Plattsburgh Rehabilitation and Nursing Center
October 26, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.10(i)(3):CLEAN BED/BATH LINENS IN GOOD CONDITION

REGULATION: (i)(3) Clean bed and bath linens that are in good condition;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during a recent recertification survey and abbreviated survey (Case #NY 953), the facility did not ensure the resident was provided with clean bed linens. Specifically, Resident #65's linens were soiled on 10/23/17 and the resident's linens remained soiled until 10/26/17. This is evidenced by: Resident #65 Resident #65 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as severely impaired cognitively and speaks only Hungarian. During an observation on 10/23/17 at 2:00 pm, the resident's bed linens were soiled with large, dried, brown stains on the fitted sheet; on the upper portion, facing the doorway. The same stains were present on 10/24/17 at 8:35 am, 10/25/17 at 8:30 am and 10/26/17 at 7:30 am. During an interview on 10/26/17 at 7:35 am, the Director of Nursing (DON) stated that dirty sheets need to be changed as soon as they are soiled. The DON removed the soiled bed linens from the resident's bed. 10NYCRR 415.5(h)(3)

Plan of Correction: ApprovedNovember 17, 2017

F254 CLEAN BED/ BATH LINENS IN GOOD CONDITION
Corrective action(s) for those residents found to have been affected by the deficient practice:
Resident #65
? Resident and record review showed no negative outcome from the deficient practice. The linen was immediately changed upon notification.
? Education provided to all nursing staff to ensure bed linen is changed when they are soiled.
Identification of other areas having the potential to be affected by the same deficient practice and corrective action to be taken:
? All residents have the potential to be affected by the deficient practice.
? A full house audit of resident bed linen to ensure the linen is clean and in good condition, any linen not to be found in compliance was removed and changed.
? Education provided to all nursing staff to ensure bed linen is clean and in good condition.
Measures that will be put in place or systematic changes made to ensure that the deficient practice does not reoccur:
? Bed Change Policy and Procedure was developed to provide guidance to nursing staff on when to change bed linens to include the following verbiage: Linens will be changed as needed due to soiling.
? All nursing staff will be educated on the policy and all new nursing staff will be educated on the policy during new employee orientation.
How the corrective action will be monitored to ensure the deficient practice does not reoccur:
? An audit will be conducted 4 times a week for 30 days at random times and shifts to check resident bed linen for cleanliness and condition, any corrective action will be identified and fixed immediately.
? The audit findings will be reported monthly and reviewed by the facility QAPI committee who will determine need for future frequency.
Responsible Party:
Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during a recertification survey the facility did not ensure that it treated and cared for each resident in a manner and in an environment that promoted maintained or enhanced his or her quality of life recognizing each resident's individuality for two (Resident #'s 19 & 64) of seventeen residents' reviewed. Specifically, the facility did not ensure Resident #'s 19 and 64 were covered and not in view of others during dressing changes. This is evidenced by: Resident #19 The resident was admitted to the nursing home on 10/13/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making and that the resident understood and was understood by others. During an observation on 10/23/17 at 12:15 pm, the Director of Nursing (DON) performed a dressing change to the resident's groin. The privacy curtain was open at the end of the bed. The resident's body was exposed below the waist. A staff member entered the resident's room to care for Resident #19's room mate and the room mate's spouse walked over to the sink to throw something in the garbage, that was accoss from and in full view of Resident #19's bed. During an interview on 10/24/17 at 7:30 am, the DON stated that she should have pulled the curtain around the bed to provide the resident with privacy. Resident #64 The resident was originally admitted on [DATE], with readmission on 9/18/2017, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as cognitively intact and understands and is understood. During a dressing change observation on 10/25/17 at 12:36 pm, Registered Nurse (RN) #3 left the resident's private room to obtain additional supplies without closing the resident's door. The resident was fully exposed from the waist down. RN #3 returned to the room, did not close the room door and continued with the dressing change. During an interview on 10/25/17 at 1:05 pm, RN #3 stated she did not realize she had left the door open. 10NYCRR 415.5(a)

Plan of Correction: ApprovedNovember 17, 2017

The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
F241 DIGNITY AND RESPECT OF INDIVIDUALITY
Corrective action(s) for those residents found to have been affected by the deficient practice:
Resident #19
? Record review showed no negative outcome from the deficient practice.
? Resident was discharged to home on 10/26/17.
Resident # 64
? Nursing and social worker assed resident with no negative outcomes noted.
? Education provided to all clinical staff to ensure resident is not in view of others during dressing changes and other aspects of care.
Identification of other areas having the potential to be affected by the same deficient practice and corrective action to be taken:
? All residents have the potential to be affected by the deficient practice.
? All privacy curtains in semi private resident rooms will be checked to ensure that they extend around the bed to provide total visual privacy.
? Education provided to all clinical staff to ensure the privacy curtains are drawn and residents are in view of others during dressing changes and other aspects of care.
Measures that will be put in place or systematic changes made to ensure that the deficient practice does not reoccur:
? All staff will be educated on resident dignity; to include ensuring residents are treated and cared for in a manner and environment that promotes and maintains their quality of life.
How the corrective action will be monitored to ensure the deficient practice does not reoccur:
? Nursing leadership will conduct a unit walk thru dignity audit daily for 30 days at random times and shifts, any corrective action will be identified and fixed immediately.
? The results will be reported monthly and reviewed by the facility QAPI committee who will determine need for future frequency.
Responsible Party:
Administrator

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs for 5 (Resident #'s 11, 19, 64, 87, and #88) of 10 residents reviewed the recertification survey. Specifically, for Resident #'s 11, 19, 64, 87, and #88, there was inconsistent documentation identifying to what extent the resident's pain was relieved by pain medications administered as needed (PRN). This is evidenced by: An undated facility policy titled PRN Orders, documented; Effectiveness of the PRN medication should be documented on the back of the MAR or Nurses progress note. A Pain Management Assessment with verbal and non-verbal numeric pain scales is attached to the policy. Resident #87 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 8/22/17, assessed that the resident usually understands, was understood, and had intact cognitive skills for daily decision making. A Comprehensive Care Plan for Alteration in comfort, dated 8/31/17: Document the effectiveness of interventions/meds. A prescription order dated 8/15/17, documented the resident was to be given [MEDICATION NAME] (used to treat moderate to moderately severe pain) 50 milligrams (mg) every 4 hours PRN for pain. The Medication Administration Record (MAR) for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] 10 times. A 0-10 pain scale prior to administration was documented 6 times with a follow-up documented as (+) effective or effect pending. There was no documentation of a follow-up numeric pain scales. During an interview on 10/25/17 at 10:00 am, the Director of Nursing (DON) stated that the policy was for staff to do a numeric pre and post pain scale level and they should be following that policy; She went over the use of the numeric pain scale with staff verbally about a month ago. Resident #88 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 7/1/17, assessed that the resident understands, was understood, and had moderately impaired cognitive skills for daily decision making. A prescription order dated 6/23/17, documented the resident was to receive [MEDICATION NAME] (narcotic used to treat moderate to severe pain) 5 milligrams (mg) every 4 hours PRN for pain. A Comprehensive Care Plan for Alteration in comfort, dated 6/23/17: Document the effectiveness of interventions/meds. The MAR for (MONTH) 23-30, (YEAR), documented the resident received [MEDICATION NAME] 15 times. A 0-10 pain scale prior to administration was documented 5 times with a follow-up pain scale documented as (+) effective. There was no documentation of follow-up numeric pain scales. The MAR for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] 34 times. A 0-10 pain scale prior to administration was documented 14 times with a follow-up documented as (+) effective. There was no documentation of follow-up numeric pain scales. The MAR for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] 43 times. A 0-10 pain scale prior to administration was documented 15 times with a follow-up pain scale documented as (+) effective. There was no documentation of follow-up numeric pain scales. During an interview on 10/25/17 at 10:00 am, the DON stated that the policy was for staff to do a numeric pre and post pain scale level and they should be following that policy; She went over the use of the numeric pain scale with staff verbally about a month ago. Resident #19 The resident was admitted to the nursing home on 10/13/17, with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having intact cognitive skills for daily decision making and that the resident understood and was understood by others. A Comprehensive Care Plan for Alteration in Comfort, dated 10/13/17, documented; Document the effectiveness of medications. Physician order [REDACTED]. The MAR and progress notes dated from 10/17 - 10/23/17, documented that the resident received [MEDICATION NAME] on 19 occasions. Of those 19 occasions, 14 documented a numeric pre pain scale and there was no numeric post pain scale. During an interview on 10/26/17 at 10:00 am, the Registered Nurse Manager (RNM) stated that staff were supposed to document numeric pre and post pain levels on the resident and that they could not evaluate the amount of relief the resident without the numeric numbers. During an interview on 10/26/17 at 11:30 am, the DON stated that the policy was for staff to do a numeric pre and post pain scale level and they should be following that policy; She went over the use of the numeric pain scale with staff verbally about a month ago. 10NYCRR 415.12(l)(1)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 329 DRUG REGIMEN IS FREE FROM UNECESSARY DRUGS
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #11
? No negative outcome from this alleged deficient practice. Resident continues on prn pain medication, record review shows appropriate drug regimen.
Resident #19
? Record review showed no negative outcome from this alleged deficient practice discharged to home on [DATE].
Resident #64
? No negative outcome from this alleged practice. Resident continues on minimal prn pain medication, record review shows appropriate drug regimen.
Resident #87
? Record review showed no negative outcome from this alleged deficient practice, discharged to home on [DATE].
Resident #88
? Record review showed no negative outcome from this alleged deficient practice, deceased on [DATE], under Hospice care
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents that receive prn pain medication have the potential for this alleged practice.
? An audit will be performed of all residents receiving prn pain medication ensuring the use of the numeric pain scale pre and post medication. Any negative findings will be immediately addressed.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? The prn pain medication policy will be reviewed/revised to ensure each resident is free from unnecessary drugs, specifically adequate monitoring with use of the numeric pain scale, pre and post medication.
? All nurses will be educated on this policy and Nurse orientation will be reviewed/revised if needed.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? Audits will be performed 3x a week for 4 weeks, weekly for 4 weeks, then randomly.
? All negative findings will be immediately addressed and nurse education provided at that time.
? Audit findings will be presented to the QAPI committee meeting for evaluation and follow-up as indicated
The date for correction and the title of the person responsible for correction of each deficiency.
Responsible person:
Director of Nursing/ Designee

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

Based on observation, staff interview, and security camera recording review during the recertification survey, the facility did not ensure food was prepared in in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that soiled food service gloves (gloves) may not be used to prepare food and that soiled food contact surfaces, such as beverage glasses, may not be used to serve food. Specifically, kitchen employees were observed touching food with soiled gloves and serving beverages with soiled beverage glasses. This is evidenced as follows. Cook #1 was observed wearing gloves and touching the handle of a food service cart then handling pasta with the same, now soiled gloves on 10/23/2017 at 12:45 pm. On 10/23/2017 at 12:56 pm, CNA #1 was observed picking up beverage glasses by touching the inside of the glasses with bare hands then serving beverages in the same glasses. The Food Service Director stated in an interview conducted on 10/23/2017 at 1:00 pm and again on 10/25/2017 at 2:38 pm, that she believes that Cook #1 uses gloves correctly and it is the incorrect procedure for staff to touch the inside of beverage glasses with bare hands. The security camera recording of the kitchen operations dated 10/23/2017 were reviewed on 10/25/2017. This recording documents the main kitchen cook touching the handle of a food service cart then handling pasta with the same, now soiled gloves. 10 NYCRR 415.14(h); 10 NYCRR Chapter 1, Subpart 14-1.80

Plan of Correction: ApprovedNovember 17, 2017

F 371 FOOD PR(NAME)URE, STORE/ PREPARE/ SERVE- SANITARY
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Cook# 1
? Gloves were changed after deficient practice, and was educated on the FDA Guidelines.
C.N.A #1
? All C.N.A.s will be educated on properly handling glasses to ensure they are not touching the inside of the glass.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents have the potential to be affected by deficient practice.
? All food service employees will be educated on the FDA guidelines of proper food handling and glove changes.
? All employees and volunteers that serve meals to the residents will be educated on proper handling of glasses when serving beverages.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? Sanitation and food handling policy will be reviewed and updated to ensure the FDA guidelines are noted.
? Food preparation and hand contact policy will also be reviewed and revised.
? All food service employees will be educated on updated policies; all new food service employees will be educated on the policies and procedures during orientation.
? All employees and volunteers that serve meals to the residents will be educated on the policies; all new employees and volunteers will be educated on orientation.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? Meal service/ prep will be audited monthly X3 months to ensure proper meal preparation, glove usage, and handling of glasses.
? Audit findings will be presented to the QAPI committee meeting for evaluation and follow-up as indicated
The date for correction and the title of the person responsible for correction of each deficiency.
Responsible person:
Food Service Director

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it established an infection prevention and control program (IPCP) that included, at a minimum, the following elements, a system for preventing, identifying, reporting, investigating, and controling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services and standard and transmission-based precautions to be followed to prevent spread of infections for four (Resident #'s 3, 11, 19, and #64) of seventeen residents reviewed. Specifically, the facility did not ensure that Residents #'s 3 and 19 were screened for [DIAGNOSES REDACTED] upon admission and did not ensure proper hand hygiene and supply handling were done in a manner that that prevented cross contamination during Resident #11's and #64's dressing changes. This is evidenced by: Resident #64 The resident was originally admitted on [DATE] with readmission on 9/18/2017, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as cognitively intact, understands and is understood. On 10/25/17 at 12:36 pm, Registered Nurse (RN) #3, was observed providing dressing changes on 3 decubitus ulcers (pressure ulcers) on the resident's buttock (left gluteus) and upper thighs (left posterior leg and right upper leg). A physician order [REDACTED]. RN #3 put on clean gloves and removed dressings from the 3 sites, removed the gloves, and put on another pair of clean gloves without performing hand hygiene between glove change. RN #3 applied [MEDICATION NAME] to the wound sites covering sites with gauze. At 12:46 pm, RN #3 entered the room with dressing supplies, placed the supplies on the resident's bed, cleaned the over-bed table with a disinfecting wipe, and placed supplies on the over-bed table. She put on clean gloves, did not perform hand hygiene, and removed the gauze covering the wound sites. She removed her gloves and used hand sanitizer to clean her hands. RN #3 left the room to obtain Q-tips from the dressing cart, re-entered the room, put on clean gloves, did not perform hand hygiene, and began cleansing the wounds with normal saline. During an interview on 10/25/17 at 1:05 pm, RN #3 stated she must have forgotten to perform hand hygiene after removing the dirty gloves and when entering the resident's room. Resident #19: The resident was admitted to the nursing home on 10/13/17 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having intact cognitive skills for daily decision making and that the resident understood and was understood by others. A undated Policy for [DIAGNOSES REDACTED] Infection Screening, documented that to prevent the transmission of [DIAGNOSES REDACTED], the facility would provide ongoing [DIAGNOSES REDACTED] infection screening to all employees and residents; A two-step TST (an injectable skin test used to determine if a person was exposed to [DIAGNOSES REDACTED]) would be needed for every resident on admission and the first TST would be administered during the admission assessment. A review of the Physician (MD) Orders, Progress Notes, Medication Administration Records (MARs) and the [MEDICATION NAME] and Immunization Records did not include documentation that a [MEDICATION NAME] Skin Test was administered. During an interview on 10/16/17 at 9:45 am, Licensed Practical Nurse (LPN) # 4 stated that she did the orders for Resident #3 and should have entered the PPD on the MAR; She had not done an admission in a long time and forgot everything that needed to be done; There used to be an admission check sheet that listed everything that had to be done on an admission, but it was not in the admission packet. During an interview on 10/26/17 at 11:30 am, the Director of Nursing (DON) stated the resident was supposed to have a TST on admission. The Infection Control Nurse was supposed to ensure that the TSTs were done and documented on the a [MEDICATION NAME] and Immunization Record. She stated she had not had the time to do it because she was teaching a Certified Nursing Assistant (CNA) class. Resident #3: The resident was admitted to the nursing home on 10/16/17 with [DIAGNOSES REDACTED]. The Admission Progress Note dated 10/16/17, documented the resident was alert and oriented. A review of the Physician (MD) Orders, Progress Notes, Medication Administration Record (MAR) and the [MEDICATION NAME] and Immunization Record did not include documentation that a [MEDICATION NAME] Skin Test was administered. During an interview on 10/16/17 at 9:45 am, Licensed Practical Nurse (LPN) # 4 stated that she did the orders for Resident #3 and should have entered the PPD on the MAR; She had not done an admission in a long time and forgot everything that needed to be done; There used to be an admission check sheet that listed everything that had to be done on an admission, but it was not in the admission packet. During an interview on 10/26/17 at 11:30 am, the Director of Nursing (DON) stated the resident was supposed to have a TST on admission. The Infection Control Nurse was supposed to ensure that the TSTs were done and documented on the a [MEDICATION NAME] and Immunization Record. She stated she had not had the time to do it because she was teaching a Certified Nursing Assistant (CNA) class. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 441 INFECTION CONTROL PREVENT SPREAD, LINENS
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #3
? No negative outcome from this alleged deficient practice, per record review, no symptoms of [DIAGNOSES REDACTED].
? Resident was discharged home on[DATE].
Resident #11
? No negative outcome, resident continues with overall improvement of wound healing.
Resident #19
? No negative outcome from this alleged deficient practice, per record review, no symptoms of [DIAGNOSES REDACTED].
? Resident was discharged home on[DATE].
Resident #64
? No negative outcome, resident continues with overall improvement of intermittent, chronic wound healing.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All new admissions have the potential for this alleged deficient practice.
? Residents admitted within the last 3 months will be audited to ensure the [MEDICATION NAME] Skin Test had been administered per facility policy.
? All residents that require dressing changes have the potential for this alleged deficient practice.
? Competencies for dressing changes will begin for all nurses to ensure infection control protocols are being followed.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? Infection control policies related to [MEDICATION NAME] Skin tests, hand hygiene, and standard/transmission-based precautions will be reviewed and revised if needed.
? Education of these policies will be given to all nurses, including demonstration instruction and competencies, specific to dressing changes.
? Nurse orientation will be reviewed/revised to ensure Infection control policies are followed and all new nurses are competent with Infection control procedures during dressing changes.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? All new admissions will be audited for 4 weeks, then random admissions once a week for 4 weeks. All negative findings will be corrected and individual nurse education at the time of the finding.
? Initially, Nurse competencies for dressing changes will be done on all nurses, any negative finding will be immediately addressed and the individual nurse will be re-educated at that time.
? Competencies will continue annually and as needed based on skill proficiency.
? Audit findings will be presented to the QAPI committee meeting for evaluation and follow-up as indicated
The date for correction and the title of the person responsible for correction of each deficiency.
Responsible person:
Director of Nursing/ Designee

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure that residents who require [MEDICAL TREATMENT] received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences so that they maintained the highest practicable physical, mental and psycho-social well-being for three of four residents reviewed for [MEDICAL TREATMENT]. Specifically: For Resident #'s 64 and #1, who were on a fluid restriction, the facility did not ensure fluid intake was recorded or assessed, and that Resident #3's Tessio Catheter (a catheter with two lumens, one in an artery and one in a vein used for [MEDICAL TREATMENT]) was monitored, that communication was maintained with the [MEDICAL TREATMENT] center, and that the resident who was on a fluid restriction had orthostatic blood pressures (blood pressures done laying or sitting and then again standing to see if a change in position made the blood pressure drop which could cause dizziness or [MEDICAL CONDITION]) done after a fall of unknown origin. This is evidenced by: The Facility Policy for Residents Receiving [MEDICAL TREATMENT], dated 1/2016, documented: A Communication Sheet is sent with the resident to [MEDICAL TREATMENT] with any concerns documented on this communication; Upon return from [MEDICAL TREATMENT] the nurse will document the time of arrival and will observe vital signs, examine the [MEDICAL TREATMENT], and overall mentation of the resident, and document all the information in the progress notes; Review the Communication sheet from the [MEDICAL TREATMENT] center. Resident #3: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Admission Progress Note dated 10/16/17, documented the resident was alert and oriented, and had a Tessio catheter in the right chest for [MEDICAL TREATMENT] three days a week. Finding #1: The facility did not ensure that the resident's Tessio catheter was monitored. The Physician (MD) Orders dated 10/17/17, documented the resident was to have [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays via the Tessio Catheter in the right chest. The Comprehensive Care Plan for [MEDICAL TREATMENT] dated 10/16/17, documented that the [MEDICAL TREATMENT] was to be monitored for signs and symptoms of infection and bleeding every shift. During an interview on 10/24/17 at 8:30 am, the resident stated that the people at [MEDICAL TREATMENT] take care of his Tessio catheter and staff at the nursing home have not looked at it. During an interview on 10/26/17 at 10:30 am, RN #6 stated that she had seen the Tessio catheter when the resident was admitted , but did not put it on the TAR until 10/24/17, therefore no one looked at the catheter. During an interview on 10/26/17 at 11:30 am, the Director of Nursing stated that it was brought to her attention yesterday that the Tessio catheter was not being monitored and it should have been. Finding #2: The facility did not ensure that communication was maintained with the [MEDICAL TREATMENT] center. A [MEDICAL TREATMENT] Consult ([MEDICAL TREATMENT] communication sheet) for the Week of 10/18/17, documented an entry from [MEDICAL TREATMENT] on 10/18/17. There was no further documentation from the [MEDICAL TREATMENT] center. A Progress Note dated 10/18/17, documented the resident returned from [MEDICAL TREATMENT]. There was no evidence that the Tessio catheter was checked on return and no documentation that the resident left the facility for [MEDICAL TREATMENT] that day. There was no further documentation in the Progress Notes from 10/18 -10/25/17, that the resident left or returned from [MEDICAL TREATMENT], that the [MEDICAL TREATMENT] center was contacted when the [MEDICAL TREATMENT] communication sheet was blank, or that the resident was assessed after [MEDICAL TREATMENT]. During an interview on 10/24/17 at 8:00 am, LPN #3 stated that the communication paperwork is sent to [MEDICAL TREATMENT] with the resident and comes back with them when they return; If the resident came back without it and she had a concern she would call the [MEDICAL TREATMENT] center. During an interview on 10/26/17 at 10:30 am, RN #6 stated that the weekly communication sheet should be done with each [MEDICAL TREATMENT] visit and if it is not done then the nurse should call the [MEDICAL TREATMENT] center. During an interview on 10/26/17 at 11:30 am, the Director of Nursing stated that she would expect that communication with [MEDICAL TREATMENT] occurred with each visit and if no communication report was received from [MEDICAL TREATMENT] then they should have been contacted. Additionally, a follow up assessment should have been done by nursing when the resident returned and documented in chart. Finding #3: The facility did not ensure that orthostatic blood pressures were completed. The physician (MD) orders dated 10/17/17, documented the resident was on a 1200 cubic centimeter (cc) per 24- hour fluid restriction. Progress notes documented: 10/17/17 - Resident fell , self-ambulating and stated I stood up and then the lights went out. 10/17/17 at 9:30 am - The fall was discussed in IDT and due to the resident's statement will do orthostatic blood pressures every shift for 24 hours. The Comprehensive Care Plan for falls dated 10/17/17, documented that orthostatic blood pressures would be monitored every shift for 24 hours. The Medication Administration Record [REDACTED]. The boxes on the MAR indicated [REDACTED]. The medical record did not include further documentation regarding orthostatic blood pressures. During an interview on 10/24/17 at 9:45 am, LPN #4 stated that she did not do the orthostatic blood pressure on 10/17/17, because it was the end of the shift and she did not have time. During an interview on 10/26/17 at 10:30 am, RN #6 stated that the orthostatic blood pressures should have been done and she was not aware that they were not. Resident #1: The resident was admitted to the nursing home on 8/25/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making and that the resident understood and was understood by others. The Comprehensive Care Plan for Nutrition: Potential malnutrition and dehydration dated 9/7/17, documented that the resident was on a 1400 cubic centimeters (CC) fluid restriction per 24 hours and that 360 cc of the 1400 cc of fluid each day would be for the medication pass. During an interview on 10/25/17 at 2:30 pm, the Resident #1 stated that he had a water pitcher that staff put ice in for him and it melted down to about a glass of water. During an interview on 10/26/17 at 8:50 am, Licensed Practical Nurse (LPN) #3 stated that the resident should not have had a water pitcher, because he was on a fluid restriction. During an interview on 10/26/17 at 8:55 am, CNA #4 stated that the resident was on a fluid restriction and she would give him ice in his water pitcher so he could suck on it; CNA #4 stated she did not document this on his fluid intake sheet. During an interview on 10/26/17 at 10:20 am, RN #6 stated that she was not aware that the resident had a water pitcher and was getting ice; The resident is on [MEDICAL TREATMENT] and a fluid restriction so should not have had a pitcher and the ice should have been added into the extra section on the fluid intake record. Resident #64: The resident was originally admitted on [DATE], with readmission on 9/18/2017 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident as cognitively intact, understands and is understood. Review of the the resident's fluid intakes from (MONTH) (YEAR) - (MONTH) (YEAR), documented the following numerous blanks for fluid intake: June (YEAR) - 32 blanks out of 72 meal times (hospitalized 7 days) July (YEAR) - 43 blanks out of 93 meal times August (YEAR) - 5 blanks out of 93 meal times September (YEAR) - 29 blanks out of 90 meal times October (YEAR) - 48 blanks out of 69 meal times (October 1-23) During an interview on 10/25/17 at 8:11 am, the Registered Nurse Manager (RNM) #1 stated that staff should be documenting intakes, especially on a resident on a fluid restriction. During an interview on 10/25/17 at 10:05 am, the Director of Nursing (DON) stated that it is expected that staff will document accurate and timely intakes on residents. 10NYCRR 415.12

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 309 PROVIDE CARE/ SERVICES HIGHEST WELL BEING
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #1
? No negative outcome from this alleged practice, the ice pitcher was immediately removed from the residents room, resident and C.N.A were immediately educated on fluid definitions to include ice.
? Resident was discharged home on[DATE] without complications.
Resident #3
? No negative outcomes from this alleged practice; documentation of monitoring the Tessio site was immediately initiated.
? Resident was discharged to home on 10/25/2017 without complications.
Resident #64
? No negative outcome from this alleged practice.
? Resident continues to attend [MEDICAL TREATMENT] without complication. All resident?s intakes will be recorded and assessed.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents on [MEDICAL TREATMENT] and/or fluid restrictions have the potential for this alleged deficient practice.
? An audit will be done on all residents on [MEDICAL TREATMENT] and/or fluid restrictions to ensure; [MEDICAL TREATMENT] communication procedures are followed, [MEDICAL TREATMENT] are monitored, fluid/intake records are defined, appropriate, recorded and assessed, and any initiated orthostatic blood pressures are recorded and assessed. Any negative findings will be immediately addressed and corrected
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? All policies related to [MEDICAL TREATMENT] and fluid restrictions will be reviewed/revised to ensure each affected resident receives the necessary care and services for their highest well being.
? Education on all noted policies will be given to all nursing staff, Nursing orientation will be reviewed/revised to include noted policies.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? All [MEDICAL TREATMENT] and/or fluid restricted residents will be audited to ensure all related policies and procedures are followed.
? Auditing will be 3X/wk for 4 weeks, then weekly for 4 weeks, then randomly. All negative findings will be immediately corrected and education to individual nursing staff.
? Audit findings will be presented by the EVS at the QAPI committee meeting for evaluation and follow-up as indicated.
The date for correction and the title of the person responsible for correction of each deficiency.
Responsible person:
Director of Nursing/ Designee






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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

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 that it maintained medical records on each resident that were complete and accurately documented for three (Resident #'s 19, 34, 64) of 10 residents reviewed. Specifically, the facility did not ensure that the sites of injection for insulin administration were documented. This is evidenced by: Policy and Procedure: Specific Medication Administration Procedures, dated (MONTH) 2012, documented: document the injection on the MAR (Medication Administration Record) along with the site used. Resident #19 The resident was admitted to the nursing home on 10/13/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making, the resident understood and was understood by others. Physician (MD) Orders dated 10/17/17, documented: [MEDICATION NAME]; Give 40 units subcutaneously every evening, [MEDICATION NAME]per sliding scale before meals and at hour of sleep. The Medication Administration Record (MAR) and progress notes dated from 10/13 - 10/22/17, documented the resident received insulin injections on 24 occasions. Of those 24 occasions, the injection site was not documented on 20 of the 24 occasions. During an interview on 10/26/17 at 10:00 am, Registered Nurse #6 stated that injection sites were supposed to be rotated and that staff should have been documenting the site of injection so staff would know where the last injection was given. During an interview on 12/26/17 at 11:30 am, the Director of Nursing (DON) stated that she was not aware that injection sites were not being documented. Staff should have been documenting them. Resident #64 The resident was originally admitted on [DATE], with readmission on 9/18/2017 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact, understands and is understood. Medical Doctors Orders documented: [MEDICATION NAME] Pens 100 units per milliliter, inject 6 units subcutaneously every morning. [MEDICATION NAME] Pens 100 units/milliliter, inject 12 units subcutaneously at bedtime. The Medication Administration Record (MAR) dated 10/1 - 10/23/17, documented 46 opportunities for insulin injections. Of those 46 opportunities, 40 did not include injection sites and 4 did not include documentation of the medication administration or site of injection; The MAR was blank. During an interview on 10/25/17 at 8:11 am, Registered Nurse Manager (RNM) #3 stated that nursing staff should document that they gave the insulin and what the blood sugars were. After reviewing the MAR, RNM #3 stated that there were some omissions of insulin and the nursing staff should have documented on the back of the MAR why it was not given and their initials; circled, on the MAR to indicate it was not given. During an interview on 10/25/17 at 10:05 am, the DON stated that after reviewing the resident's MAR, that the sites of insulin injections should have been documented on the MAR. 10NYCRR 415.22(a)(1-4)

Plan of Correction: ApprovedNovember 17, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 514 RES RECORDS COMPLETE/ACCURATE/ACCESSIBLE
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Resident #19
? No negative outcome from this alleged deficient practice. The resident was discharged home on[DATE] with no complications related to insulin injections.
Resident #64
? No negative outcome, the resident continues insulin injections with no complications.
? Upon discovery, the Medication Administration Procedure was reviewed and education began to all nurses, related to injections and the documentation of injection sites.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents receiving injections have the potential for this deficient practice.
? Education related to the documentation of injection sites continues.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? The Medication Administration Procedure related to the documentation of injections will be reviewed, revised if needed.
? Education will continue to all nurses to ensure the resident records are accurate and complete with the documentation of injection sites.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? All residents receiving injections will be audited for injection site documentation 2x/wk for 4 weeks, then once a week for 4 weeks, then randomly.
? Any negative findings will be addressed and the individual nurse will be re-educated at that time.
? Audit findings will be presented to the QAPI committee meeting for evaluation and follow-up as indicated
The date for correction and the title of the person responsible for correction of each deficiency.
Responsible person:
Director of Nursing/ Designee

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

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 10/26/2017 at 10:15 am, revealed that the emergency generator does not include a remote annunciator. The Director of Environmental Services stated in an interview conducted on 10/26/2017 at 10:45 am, that due to its year of manufacture, the emergency generator does not have electronic capability to include 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: ApprovedNovember 21, 2017

K 916 NFPA 101 Electrical Systems-Essential Electric Systems
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
? The age of the emergency generator currently in place does not support remote annunciation outside the generating room.
? The facility will submit a waiver form DOH-5223 to the NYS BAER.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents have the potential to be affected by the deficient practice.
? The facility will submit a waiver form DOH-5223 to the NYS BAER.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? Current facility policy states: Should the facility have a loss of power, the maintenance department will man the facility 24 hrs a day making rounds every hour to ensure the generator is operating optimally and document results.
? Documented results include the time, Amps, volts, temperature and condition of the generator.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? The emergency generator is monitored weekly and a full load run is conducted at least once every 30 days.
? The outcome of the waiver will be reported to the QAPI committee for evaluation and follow up as indicated.
Responsible person:
Director of Environmental Services

K307 NFPA 101:FUNDAMENTALS - BUILDING SYSTEM CATEGORIES

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

Based on staff interview during the recertification survey, the facility did not conduct a building systems risk assessment as required by adopted regulation. NFPA 99 Health Care Facilities Code 2012 Edition section 4.2 requires that building systems, such as gas and vacuum systems; electrical systems; heating, air conditioning, and ventilation systems; electrical equipment; and gas equipment are to undergo a formal, defined, and documented risk assessment procedure by qualified personnel. Specifically, the required building systems risk assessments were not conducted. This is evidenced as follows. The Director of Environmental Services stated in an interview conducted on 10/24/2017 at 8:45 am, that the facility building systems have not undergone a risk assessment and been assigned risk categories. 42 CFR 483.70 (a) (1); 2012 NFPA 99 4.2

Plan of Correction: ApprovedNovember 16, 2017

K 901 NFPA 101 Fundamentals- Building System Categories
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
A building systems risk assessment will be completed as required by NFPA 99 Health Care Facilities Code 2012 Edition section 4.2.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents have the potential to be affected by the deficient practice.
? A risk team that is familiar with the requirements as well as facility systems will be developed and the building systems risk assessment will be completed.

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? The risk assessment will be kept for review periodically as facility systems/ equipment change by the risk team.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? The risk team will present the initial assessment to the QAPI committee, and quarterly thereafter for review of any changes or updates.
Responsible person:
Director of Environmental Services


K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

Based on staff interview and record review during the recertification survey, the facility did manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide continuing education associated with the handling of medical oxygen cylinders. This is evidenced as follows. The Administrator stated in an interview conducted on 10/26/2017 at 10:30 am, that training on the risks and use of oxygen cylinders is conducted upon new hire orientation, but not periodically. No records were available for survey review documenting periodic training of personnel on the risks and use of oxygen cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedNovember 16, 2017

K 926 NFPA 101 Gas Equipment- Qualifications and Training
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
All personnel that are concerned with the application, maintenance and handling of pressurized oxygen cylinders will be trained on the risks of handling, and maintenance of oxygen cylinders, to include safety guidelines and usage requirements.
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
? All residents have the potential to be affected by the deficient practice.
? Staff Development Coordinator will coordinate the required training on new employee orientation and on an annual basis.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
? The Oxygen Therapy Policy was updated to add the guidelines stated in NFPA 99 Health Facilities Code, 2012 Section 11.5.2.1- 11.5.2.1.4 Qualification and Training of Personnel
? Continuing education will be provided on an annual basis with coordination of the Oxygen vendor/ distributor.
? Method used to demonstrate knowledge of training content will be a written test.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
? A monthly audit will be conducted on 5 employees that are concerned with the application, maintenance and handling of pressurized oxygen cylinders, to test their knowledge on the risks and proper handling.
? Audit findings will be presented by the SDC at the QAPI committee meeting for evaluation and follow-up as indicated.
Responsible person:
Staff Development Coordinator


K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2017
Corrected date: December 22, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition section 8.1.1 requires complete automatic sprinkler protection throughout the premises. Section 8.15.10.3 does not require installing sprinkler protection in electrical equipment rooms provided certain conditions are met, including maintaining a two-hour fire separation from all other parts of the building. Specifically, not all areas were provided with automatic sprinkler protection, and the wall separating the Bus Room (normal power connection) from other parts of the facility did not provide the required two-hour fire separation. This is evidenced as follows. Observations of the common wall between the Bus Room and Telephone Room on 10/24/2017 at 1:30 pm, revealed a 20-foot length of 4-inch by 3-inch penetrations where the wall meets the underside of the roof. These penetrations compromise the 2-hour fire separation. Observations of resident room [ROOM NUMBER] on 10/25/2017 at 10:00 am, revealed the absence of sprinkler protection in the closet. The Director of Environmental Services stated in an interview conducted on 10/24/2017 at 1:30 pm and again on 10/25/2017 at 10:00 am, that his department was unaware of the missing sprinkler head and the unsealed penetrations. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.1.1, 8.15.10.3

Plan of Correction: ApprovedNovember 16, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The filing of this plan of correction does not constitute an admission that the deficient practice occurred; rather it is to be in compliance as required by the issuing agency.
K 351 NFPA 101 Sprinkler System ? Installation
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice;
Bus Room and Telephone Room
? 2 layers of 5/8? fire code X Sheetrock will be applied to each side of the wall between the Phone Room and the Bus room to seal the penetrations. Approved fire caulking will be applied to any cracks.
room [ROOM NUMBER]
? Sprinkler protection will be installed in the closet of room [ROOM NUMBER].
How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken;
Bus Room and Telephone Room
? A complete facility inspection of all electrical equipment rooms revealed they have sprinkler protection and are in compliance.
? All other smoke partition walls were inspected for penetrations.
room [ROOM NUMBER]
? A complete room to room inspection identified 2 additional closets without the sprinkler protection. Sprinkler protection will be installed. No other areas in the facility were found.

What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur;
Bus Room and Telephone Room
? Inspection proves that all other electrical equipment rooms have sprinkler protection. There are no other rooms connected to the facility that require 2 hour separation that do not have sprinkler protection.

room [ROOM NUMBER]
? Upon completion of installing sprinkler protection in the identified closets, there will not be any other areas with out sprinkler protection.
? Changes and or additions to the structure will be monitored to ensure compliance is met.
How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice.
Bus Room and Telephone Room
? The firewall in the bus room will be monitored quarterly. Audit tool will be used to inspect for any penetrations in the firewall.
room [ROOM NUMBER]
? The sprinklers in the closet areas will be monitored monthly. Audit tool will be used to inspect for dust and placement.
Audit findings will be presented by the EVS at the QAPI committee meeting for evaluation and follow-up as indicated.
Responsible person:
Director of Environmental Services