mood, as he feels everything is his and no one is allowed to touch it without asking him. He then will be weepy. Appears tired but refuses to go to bed. A Nurse Progress Note dated 8/04/18 at 3:15 PM, documented the physician was made aware the resident was becoming more agitated and verbally abusive at night. New orders were received for [MEDICATION NAME] 50 mg and [MEDICATION NAME] 50 mg at bedtime. A Nurse Progress Note dated 8/10/18 at 3:15 pm, has been verbally abusive to his wife, having periods of paranoid thinking. He thought he was being held captive and everyone was taking everything from him. The resident's behavior was discussed with the physician and [MEDICATION NAME] was discontinued and [MEDICATION NAME] (an antipsychotic) 5 mg ordered along with a consult for mobile geriatric. A Dementia Careplan dated 12/19/17, listed approaches to establish and maintain a daily routine with consistent caregiver; explain all procedures prior to beginning care in a simple manner; allow extra time to respond to or ask questions and to offer choices; speak slowly and use short simple phrases. A Recreational Therapy Careplan dated 12/28/17, lists approaches to invite the resident to go outside, to church, room visits, music, bingo, pet therapy, guinea pig, visits and movies. During an interview on 8/20/18 at 10:43 am, LPN #2 stated non-pharmacological approaches used when the resident is agitated is to give him snacks. He also thinks the nursing home is his place of business and he thinks the staff are his employees. He worries that his business is not being taken care of. He is assured by staff that the books are kept in order. During an interview on 8/20/18 at 10:45 am, LPN #3 stated she offers the resident a beverage to divert his attention to what he is thinking about. Talking on the phone to his family helps. After he speaks to his family they will have a pizza delivered to him. This occurs on a daily basis. During an interview on 8/20/18 at 10:57 am, Registered Nurse Manager (RNM) #3 stated the interventions taken by staff to calm the resident should be in his dementia careplan, but they are not. Resident #28 This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severe cognitive impairment. The resident sometimes understands and usually is understood. Nurse Practitioner (NP) note (undated) documented the resident is confused with continued periods of agitation. shouting out, screaming and not sleeping. She does not recognize the NP. The resident has advanced dementia with anxiety and depression. [MEDICATION NAME] was continued for anxiety and depression. Nursing Progress Note dated 7/03/18 at 12:10 am, documented the resident was heard saying yohoo I am in here and I am on the floor. Resident was found sitting on the floor looking at a picture book. A Nursing Progress Note dated 7/18/18 dated 12:39 pm, documented the resident had been calling out this morning. She has attempted to undress herself. A Nursing Progress Note dated 7/26/18 at 5:04 pm, documented she was found sitting on the floor between her chair and the bed. She held the chair electrical cord in her hands. She was naked except for one shoulder covered in a hospital gown. Her attends were shredded in her recliner. The chair was disconnected from the electrical source. A Nursing Progress Note dated 8/06/18 at 4:15 pm, documented resident was found half sitting and half lying on the floor in front of her recliner. She had removed all clothing including her attends. A Dementia Careplan dated 1/21/17, listed approaches to establish and maintain daily routine with consistent caregiver; explain all procedures prior to beginning care in a simple manner; allow extra time to respond to or ask questions and to offer choices, speak slowly and use short simple phrases. A Recreational Therapy Careplan dated 1/23/17, listed an approach of pet therapy, invite the resident to go outside on the patio or courtyard, visit while in room and to encourage participation to activities of choice. During an interview on 8//20/18 at 10:31 am, CNA #4 stated when the resident's husband visits, he is able to calm the resident. Interventions which also are effective are to rub her arms and talk softly to her, bring her near the nursing station, redirect and toilet and change her. During an interview on 8/20/18 at 10: 35 am, CNA #5 stated sitting and talking to the resident while holding her hand is effective. During an interview on 8/20/18 at 10:40 am, LPN #2 stated giving the resident magazines to keep her hands busy is effective. During an interview on 8/20/18 at 10:50 am, RNM #4 stated the resident's husband takes her to music. She stated the interventions taken by staff to calm the resident should be listed in the resident's careplan but are not. 10NYCRR415.12

Plan of Correction: ApprovedSeptember 27, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Developed person-centered dementia care plan for resident #24 on (MONTH) 11, (YEAR).
Person-centered dementia care plan was developed for resident #28 on (MONTH) 12, (YEAR).
Person-centered dementia care plans will be developed for all residents with dementia-related behaviors.
Audits to ensure dementia residents have a person-centered care plan will be done for all new admissions with a [DIAGNOSES REDACTED].
Results of the audit will be reported to the Quality Assurance Committee and the Committee will determine need for further audits.
The Director of Nursing is responsible for compliance.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that patient care-related electrical equipment (PCREE) is tested and inspected prior to being placed in service and maintained with consideration of the owner's manuals. Specifically, PCREE such as nebulizers and oxygen concentrators (concentrator) were not inspected prior to being placed in service or maintained as prescribed in the owner's manuals. This is evidenced as follows. All PCREE were assigned to residents. Residents were in their rooms during all observations. Observations on 08/13/2018 at 1:10 PM, revealed that nebulizer # 6737 and nebulizer # 6142 were not in use and plugged into electrical outlets. Review of the Warnings and Cautions section of the nebulizer owner's manual on 08/14/2018, revealed that the nebulizer is to be unplugged immediately after use. The Staff Development Coordinator Nurse stated in an interview conducted on 08/13/2018 at 1:40 PM, that owner's manuals safety guidelines are not consulted when training staff on the safe use of PCREE. Further observations on 08/13/2018 at 1:10 PM, revealed that a concentrator was in use by a resident in resident room [ROOM NUMBER]. The Director of Engineering and Cardiopulmonary Services stated in an interview conducted on 08/13/2018 at 1:20 PM, that the concentrator found in resident room [ROOM NUMBER] is not part of the PCREE inventory and the nursing home provides for their own concentrators. The Director of Nursing stated in an interview conducted on 08/13/2018 at 1:40 PM, that she is not sure if the concentrator found in resident room [ROOM NUMBER] was inspected prior to use. Record review of the PCREE inspection logs on 08/13/2018, revealed that there was no inspection record for the concentrator found in resident room [ROOM NUMBER]. Record review of the facility policy Electrical Safety Testing revealed all rental or loaner equipment will be tested prior to being put into use. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedSeptember 21, 2018

Policy and procedure for operating a mini nebulizer was revised on (MONTH) 10, (YEAR) to ensure staff unplug the nebulizer when not in use.
All Nurses will be in-serviced on the revised policy and procedure.
Staff will be educated on the safe use of electrical medical equipment as per the owner's manual and facility policy and procedure.
As per policy, all equipment will be tested and inspected prior to being placed in service.
Audits to ensure staff comply with the safety precautions / recommendations when mini nebulizers are in use will be done weekly for 4 weeks then monthly for 2 months.
Results of the audits will be reported to the PI Committee and the need for further audits will be determined by the Committee.
The Director of Nursing will be responsible for compliance.
Audits of the equipment inspections will be conducted 1 time per week for 2 months and the results of the audits will be reported to the Safety Committee.
The Safety Committee will determine need for further audits.
The Safety Officer is responsible for compliance.

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: August 21, 2018
Corrected date: November 19, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide emergency power as required by adopted regulations. NFPA 99 Health Care Facilities Code 2012 edition section 6.4.1.1.17 requires that the emergency power source (emergency generator) is to include a remote annunciator that is storage battery powered and located outside of the generating room in a location readily observed by operating personnel. Specifically, the emergency generator does not include a remote annunciator. This is evidenced as follows. Observations on 08/15/2018 at 12:15 PM, revealed that the emergency generator does not include a remote annunciator. The Director of Engineering stated in an interview conducted on 08/15/2018 at 12:15 PM, that the generator is not but has the capability of being wired with a remote annunciator. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.4.1.1.17; 10 NYCRR 415.29, 711.2(a)(1); 1999 NFPA 99 3-4.4.1.1.15

Plan of Correction: ApprovedSeptember 21, 2018

In process of requesting a quote from Siemens for a remote annunciator. The remote annunciator for the emergency generator will be installed in accordance with NFPA 70, NFPA 99 and NFPA 110.
A remote annunciator will be installed as required.
Engineering and Nursing Home employees will be educated on the function of the remote annunciator which will send notification that we are on generator power.
The Director of Engineering will be responsible for the completion of the remote annunciator and report it to the Safety Committee.

EP TRAINING PROGRAM

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 18, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not annual training for all existing staff in emergency preparedness policies and procedures consistent with their expected roles. This is evidenced as follows: A review of the Emergency Plan, Training Program and interview with the Director of Nursing on 08/14/2018 at 4:20 PM, revealed that certified nursing assistants only receive annual training in the Emergency Plan; other staff such as nurses, activities employees, and dietary employees do not receive annual training. 42 CFR: 483.73(d)(1)(ii)

Plan of Correction: ApprovedSeptember 21, 2018

All Nursing Home employees will be trained on the Emergency Preparedness Plan and their respective roles by (MONTH) 18, (YEAR).
Initial training in emergency preparedness is done during orientation. Annual training will be completed for all employees of their respective roles annually.
Documentation of the training will be maintained for each employee.
The results of the training will be discussed at the Safety Committee Meeting.
The Emergency Preparedness Supervisor will be responsible for compliance.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 edition section 14.6.2.4 requires that a record of all inspections, testing, and maintenance shall be provided including smoke detector sensitivity testing. Specifically, records of smoke detector sensitivity testing have not been provided. This is evidenced as follows: The fire alarm testing reports from (YEAR) to the present were reviewed on 08/15/2018. No records were available for survey review documenting smoke detector sensitivity testing. The Director of Engineering stated in an interview conducted on 08/16/2018 at 4:45 PM that the facility does not have a current record of smoke detector sensitivity testing. The vendor that tests the fire alarm system asserts sensitivity testing is conducted every time the smoke detectors are tested , but the sensitivity testing is not recorded. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.6.1.3; 2010 NFPA 72 14.6.2.4; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.3, 9.6.1.4; 1999 NFPA 72: 7-5.2.2

Plan of Correction: ApprovedSeptember 14, 2018

Smoke detector sensitivity was conducted by our contractor on (MONTH) 15, (YEAR).
Semi-annually detectors will be checked and recorded for sensitivity as per the regulation as indicated on the NFPA72 Inspection and Testing Form on August15, (YEAR).
Semi annually the reports will be submitted to the Safety Committee for one year to ensure the sensitivity testing is completed.
The Safety Officer will be responsible for compliance.

K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - INFORMATION AN

REGULATION: Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey the facility did not maintain the piped medical gas system in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 5.1.11 requires that piping serving medical gas systems have every twenty (20) feet green labels with white lettering. Specifically, the piping serving the medical oxygen system was not labeled as required. This is evidenced as follows: Observations above the suspended ceiling on 08/16/2018 at 11:00 AM, revealed that the piping serving the medical oxygen system did not have the required labeling. The Director of Engineering stated in an interview conducted on 08/16/2018 at 11:00 AM, that he will have the oxygen piping labeled as is required. 42 CFR 483.70 (a) (1); 2012 NFPA 99 5.1.11; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-4

Plan of Correction: ApprovedSeptember 14, 2018

Code compliant labels have been received.
Installation of the required labeling will be completed.
The Engineering Manager will audit the completion of the installation of the labeling and report it to the Safety Committee Meeting.
The Engineering Manager is responsible for compliance.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 16, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan's policies and procedures did not include the use of volunteers, such as State and Federal health care professionals to address surge needs, in an emergency. This is evidenced as follows. A review of the Emergency Plan on 08/13/2018, revealed the policies and procedures did not include the use of medical volunteers to address an emergency, such as an influx of patients or residents. The Administrator and Director of Nursing stated in an interview conducted on 08/13/2018 at 8:45 am, that the facility Emergency Plan will be revised to include the use of medical volunteers. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedOctober 1, 2018

A Volunteer Emergency Management policy and procedure was developed on (MONTH) 13, (YEAR). The Fulton County Civil Defense Office will be contacted should volunteers be needed during an emergency.
Our Emergency Plan has been was revised on (MONTH) 13, (YEAR) to indicate the use of medical volunteers.
Should volunteers be needed in the event of a surge emergency they would be utilized as per our policy and procedure.
Management staff will be educated on the new policy.
The education results will be reported to the Safety Committee Meeting.
The Emergency Management Supervisor is responsible for compliance.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan did not include provisions detailing their role for the care and treatment of [REDACTED]. This is evidenced as follows: A review of the Emergency Plan on 08/13/2018, revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator and Director of Maintenance stated in an interview conducted on 08/13/2018 at 8:45 AM, that county emergency preparedness officials will be contacted and the Emergency Plan will be revised to include provisions outlining their role for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedSeptember 14, 2018

A policy and procedure will be developed to operate under the 1135 waiver authority should the facility need to respond to a disaster.
The Fulton County Civil Defense Coordinator has been contacted to develop specific roles for the county and facility should we need to operate at an alternate care site.
The Emergency Management Plan will be revised and appropriate staff will be educated on the revisions.
The revised plans will be discussed at the next Safety Committee Meeting.
The Emergency Management Supervisor will be responsible for compliance.

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 21, 2018
Corrected date: October 18, 2018

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain equipment using gas or related gas piping and electrical wiring and equipment in accordance with the adopted regulations. NFPA 54, National Fuel Gas Code 2011 Edition Section 9.3 requires that Type II gas dryers specifically provide air for fuel combustion (make-up air). NFPA 70 National Electrical Code 2011 Edition Article 210.8 requires that Ground Fault Circuit Interrupter protection (GFCI) be provided on electrical outlets within six-feet of a sink rim or water source. Specifically, make-up air was not provided for gas dryers and electrical outlet GFCI protection was not provided on outlets located near water sources. This is evidenced as follows: Observations of the laundry room on 08/15/2018 at 11:20 AM, revealed that the door to the outside of the room was open and the fuel-fired clothes dryer did not have dedicated make-up air ducting. Record review of the clothes dryer owner's and installation manual on 08/15/2018, revealed that an outdoor wall vent be provided for fuel combustion make-up air. The Director of Environmental Services stated in an interview conducted on 08/16/2018 at 8:50 AM, that while the dryer is in use, the laundry room door to the outside is closed during the winter The Director of Maintenance stated in an interview conducted on 08/16/2018 at 8:50 AM, that he will have venting installed in the laundry room to provide make-up air for the dryer. Observations 08/16/2018 at 9:40 AM, found that GFCI protection on electrical outlets were missing near water sources in resident room #'s 1, 3, 10, 16, 23, 26, 27, 28, and #36; the West Unit kitchenette; and by washing machines in the laundry (2 each). The Director of Engineering stated in an interview conducted on 08/16/2018 at 4:45 PM, that he will install GFCI protection on electrical outlets near water sources. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.1, 9.1.2; 2011 NFPA 54 9.3; 2011 NFPA 70 Article 210.8; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 54; 1999 NFPA 70 Article 210.8

Plan of Correction: ApprovedSeptember 14, 2018

The gas dryer will have appropriate make up air.
Venting will be installed in the Laundry Room for the required make up air.
The Engineering Manager will insure the venting is completed and report it's completion to the Safety Committee Meeting.
The Engineering Manager will be responsible for compliance.
GFCI outlets will be installed in rooms 1, 3 10, 16, 23, 26, 27, 28 and 36, West Kitchenette and by washing machines in the Laundry Room by (MONTH) 18, (YEAR).
A survey is being conducted within the facility to install the required GFCI protection on electrical outlets within 6' of a water source.
The Engineering Manager will audit to ensure the installation is complete.
The results of the audit will be reported to the Safety Committee Meeting.
The Engineering Manager is responsible for compliance.