St Catherine Laboure Health Care Center
January 10, 2018 Certification/complaint Survey

Standard Health Citations

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Standard survey completed 1/10/18, the facility did not provide, based on the comprehensive assessment and care plan, an ongoing activities program to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. One (Resident #22) of two residents observed for activities was not provided sensory stimulation and group activities as planned. The finding is: 1. Resident #22 was admitted [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/8/17 revealed the resident is in a persistent vegetative state and is dependent on staff for all activities of daily living. Review of an Activities Quarterly Participation Review (assessment) dated 11/16/17 revealed the resident is provided with 1:1 in-room visitation including sensory programming such as reading and playing music and she continues to be included in larger group programming including socials, special events and musical entertainment when out of bed and as able. The Quarterly Participation Review documented that the Resident's activity goals were met. Review of the comprehensive care plan (CCP), last reviewed 11/21/17, revealed the resident is non-verbal and unable to make her needs known. The CCP documented a goal for the resident to attend group activities as needed and be provided with 1:1 visits, music, and linked senior activities for sensory stimulation. CCP interventions include providing the resident with sensory stimulation and encouraging her to make eye contact with staff during 1:1 visits. The current Bedside Kardex Report printed 1/5/18 documented that the resident is provided with 1:1 visitation including sensory stimulation programs such as reading and playing music and will be included in larger group programming including socials, special events and entertainment when out of bed as tolerated and able. Intermittent observations of the resident on 1/4/18, 1/5/18, and 1/8/18 between the hours of 8:30 AM and 3:40 AM and 1/9/18 from 8:17 AM to 11:26 AM revealed the resident was either lying in bed or sitting in a Broda (specialized) wheelchair in her room. There was a television and a portable radio/tape player in the resident's room, however neither one was turned on during the observations. Review of the (MONTH) (YEAR) Activities Calendar revealed that three to four group activities were schedule daily between 10:00 AM and 2:30 PM. Review of the Unit 2 Activity Attendance records for (MONTH) (YEAR) and (YEAR) revealed the resident attended one Special Event/ Entertainment on 11/1/17. Further review of the (MONTH) (YEAR) Activity Attendance record dated 1/4/18 to 1/8/18 revealed documentation that T (television) and V (short social visit) were provided daily. Interview with the Director of Life Enhancement (Activities Director) on 1/9/18 at 10:13 AM revealed there is no Activity Attendance sheet available for (MONTH) (YEAR). During the interview, the Director stated that the Activity Aide would be responsible to turn the resident's television on every day. The Director stated that the goal is to coordinate and work with nursing and get the resident's out of bed schedule. Interview with the Registered Nurse (RN #1) Unit Manager (UM) on 1/9/18 at 3:34 PM revealed that nursing will do a better job of letting activities know when the resident is out of bed and that she assumed that activities would take the resident to group activities when she is out of bed, sitting in the hallway. The RN UM stated that she was not aware of a goal to provide Activities with an out of bed schedule for Resident #22. Interview with the Activities Aide (#1) on 1/10/18 at 9:35 AM revealed the activities department passes out the Chronicle (activities schedule/ newsletter) daily and that is indicated by a V on the attendance record. The Activities Aide stated When we pass them out, everyone gets a Chronicle. Either I or someone will turn the (resident's) TV on, it's usually on. It became automatic to put a T on the sheet. If she is out of bed, either the aide or I will take her to an activity. It is my responsibility. Interview with the Director of Life Enhancement on 1/10/18 at 12:45 PM revealed that she checked the cassette player in Resident #22's room and it was not set to the repeat cycle and was stopped. 415.5(f)(1)(ii)

Plan of Correction: ApprovedFebruary 19, 2018

F 679
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
The resident room (#22) was checked following the findings, and immediately rectified. A notice was posted for staff to ensure her television is plugged in and on at all times when resident is in her room, as well as communicated to Nursing. CD Player/Radio was also checked, to ensure the option to ?repeat CD? was selected to provide sensory stimulation for resident at all times. Resident was out of bed and was being included in scheduled group activities. Resident has expired.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
Applicable residents within the facility were examined to ensure programming was being provided, including television and/or CD Player/Radio functioning. All residents were assessed regarding their appropriateness for attending group activities programs. Those residents who could or desire to be in group activities had their care plans adjusted. Any concerns were immediately corrected.

What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
Education was provided to applicable staff responsible for ensuring an ongoing program of sensory stimulation is being provided as well appropriateness of resident involvement in group activities.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
The corrective action will be monitored by the Director of Life Enhancement/Activities.
An audit will be completed on a weekly basis for 2 residents per unit (4 total residents per week) on a rotating basis that are care planned to receive an ongoing program of sensory stimulation or who are applicable for group activities.
The results of these audits will be reported on at our next 2 Quarterly Quality and Resident Safety Committee meetings by the Director of Nursing. After the 2nd Quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
Date for Correction: (MONTH) 7, (YEAR)
Responsible Person: Director or Life Enhancement

FF11 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review completed during the standard survey completed on 1/10/18 the facility did not ensure that each resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Two (Residents #65, 66) of five residents observed for ADL's had issues. Specifically, Resident #66 had long toe nails and a foul body odor. Resident #65 was not provided with complete perineal care and did not attend activities due to lack of personal clothing. The findings are: 1. Resident #66 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 12/12/17 revealed that the resident is cognitively intact, understands and is understood. In addition, the MDS documents the resident requires extensive staff assistance for personal hygiene. The MDS indicated the resident has a [MEDICAL CONDITION] and a Foley catheter. Review of the Bedside Kardex Report used by certified nurse aides (CNAs) to provide care, dated 1/5/18 revealed the resident requires the extensive assistance of one staff for personal hygiene. Review of the computerized Comprehensive Care Plan (initiated on 9/13/17) revealed the resident has an ADL self-care deficit related to his advance [MEDICAL CONDITION], wounds and osteo[DIAGNOSES REDACTED]. With planned interventions for the resident to complete upper body extremities and total staff dependence for lower body ADL's. Observation on 1/9/18 at 7:24 AM revealed Certified Nursing Aide (CNA #3) and CNA #2 entered the room to perform morning care for the resident. CNA #3 removed a [MEDICATION NAME]/ abdominal binder the resident was wearing which was heavily soiled with dried brown debris. The resident's toenails were elongated about ½ - ¾ past the ends of the toes. When CNA #2 positioned the resident to complete personal care, a foul odor was detected when the resident's legs were spread. CNA #2 washed the resident's groin using four washcloths, two on each side, and each wipe the washcloth surface was observed soiled with a large amount of brownish/grey discolored debris. CNA #2 then washed each groin with soap again and rinsed until the debris was no longer visible on the washcloths. During an interview on 1/9/18 at 7:59 AM, CNA #2 stated she is the primary aide for the resident. During an interview on 1/9/18 at 4:08 PM, the Registered Nurse (RN #1) Nurse Manager NM stated that staff can obtain clean abdominal binders from the central supply in the hospital at any time. The resident is planned to receive two showers a week and is not incontinent so the resident's groin should not have had large amounts of debris with daily cleansing which he is planned to receive. Additional interview with the RN NM revealed that the podiatrist who cuts toenails has not completed services for this resident since admission in September. 2. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands, and is understood. The MDS documented that the resident is non-ambulatory and dependent on staff for all activities of daily living. Review of a hospital discharge summary dated 12/1/17 and updated 12/4/17 revealed the resident's discharge [DIAGNOSES REDACTED]. Review of an Admit Visit Note, written by a Physician Assistant (PA) dated 12/5/17 revealed the resident was admitted with a Foley catheter (tube inserted into the bladder to drain urine) which will be discontinued with plans to monitor for voiding to limit the risk of recurrent infection. Review of the current CCP last reviewed 12/19/17 and the Bedside Kardex Report, used by certified nurse aides (CNAs) to provide care, printed 1/5/18 revealed the following interventions: - The resident is non-ambulatory and is transferred using a mechanical lift with the assistance of two staff - When out of bed, utilize a Pedal Broda chair (specialized positioning wheelchair) in the tilt position - Extensive assistance by two staff to turn and reposition in bed - Total staff assistance for personal hygiene, bathing/showering, and dressing - The resident is incontinent of bowel and bladder; the Foley catheter was discontinued on 12/5/17 and requires total assistance for bowel and urine a.) Observation on 1/8/18 at 10:57 AM revealed CNA #1 provided morning care to the resident while in bed, with the assistance of the Assistant Director of Nursing (ADON). The CNA was observed to wash, then rinse and dry the resident's bilateral groin and pubic area. The CNA then carried the basin to the bathroom and dumped the water into the toilet. The CNA did not visualize or cleanse the female genitalia while providing perineal care. Interview with CNA #1 on 1/9/18 at 1:19 PM revealed when providing perineal care, I wash across the pubic area, down each groin and then down the middle. Some women do not like when we spread the inner (genitalia) and it gives me shivers now. Interview with CNA #1 on 1/10/18 at 10:00 AM revealed that Resident #65 was incontinent of urine prior to the provision of morning care on 1/8/18. Review of a facility policy and procedure (P&P) entitled Incontinent Care for a female resident dated 2/1/09 revealed the following: Using a wet washcloth with soap/periwash, nursing staff are to open labia (female genitalia) and washing downward cleansing the center of the perineum and passing over the meatus (external opening that urine passes through) - wash downward cleansing the inner labia farthest from you - wash downward cleansing the inner labia closest to you - wash downward cleansing the outer labia farthest from you - wash downward cleansing the outer labia closest to you - rinse and dry all areas in the same manner with a clean cloth b.) Intermittent observations on 1/4/18, 1/5/18, 1/8/18 and 1/9/18, between the hours of 8:30 AM and 3:00 PM revealed the resident was wearing a hospital gown and lying in her bed. The resident was not observed out of bed and there was no Broda chair in the resident's room. During an interview on 1/4/18 at 10:04 AM, the resident stated that she does not get out of bed to go to activities because she does not have any clothes. The resident stated that she has been at the facility for a month and staff are aware that she did not have any clothes. Observations of the resident's room on 1/5/18 at 10:22 AM and 1/8/18 at 7:30 AM revealed there were no clothes in the resident's dresser, closet or bedside table. During an interview on 1/8/18 at 7:30 AM, the resident stated that she is agreeable to getting out of bed. Interview with the Certified Nurse Aide (CNA #1) assigned to the resident, on 1/9/18 at 10:59 AM revealed she probably hasn't asked the resident is she wants to get out of bed and she hasn't seen a chair to use. Observation at the time of the interview revealed the CNA looked at several Geri-chairs located in the hallway near the resident's room and stated, maybe it's this one while pointing to a pink tilting chair at the end of the hall. A Physical Therapy Progress Note dated 12/28/17 at 8:53 AM documented that the resident was issued a Pedal Broda for OOB (out of bed) use. Recommend tilt position when OOB for improved stability and safety. Care plan updated. Interview with the Director of Rehabilitation Services on 1/9/18 at 11:39 AM revealed therapy issued the resident a Pedal Broda chair which is up on the unit. Observation on 1/9/18 at 11:59 AM revealed the Director pointed out the resident's Broda chair, located in the hallway near the resident's room, on the nursing unit. The Broda chair was a low, grey vinyl chair that had the resident's name written on an attached label. Interview with the resident on 1/9/18 at 10:26 AM revealed she would like to go to group activities if she had clothes, particularly religious activities. During an interview in the presence of the Registered Nurse (RN #1) Unit Manager UM) on 1/9/18 at 12:45 PM, the resident stated that she was agreeable to getting out of bed. Interview with the Physician Assistant (PA) on 1/9/18 at 11:14 AM revealed there was no reason that the resident can't be out of bed. Interview with the RN UM on 1/9/18 at 3:40 PM revealed she was not aware that the resident did not have any clothes. Interview with the Social Worker on 1/10/18 at 9:20 AM revealed she was not aware that the resident did not have any clothes. Interview with CNA #1 on 1/10/18 at 11:31 AM revealed she was aware that the resident did not have any clothes and that the dresser drawers were empty. When asked if she told anyone that the resident did not have clothes, the CNA stated Yes, everyone knew. 415.12 (a)(3)

Plan of Correction: ApprovedFebruary 15, 2018

F677 ADL Care Provided for Dependent Residents
1. For resident # 66, his soiled binder was replaced. His toenails were trimmed. A thorough bath was given to him. The Certified Nursing Assistant responsible for his care had the procedure for complete care reviewed with her.
For resident # 65, she received thorough perineal care. The Certified Nursing Assistant responsible for her care had the proper procedure for perineal/incontinent care reviewed with her. She was dressed in her clothes based on her preference, and has attended activities of her choice.
2. All residents have the potential to be affected by these deficient practices.
Two other residents are wearing abdominal binders and both were checked and cleaned.
All residents had their toenails checked and were trimmed if appropriate. Those who could not have their toenails trimmed by nursing staff have had their name placed on the list for podiatry to care for their toenails.
All residents have been checked by facility social worker to be sure they have enough clothing so they can get dressed every day and attend activities as they want to. For those residents who did not have enough clothing, the Social Worker will be contacting their responsible party to have them obtain clothes for the residents. Those residents who do not have clothes or a responsible party will have clothes provided to them by the facility.
Nurse managers/supervisors are checking all residents for odors when they are making rounds to be sure they are being provided the proper procedure for perineal/incontinent care and complete baths to check and see if any other residents have been affected by these deficient practices.
3. To ensure that the deficient practices does not reoccur, all Certified Nursing Assistants will be inserviced by ADON/Nurse Manager/supervisor on:
Proper perineal/incontinence care, Total bath procedure, Daily checking of toenails and reporting to Nurse Manager / supervisors any residents who require podiatry services, Checking all residents who wear abdominal binders to be sure they are clean and replace as needed, Checking to be sure all residents have enough clothing to wear daily and to notify Nurse Manager if more clothing items are needed.
4. The corrective action will be monitored by the Assistant Director of Nursing.
Weekly audits will be completed by the Nurse Managers / supervisors to be sure 5 residents are receiving: Proper perineal/incontinent care by the Certified Nursing Assistant, Resident?s toenails do not require podiatry services, Checking resident if they have an abdominal binder to be sure it is not soiled, Proper cleaning/bathing procedure for residents. These audits will include the observation /competencies of CNAs conducting and providing perineal/incontinent care. Toenails will be visualized to ensure they are trimmed. Clothing is available and residents will be dressed and ready to attend activities as they wish.
Residents will be audited on a rotating basis
The results of these audits will be reported on at our next two quarterly Quality and Resident Safety Committee meeting by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
5. The Director of Nursing is responsible for the correction of this deficiency.
Completion date: (MONTH) 7, (YEAR)

E3BP 402.6(d):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (d) A provider may temporarily approve a prospective employee while the results of the criminal history record check are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

Based on interviews and record reviews during the Standard survey completed on 1/10/18, the facility did not supervise one (Maintenance Mechanic) of two employees that received a negative determination letter, since the last survey, pending a reviews through the New York State Criminal History Check program. The finding is: 1) Review of the personnel file for Employee #1 (Maintenance Mechanic) on 1/9/18 revealed the following: -The file contained a New York State Department of Health CHRC 102, Acknowledgment and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information form, for the Employee, dated 4/16/16. -The facility had received a Pending Denial to Provider letter from the New York State Department of Health CHRC program for the employee dated 11/28/17. -Employee #1 worked at the facility from 3/17/16 through 12/29/17. -The file contained no documentation for the supervision of Employee #1 during this time. -Review of work order logs, time detail reports, and shift schedules revealed Employee #1 had worked on the Second Floor on 91 days between 4/4/16 through 12/18/17 and worked on the Third Floor on 107 days between 3/17/16 through 12/29 /17. Interview with the Human Resources Specialist (Authorized Person) on 1/9/18 at approximately 9:40 AM revealed: - The Employee worked at the facility, on the Second and Third Floors, from 3/17/16 through 12/29/17. - The facility was not supervising the employee during this time. -The Human Resources Specialist (Authorized Person) was not aware Employee #1 was working in the facility. - The Human Resources Specialist (Authorized Person) had sent an email to Employee #1's bosses stating the facility had not received a determination letter from the New York State Department of Health CHRC program for Employee. On 1/9/18, a review of the email from the Human Resources Specialist to the Facilities Director and the Facilities Manager dated 5/3/17 revealed the facility had not received a determination letter from the New York State Department of Health CHRC program for Employee #1. Review of the facility's Arrests, Convictions, and Criminal Background Checks Policy and Procedure on 1/9/18 revealed the following: -During the period when the fingerprints are outstanding, a candidate may be allowed to work in a temporary status. While in temporary status, the associate must be supervised by the associate's immediate supervisor no less than weekly per the Department of Health regulations. Supervision must be documented in writing on a weekly basis. The Human Resources Director will ensure this occurs by maintaining a tracking log and ensuring the Provisional Employment Performance Review Form is completed each week. The authorized CHRC person will notify the supervisor when this process may end. All paperwork relating to the temporary employment will be turned into the Human Resources department and placed into the personnel file. Interview with the Facilities Manager on 1/10/18 at approximately at approximately 2:04 PM revealed: -Employee #1 reported to the Facilities Manager. -The Facilities Manager thought Employee #1 had been cleared to work in the facility because the employee had been working at the facility since (YEAR). -The Facilities Manager had no documentation for the supervision of the employee and was not supervising the employee. 402.4(b)(2)(i) 402.6(d)

Plan of Correction: ApprovedFebruary 1, 2018

R 722 Criminal History Record Check Process
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
The Immediate supervisor for the identified associate will be provided with corrective action and in-serviced on the CHRC policy.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
The HR Business Partner/ designee will audit all associates with job titles requiring a Criminal Record Check to assure that the Record Check has been done. The associates that have the potential to work in the skilled nursing facility and have either pending denial letters or pending CHRC results will be removed from the schedule and not allowed to perform duties at the nursing facility.
In addition there will be a change to the arrests, convictions, and criminal history background check policy to state that?Unless there are extreme circumstances such as the State?s website is not working. Candidates will no longer be in a temporary status with the exception of CAN trainees. Any exceptions must be mutually agreed upon between the Administrator, HR Director, and the respective supervisor.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
Directors and supervisors of applicable departments (Maintenance and Environmental services) that provide services and staff to the nursing facility have been informed by the HR Director that any staff member who has a pending CHRC cannot perform duties at the nursing facility unless a meeting takes place with the immediate supervisor, the HR Director and Administrator to determine a plan of action. If an instance exists where a supervisor has a need to assign an associate to the nursing facility to perform duties, then the supervisor will be required to contact the HR Director for a plan of action which includes following the CHRC process and providing the provisional supervision at the site.
If an associate has the need and approval to work in a temporary / provisional status, supervision must be documented in writing on a weekly basis on the HRF 93 ?Provisional employment performance review form?. The HR Director will instruct the supervisor both verbally and in writing to complete the Provisional employment performance review form each week. It is the supervisor?s responsibility to ensure this is done. The authorized CHRC person will notify the supervisor when this process may end. All paperwork relating to the temporary employment will be turned into the HR department and placed into the personnel file.
A secondary biweekly audit of all hires, transfers and terminations will be conducted at the Corporate HR level to ensure that the CHRC policy is followed. This will begin no later than (MONTH) 4, (YEAR).
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice:
An audit tool has been developed. This newly established centralized process will be a double check for the work done at the site. Results from this audit will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Director of Human Resources

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

Based on interview and record review during the Standard survey completed on 1/10/18, the facility did not immediately remove one (Maintenance Mechanic) of two employees, from providing direct care or supervision to residents, after the facility had received a negative determination letter, for the employee, from the New York State Criminal History Check (CHRC) program. The finding is: Review of the personnel file for Employee #1 (Maintenance Mechanic) on 1/9/18 revealed the following: -The facility had received a Pending Denial to Provider letter from the New York State Department of Health CHRC program, for the employee #1, dated 11/28/17. -Employee #1 worked in the facility for six days after the facility had received a Pending Denial to Provider letter from the New York State Department of Health CHRC program -Review of work order logs, time detail reports, and shift schedules revealed Employee #1 had worked on the Second Floor on 12/6/17, 12/9/17, and 12/18/17. -Review of work order logs, time detail reports, and shift schedules revealed Employee #1 had worked on the Third Floor on 11/30 /17, 12/27/17, and 12/29/17. Interview with the Human Resources Specialist (Authorized Person) on 1/9/18 at approximately 9:40 AM revealed: -The facility had received a Pending Denial to Provider letter from the New York State Department of Health CHRC program for the employee dated 11/28/17. -Employee #1 worked on the Second Floor on 12/6/17, 12/9/17, and 12/18/17 -Employee #1 had worked on the Third Floor on 11/30/17, 12/27/17, and 12/29/17. -She was not aware that Employee #1 was still working in the facility after the facility had received a Pending Denial to Provider letter from the New York State Department of Health CHRC program for the employee dated 11/28/17. -She was not aware Employee #1 was still working in the facility until after 12/29/17. On 1/9/19, a review of the facility's Arrests, Convictions, and Criminal Background Checks Policy and Procedure effective date 9/22/17 revealed the following: -When background check results are received, the Human Resources Generalist, or Recruiter will review for criminal convictions (felony or misdemeanor). If the Department of Health determines the applicant may not be considered for employment due to an arrest or criminal conviction, Human Resources personnel will defer that the decision to the Department of Health during which time the employment of the associate will be terminated. - Current associates will be terminated from employment immediately if the Department of Health determines that they must be removed from employment due to an arrest or criminal conviction. In such cases, the employer will defer to the Department of Health, and will not conduct an investigation or consider any explanation by the associate. Interview with the Facilities Manager on 1/10/18 at approximately 2:04 PM revealed: -Employee #1 reported to the Facilities Manager. -Employee #1 had worked in the facility on 11/30/17, 12/6/17, 12/9/17, 12/18/17,12/27/17, and 12/29/17. -The Facilities Manager thought Employee #1 had been cleared to work in the facility because he had been working at the facility since (YEAR). 402.7(2)(i) 402.7(3)(i) 402.9(a)(1)(v)

Plan of Correction: ApprovedFebruary 1, 2018

R 722 Criminal History Record Check Process
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
The Immediate supervisor for the identified associate will be provided with corrective action and in-serviced on the CHRC policy.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
The HR Business Partner/ designee will audit all associates with job titles requiring a Criminal Record Check to assure that the Record Check has been done. The associates that have the potential to work in the skilled nursing facility and have either pending denial letters or pending CHRC results will be removed from the schedule and not allowed to perform duties at the nursing facility.
In addition there will be a change to the arrests, convictions, and criminal history background check policy to state that?Unless there are extreme circumstances such as the State?s website is not working. Candidates will no longer be in a temporary status with the exception of CAN trainees. Any exceptions must be mutually agreed upon between the Administrator, HR Director, and the respective supervisor.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
Directors and supervisors of applicable departments (Maintenance and Environmental services) that provide services and staff to the nursing facility have been informed by the HR Director that any staff member who has a pending CHRC cannot perform duties at the nursing facility unless a meeting takes place with the immediate supervisor, the HR Director and Administrator to determine a plan of action. If an instance exists where a supervisor has a need to assign an associate to the nursing facility to perform duties, then the supervisor will be required to contact the HR Director for a plan of action which includes following the CHRC process and providing the provisional supervision at the site.
If an associate has the need and approval to work in a temporary / provisional status, supervision must be documented in writing on a weekly basis on the HRF 93 ?Provisional employment performance review form?. The HR Director will instruct the supervisor both verbally and in writing to complete the Provisional employment performance review form each week. It is the supervisor?s responsibility to ensure this is done. The authorized CHRC person will notify the supervisor when this process may end. All paperwork relating to the temporary employment will be turned into the HR department and placed into the personnel file.
A secondary biweekly audit of all hires, transfers and terminations will be conducted at the Corporate HR level to ensure that the CHRC policy is followed. This will begin no later than (MONTH) 4, (YEAR).
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice:
An audit tool has been developed. This newly established centralized process will be a double check for the work done at the site. Results from this audit will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Director of Human Resources

FF11 483.45(d)(1)-(6):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- §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Standard survey completed 1/10/18, the facility did not ensure that each resident's drug regime is free from unnecessary drugs, when used without adequate monitoring. One (Resident #65) of five residents reviewed for unnecessary medications received daily insulin without obtaining a blood glucose level per physician order. The finding is: 1. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/17 revealed the resident has moderate cognitive impairment, understands, is understood and receives daily insulin. Review of physician's orders [REDACTED].< (under) 120. Review of Medication Administration Records (MARs) dated 12/4/17 to 1/9/18 revealed the seven units of [MEDICATION NAME] was transcribed according to the 12/4/17 and 1/2/18 physician's orders [REDACTED]. Additional review of the 12/2017 and 1/2018 MARs and the 12/2017 and 1/2018 Treatment Administration Records dated 12/2017 and 1/2018 revealed no documented evidence that a blood glucose level was obtained prior to administration of the daily [MEDICATION NAME] at HS. Review of the entire medical record, including Nursing Progress Notes and Laboratory Reports revealed no documented evidence that blood glucose levels were obtained daily at HS. Interview with the Licensed Practical Nurse (LPN #2) on 1/10/18 at 11:05 AM revealed she was unable to find any HS blood glucose checks results in the computer and she stated that the resident does not currently have an order for [REDACTED]. Interview with the Registered Nurse (RN #1) Unit Manager (UM) on 1/10/18 at 11:10 AM revealed the resident had a BMP (basic metabolic profile - blood test) drawn on 1/3/18 at 7:45 AM and the resident's blood glucose was 181 (normal 74 - 100). Further interview with the RN UM on 1/10/18 at 11:52 AM revealed she spoke to the PA (Physician Assistant) and new orders were obtained to check the resident's blood glucose level before meals twice a week. 415.12(l)(1)

Plan of Correction: ApprovedFebruary 19, 2018

F757 Drug Regimen is Free from Unnecessary Drugs
1. For resident #65, the Medication Administration Record [REDACTED]?s blood sugar prior to administering insulin per medical provider order.
2. All residents who receive insulin with a medical provider?s order to check blood sugar prior to insulin administration have a potential to be affected by this deficient practice. Nurse Managers checked all insulin orders to be sure all insulin and blood sugar check orders are correctly entered into the eMAR (electronic medical record).
3. All nurses (RNs and LPNs), will be inserviced by ADON/Nurse Managers/supervisors on proper order entry and complete order entry into eMAR.
4. The corrective action will be monitored by the Assistant Director of Nursing. Weekly audits will be completed by each Nurse Manager after checking the medical provider?s orders for 2 residents per unit (4 residents total per week) who are receiving insulin and have required blood sugar checks by the nurse checking for accuracy. Residents will be audited on a rotating basis each week.
The results of these audits will be reported on at our next two quarterly Quality and Resident Safety Committee meetings by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
5. The Director of Nursing is responsible for the correction of this deficiency.
Completion date: (MONTH) 7, (YEAR)

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview completed during the Standard survey completed 1/10/18, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. One (Resident #65) of one resident observed for range of motion (ROM) services received incomplete range of motion and ROM was not provided as planned. The finding is: 1. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/17 revealed the resident has moderate cognitive impairment, understands, and is understood. The MDS documented that the resident had functional limitations in range of motion of both the upper and lower extremities. Review of the current comprehensive care plan (CCP) last reviewed 12/19/17 and the Bedside Kardex Report, used by certified nurse aides (CNAs to provide care) printed 1/5/18 revealed the resident has limited physical mobility related to a history [MEDICAL CONDITION] (severe blood infection), acute UTI (urinary tract infection), B AKA, and limited ROM. CCP and Kardex interventions include the provision of PROM (passive ROM - exercises performed on the resident by nursing staff) to BUE (bilateral upper extremities) three times per week and AAROM (active assisted ROM - the resident performs the exercises with assistance from staff) to B hips three times per week. The CCP documented goals for the resident to maintain her highest level of functional mobility, maintain upper extremity ROM, and remain free of complications related to immobility, including contractures (loss of joint mobility). Additional review of the CCP revealed the resident was admitted to the facility for short term and the plan is for her to go home with her son and services when able. Interview with the Director of Rehabilitation Services on 1/9/18 at 11:38 AM revealed that Resident #65 has good range of motion of her elbows, however both of her shoulders are very limited. The resident is not a good candidate for rehab (rehabilitation) and the current plan is to provide ROM which is provide by CNA (certified nurse aide) staff. Observation on 1/10/18 at 10:16 AM revealed a Certified Nurse Aide (CNA #1) provided ROM services to the resident while she was lying in bed. The CNA was observed to provide PROM including flexion and extension to the resident's bilateral shoulders, elbows, wrists, and fingers. The CNA did not provide abduction (movement away from the body) and adduction (movement towards the body) or internal or external rotation to the resident's shoulders. Further observation revealed the CNA provided PROM to the resident's lower extremities, including flexion, extension, abduction, and adduction to the resident's hips. During the observation, the CNA passively moved the resident's legs and did not encourage the resident to initiate the movements on her own. During an interview on 1/10/18 at 10:26 AM, CNA #1 states that the resident's lower extremities are passive, you assist her, sometimes she moves her legs. The CNA stated that she doesn't do abduction or adduction to the resident's arms and never did. Interview with the Occupational Therapist on 1/10/18 at 11:19 AM revealed that she expects shoulder internal and external rotation and abduction and adduction to be done during ROM. PROM is done by the helper and AAROM means that the individual is encouraged to help with the exercise to the best of their ability and is assisted by the helper. 415.12(e)(2)

Plan of Correction: ApprovedFebruary 19, 2018

F688 Increase/Prevent Decrease in ROM/Mobility
1. For resident #65, the correct range of motion exercise process per care plan for this resident was reviewed with the Cna involved by the Director of Rehab services. Definitions of Passive range of motion (PROM) and Active assist range of motion (AAROM) were reviewed with the cna. Re-demonstration of range of motion was completed by the cna. Resident was assessed and evaluated by Occupational Therapy to determine current Range of Motion (ROM) status.
2. All residents have the potential to be affected by this deficient practice. All care plans will be reviewed to identify residents who are receiving passive and active assistive range of motion from cna?s to ensure that they are scheduled and provided with the appropriate recommendations from the applicable therapists.
3. To ensure the deficient practice does not reoccur, all can?s will be inserviced on proper range of motion procedures and terminology related to range of motion by the therapy department designee.
4. The corrective action will be monitored by the rehab director. A weekly audit will be completed by the rehab director verifying 2 residents per unit per week (a total of 4 residents per week) to ensure appropriate passive and active assistive range of motion is completed. Results of these audits will be reported on at our next 2 quarterly quality and resident safety committee meetings by the rehab director. After the 2nd quarterly quality and resident safety committee meeting, a recommendation will be made to the continuation and reporting of these audits.
5. Therapy Director is responsible for the correction of this deficiency.
Completion date: (MONTH) 7, (YEAR)

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: January 10, 2018
Corrected date: March 7, 2018

Citation Details

Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18, the facility did not establish and maintained 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. Specifically, one (Unit 2) of two resident units observed for infection control practices during blood glucose monitoring; nursing staff did not properly clean and disinfect shared glucose meters between resident use in accordance with the manufacture's guidelines. Residents #39 was involved. The finding is: Review of the facility's policy and procedure (P&P) entitled Glucometer use, cleaning and control testing dated 12/2017 revealed that cleaning the glucometer shall take place following each use of the device; the procedure for cleaning the device shall follow manufacturer's directions and must us only an EPA (Environmental Protection Agency) registered germicidal disinfectant product approved by the glucometer manufacturer. Observation on 1/4/18 at 1:26 PM revealed Licensed Practical Nurse (LPN #3) completed a glucose meter test on resident #39 with a Medline Evencare G2 blood glucose meter. When LPN #3 was finished she placed the glucose meter in her gloved hand and walked down the hall to the medication cart and placed the glucose meter in a zippered bag without cleaning or disinfecting the glucose meter. During an interview on 1/4/18 1:40 PM, LPN #3 stated that Unit 2 only has one glucose meter for multiple residents and stated that the glucose meter was stored in the bag because that was the last glucose reading she had to complete for her shift. During an interview on 1/4/18 at 3:57 PM, the Registered Nurse (RN) Nurse Manager (NM) stated that Unit 2 has one glucose meter which is used for at least seven diabetic residents who receive daily finger sticks. The RN NM stated that the facility policy directs cleansing the glucose meter with Clorox wipes, the meter is to stay wet for one minute after use; the policy does not direct cleansing before use. Review of the CDC (Center for Disease Control) Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings revealed Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instruction, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Review of the manufacturer's instructions for cleaning the EvenCare G2 blood glucose meter, used to test blood glucose levels in the facility, revealed the EvenCare G2 Meter cleaning and disinfecting is very important in the prevention of infectious disease and lists several EPA registered disinfecting wipes recommended for cleaning and disinfecting the meter. 415.19(a)(1)(b)(2)

Plan of Correction: ApprovedFebruary 19, 2018

F880 Infection Prevention and Control
1. For resident #39, the glucometer was properly cleaned and disinfected per policy when the issue was brought to the nurse?s attention.
2. All residents who require fingersticks with the glucometer have the potential to be affected by this deficient practice. All other glucometers in the facility were re-cleaned using the appropriate cleansing agent.

3. To ensure that the deficient practice does not reoccur, all nurses will be inserviced by our ADON/supervisor on our policy for cleaning and disinfecting glucometers in between resident use.
4. The corrective action will be monitored by the Assistant Director of Nursing.
Weekly audits will be conducted by Nurse Manager/supervisor monitoring the process of 2 LPNs per unit each week (4 LPNs audited per week for 2 total units) completing the cleaning and disinfecting process after a fingerstick and glucometer reading was completed on 2 residents per nurse (4 residents total per unit). The LPNs will be utilizing the approved disinfecting product and adhering to our policy. All nurses will be monitored and audited on a rotating basis.
The results of these audits will be reported on at our next two quarterly Quality and Resident Safety Committee meeting by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
5. The Director of Nursing is responsible for the correction of this deficiency.
Completion date: 3-7-2018

FF11 483.10(g)(4)(i)-(vi):REQUIRED NOTICES AND CONTACT INFORMATION

REGULATION: §483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) (iii) Information regarding Medicare and Medicaid eligibility and coverage; (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; (v) Contact information for the Medicaid Fraud Control Unit; and (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18 the facility did not ensure the resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups. Including but not limited to the State Long-Term Care Ombudsman program. Additionally, information and contact information for State and local advocacy organizations including but not limited to the State Long-Term Care Ombudsman program. Specifically, the facility posted a number that was not associated with the county Ombudsman Program. The finding is: 1. During intermittent observations on 1/4/18, 1/5/18, 1/8/18 and 1/9/18. The facility had an 8 1/2 inch by x 11 inch paper posting entitled Where to file a Grievance which listed the contact information for the Long-Term Care Ombudsman Program as [PHONE NUMBER] posted on a bulletin board on the first floor near the facility entrance. This phone number was for New York Connects, an information service for Long Term Care support, not the number for the Ombudsman. On 1/9/18 at approximately 1:00 PM the number posted was called, and the operator from that system was asked to provide the number for the County Ombudsman Program who then provided the [PHONE NUMBER] phone number which is the NYS (New York State) Department of Health Nursing Home Hotline Number. During an interview on 1/9/18 at 11:51 AM, the facility's Ombudsman stated that she wants all the residents to have the ombudsman number and has relayed this to the Administrator. During an interview on 1/9/18 at 2:41 PM, the Administrator stated that the number posted on the posting was provided to him by the Ombudsman. 415.3(c)(1)(vi)

Plan of Correction: ApprovedFebruary 19, 2018

F574
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
The appropriate contact number for the NYS LTC Ombudsman Program has now been updated and posted.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
Any and all areas where the NYS LTC Ombudsman Program phone number are present will reflect the appropriate number.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
A monthly audit will be completed by the Administrator / designee to ensure that the NYS LTC Ombudsman contact number is posted and correct.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
A monthly audit will be completed by the Administrator / designee to ensure that the NYS LTC Ombudsman contact number is posted and correct.
The results of this audits will be reported on at our next two quarterly Quality and Resident Safety Committee meetings by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Administrator

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(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 §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(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: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18, the facility did not ensure the each resident medical record was maintained in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and Systematically organized. Three (Residents # 22, 39, 65) of 22 medical records reviewed had issues. Specifically, Residents #65 & 22 lacked documentation of activity involvement for (MONTH) (YEAR), Resident #22 had inaccurate documentation of Activity involvement in (MONTH) (YEAR), Resident #39 had a witnessed episode of respiratory distress which was not documented in the medical record. The findings include but are not limited to: 1. Resident #22 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/8/17 revealed the resident is in a persistent vegetative state and is dependent on staff for all activities of daily living. Review of an Activities Quarterly Participation Review (assessment) dated 11/16/17 revealed the resident is provided with 1:1 in-room visitation including sensory programming such as reading and playing music and she continues to be included in larger group programming including socials, special events and musical entertainment when out of bed and as able. The Quarterly Participation Review documented that the Resident's activity goals were met. Review of the comprehensive care plan (CCP), last reviewed 11/21/17, revealed the resident is non-verbal and unable to make her needs known. The CCP documented a goal for the resident to attend group activities as needed and be provided with 1:1 visits, music, and linked senior activities for sensory stimulation. CCP interventions include providing the resident with sensory stimulation and encouraging her to make eye contact with staff during 1:1 visits. The current Bedside Kardex Report printed 1/5/18 documented that the resident is provided with 1:1 visitation including sensory stimulation programs such as reading and playing music and will be included in larger group programming including socials, special events and entertainment when out of bed as tolerated and able. Intermittent observations of the resident on 1/4/18, 1/5/18, and 1/8/18 between the hours of 8:30 AM and 3:40 AM and 1/9/18 from 8:17 AM to 11:26 AM revealed the resident was either lying in bed or sitting in a Broda (specialized) wheelchair in her room. There was a television and a portable radio/tape player in the resident's room, however neither one was turned on during the observations. Review of the Unit 2 Activity Attendance records for (MONTH) (YEAR) and (YEAR) revealed the resident attended one Special Event/ Entertainment on 11/1/17. Further review of the (MONTH) (YEAR) Activity Attendance record dated 1/4/18 to 1/8/18 revealed documentation that T (television) and V (short social visit) were provided daily. Interview with the Director of Life Enhancement (Activities Director) on 1/9/18 at 10:13 AM revealed there was no Activity Attendance sheet available for (MONTH) (YEAR). The Director stated that the monthly attendance record for (MONTH) (YEAR) was misplaced and staff were unable to locate it. The Director stated that she had checked the attendance sheets on a daily basis and is sure that residents' activity attendance was being documented, however there is no documentation available at this time. During an interview on 1/10/18 at 9:35 AM, the Activities Aide (#1) stated either I or someone will turn the (resident's) TV on, it's usually on. It became automatic to put a T on the sheet. 2. Resident #39 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact understands and is understood. Review of the CCP initiated on 12/13/17 revealed the resident has altered respiratory status and difficulty breathing related to anxiety, end stage [MEDICAL CONDITION], respiratory arrest and sleep apnea. With planned interventions to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. In addition, to report to the physician increased respirations, decreased pulse oximetry, accessory muscle usage, purse-lip breathing. During the initial tour on 1/4/18 at 8:31 AM, the resident was sitting in bed in a semi-fowlers position wearing nasal oxygen (O2) and was markedly short of breath, with a respiratory rate of 30 per minute, using accessory muscles and pursed-lip breathing. During the observation, the resident told the surveyor the nurse knows she is having breathing difficulties and Licensed Practical Nurse (LPN #3) was outside the resident's door with the medication cart. Additional observation on 1/4/18 at 8:51 AM revealed the resident was receiving a breathing treatment with slower respirations and the resident appeared calm sitting in bed. During an interview on 1/4/18 at 1:23 PM, the resident stated she was recently hospitalized with an upper respiratory infection and pneumonia three weeks ago. Review of the Nursing Progress Note dated 1/4/18 revealed LPN #2 revealed the provider was in and ordered [MEDICATION NAME] (used to treat anxiety disorders) 5 milligrams (mg) twice a day, [MEDICATION NAME] (used to treat anxiety and nervousness) 2 mg four times a day, and increased fluid restrictions to two liters a day. There is no documentation form LPN #3 regarding the resident's respiratory distress, witnessed by the surveyor. During an interview on 1/10/18 at 12:29 PM, the Registered Nurse (RN) Nurse manager (NM) stated that the resident has unstable [MEDICAL CONDITION] with symptoms and that staff are expected to monitor, report and document episodes of respiratory distress. During the interview, the RN NM reviewed the 24-hour report for the day shift on 1/4/18 and stated that the resident had no documentation on the 24-hour report. 415.22 (a)(1,2)

Plan of Correction: ApprovedFebruary 19, 2018

F842 Resident Records
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
(Resident #22, #65) Unable to locate any documentation of activity involvement for (MONTH) (YEAR). (Resident #22) Corrective summary note was entered into her Medical Record stating that there were discrepancies with her documentation on the activity attendance record from 1/4/18 to 1/8/18. (Resident #39) A late note was entered into the electronic Medical Record by the Nurse responsible for her care on (MONTH) 4th, (YEAR) at 8:31AM. This note was in regards to her episode of respiratory distress.
How will you identify other areas 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 effected by these deficient practices. An audit was completed of monthly attendance records as well as room visitation for room-bound residents, any concerns were immediately corrected. Assessments completed by Nurse Managers/Supervisors on all residents with respiratory difficulties to be sure an assessment has been done and documented in the electronic Medical Record at the time of any respiratory difficulties noted.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
To ensure that the deficient practice does not reoccur, the Activity Staff will be inserviced by the Director of Life Enhancement regarding accurate and appropriate attendance documentation for all residents. Beginning (MONTH) (YEAR), electronic attendance records in PCC/P(NAME) will be completed on a daily basis to ensure documentation is readily available and accessible. Beginning (MONTH) (YEAR), Activities Aides will be responsible for completing detailed documentation for room visitation, and residents that are care planned for sensory stimulation programs.
All Nurses will be inserviced by the Assistant Director of Nursing/Nurse Managers/Supervisors on required documentation any time a resident has difficulty breathing or a change in condition along with Medical Provider notification and documentation of this notification.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
The corrective will be monitored by the Director of Life Enhancement and Assistant Director of Nursing. Director of Life Enhancement will complete weekly audits on electronic attendance records and visitation documentation for 4 residents per floor per week. Any discrepancies found during the audits will be addressed immediately. Ongoing education will be provided to staff members. Residents attendance and program participation will be audited on a rotating basis. The results of these audits will be reported on at our next 2 Quarterly Quality and Resident Safety Committee meetings by the Director of Life Enhancement. After the 2nd Quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
Weekly audits will be completed by the Nurse Manager after review of 2 residents per unit (4 residents total per week) with known respiratory difficulties or new onset of respiratory issues checking LPN/RN documentation for an assessment, complete note in the electronic medical record and the documentation of Medical Provider notification. Residents will be audited on a rotating basis. The results of these audits will be reported on at our next 2 Quarterly Quality and Resident Safety Committee meetings by the Director of Nursing. After the 2nd Quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.

Date for Correction: 3/7/2018
Responsible Person: Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 1/10/18 the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. One (Resident #66) of nineteen residents reviewed for dignity was dressed in a soiled abdominal binder, was exposed with the door wide open and the privacy curtain not drawn and was in dressed in a hospital gown throughout the entire survey. The findings are: 1. Resident #66 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/27/17 revealed that the resident is cognitively intact and is understood and understands. a. Observations of the resident in bed in a hospital gown were as follows: - 1/4/18 at 2:56 PM, Resident he was lying bed dressed in a hospital gown, during an interview. - 1/5/18 at 11:30 AM, Resident was in hospital gown. - 1/8/18 at 8:39 AM, Resident in bed with hospital gown on. - 1/8/18 at 1:45 PM, Resident in bed with a hospital gown on. - 1/9/18 at 9:45 AM, Resident still in bed and in hospital gown. - 1/9/18 at 2:00 PM, Resident in bed in a hospital gown. - 1/10/18 at 9:00 AM, Resident was in bed in hospital gown. Review of Care Plan on 1/9/18 revealed there were no documented preferences regarding the resident's clothing. b. Observation on 1/9/18 at 7:24 AM revealed Certified Nursing Aide (CNA #3) and CNA #2 entered the resident's room to complete morning care. CNA #3 removed a [MEDICATION NAME]/abdominal binder the resident was wearing. The binder was heavily soiled with dried brown debris from top to bottom and observed on the outside and inside. The resident's [MEDICAL CONDITION], nor tube feeding was leaking. c. Observation on 1/9/17 at 3:41 PM revealed a Licensed Practical Nurse (LPN #4) removed leg braces from the resident's legs. Resident #66 was in bed by the doorway which was open to the common resident hall and the roommate and a visitor were in the room sitting approximately four feet from the resident; the privacy curtain between the residents was not drawn closed. The resident was only wearing a hospital gown without briefs and was exposed up to the hip. During an interview on 1/9/18 at 3:41 PM, LPN #4 stated he was only removing the leg braces from the resident's leg. During an interview on 1/9/18 at 2:00 PM the resident was in his bed in a hospital gown. When asked why he was in the gown and not dressed he stated he did not know and that he always wears a hospital gown. When asked if he preferred this he shrugged his shoulders. He stated he didn't mind wearing the hospital gown, but wouldn't mind wearing other clothes but didn't think he had any. During an interview on 1/10/18 at 8:17 AM, the Registered Nurse (RN#1) Unit Manager stated this resident doesn't get out of bed and we normally do not get the residents who stay in bed dressed. They stay in a hospital gown. The resident has a [MEDICAL CONDITION] and a catheter and being in regular clothes would be uncomfortable and the hospital gown is more comfortable. I never really thought about him always wearing a hospital gown. I do not really know if he prefers to be dressed. I never asked. I will go ask him his preference. I do not know if he has any other clothes to wear, I will check with him about this and maybe his mother will bring some in for him. During an interview on 1/10/18 at 8:51 AM, RN#1 Unit Manger stated she spoke with the resident regarding the hospital gown. He stated he doesn't mind wearing the hospital gown as he wore it at home, but wouldn't mind wearing his own pajamas but wasn't sure if his mother would bring some in for him. I called his mother and she will be bringing in some pajamas for him to wear. Review of a document entitled Rights as a Nursing Home Resident dated (YEAR) revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life. Recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The resident has a right to be treated with respect and dignity, including: the right to retain and use personal possessions, including clothing. 415.3(c)(1)(i)

Plan of Correction: ApprovedFebruary 15, 2018

F550 Resident Rights/Exercise of Rights
1. For resident #66, his soiled binder was replaced, the LPN responsible for removing his braces was reminded to always close the resident?s door and pull the curtain between residents when providing care, never exposing the resident, staff providing care to resident reminded to ask resident what clothes he would like to wear in and out of bed for the day. Clothing items for resident have been obtained and are present in room. His preferences of clothing were added to the resident?s care plan.
2. All residents have the potential to be affected by these deficient practices.
Two other residents are wearing abdominal binders and both were checked and cleaned.
Clinical Nurse Managers/supervisors will monitor care being given to the other residents to be sure no resident is being exposed, that doors are being closed, and that curtains are pulled between residents when care is being given as they make daily rounds.
All alert and oriented residents will be interviewed by the facility social worker for their clothing preferences when in and out of bed. All non - alert and oriented residents will have the resident?s responsible party contacted by the social worker for the resident?s clothing preferences in and out of bed.
3. To ensure that the deficient practice does not reoccur, all staff will be inserviced on resident rights by our Director of Social Work to include: 1) All residents to be treated with respect and dignity; 2) The need to enhance each resident?s quality of life; 3) Right of each resident to retain and use personal possessions including clothing; 4) Checking on and replacing any soiled items each resident may be wearing including abdominal binders; 5) Care plans are to include any resident preferences, including clothing wishes; 6) Privacy is always to be maintained including closing the resident?s door and pulling the curtain in between residents when providing care.
4. The corrective action will be monitored by the Assistant Director of Nursing.
Weekly audits will be completed by the Nurse Managers verifying 5 residents:
are dressed in appropriate clothing in and out of bed per their wishes and in accordance with each resident?s care plan.
are receiving care privately with the room door closed and curtain pulled in between residents
have clean non-soiled clothing in including abdominal binders
Residents will be audited on a rotating basis
The results of these audits will be reported on at our next two quarterly Quality and Resident Safety Committee meetings by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
5. The Director of Nursing is responsible for the correction of this deficiency.
Completion date:_March 7, (YEAR)

FF11 483.10(f)(1)-(3)(8):SELF-DETERMINATION

REGULATION: §483.10(f) Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section. §483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. §483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. §483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility. §483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Standard survey completed 1/10/18, the facility did not ensure that the resident has a right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care and make choices about aspects of his or her life in the facility that are significant to the resident. One (Resident #65) of two residents reviewed for choices was not provided a choice regarding whether to receive a bath or shower; the resident's plan of care did not identify the resident's preference; and the resident did not receive showers in the facility in accordance with her wishes. The finding is: 1. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/11/17 revealed the resident has moderate cognitive impairment, understands, and is understood. The MDS documented that it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of an Activities Initial Review dated 12/7/17 revealed it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Additional review revealed the follow-up questions regarding the type and frequency of bathing were blank. Additional review of the Activities Initial Review revealed it was completed with the resident as the primary respondent. Review of the current comprehensive care plan (CCP) last reviewed 12/19/17 and the Bedside Kardex Report printed 1/5/18 revealed the section for Bathing documented Bathing/Showering: The resident will require total assist. The CCP documented that the resident has [MEDICAL CONDITION] over her entire body and complains of pruritic (itching) of her back, chest, and arms. Additional review revealed the resident is non-ambulatory and is transferred with the assistance of two staff using a mechanical lift. Review of computerized Point of Care (P(NAME)) documentation, completed by certified nurse aide (CNA) staff dated 1/2018 revealed the ADL (activities of daily living) section for Bathing did not specify the resident's preference. During an interview on 1/4/18 at 9:54 AM, the resident stated that she just asked the physician and got permission for a shower last week. The resident stated that she had not received a shower since she was admitted to the facility. Observation on 1/8/18 from 10:57 AM to 11:22 AM revealed the resident received a bed bath provided by a Certified Nurse Aide (CNA #1 who was assigned to the resident) with the assistance of the Assistant Director of Nursing (ADON). Observation on 1/9/18 at 10:28 AM revealed the resident was lying in bed. During an interview at the time of the observation, the resident stated she had just received a bed bath and Yes, I would like to take a shower. During an interview on 1/9/18 at 10:59 AM, CNA #1 stated that she has not given the resident any showers and she was told the resident could not have a shower. Interview with the Physician Assistant (PA) on 1/9/18 at 11:14 AM revealed there was no reason that the resident can't be out of bed and that it is okay for her to receive a shower as long as staff wrap her left arm IV (intravenous) site. Review of Nursing Progress Notes and Treatment Administration Records (TARs) dated 12/5/17 to 1/8/18 revealed no documented evidence that the resident refused a shower. 415.5(b)(1,3)

Plan of Correction: ApprovedFebruary 15, 2018

F561 Self-Determination
1. For resident #65, she was asked and stated she preferred a shower. A shower was given to her, and her care plan was updated to reflect her wishes. Assigned shower days and shifts were agreeable to her and added to her care plan.
2. All residents have the potential to be affected by this deficient practice.
All alert and oriented residents were interviewed for their bathing/showering preferences by facility social worker. All non-alert and oriented residents will have the resident?s responsible party contacted by the social worker for their known bathing/showering preferences. These preferences have been added to the resident?s care plan.
3. To ensure the deficient practice does not reoccur, all nursing and activities staff will be inserviced by the ADON on resident preferences regarding bathing/shower preferences. The Director of Life Enhancement will complete the questions on the resident?s activities initial review that pertain to resident?s preference regarding their choice of a shower or bath. The Interdisciplinary Team will meet to review each resident?s preferences and the care plan will then be adjusted according to the resident?s wishes. Each residents care plan will be reviewed as part of the ongoing audits to ensure bathing preferences are identified and documented. Quarterly, prior to each care plan meeting, the Nurse Manager will meet with each resident and/or responsible party to be sure their preference for shower or bath is agreeable to them. Adjustments will be made as requested by the resident and/or responsible party. Each resident?s care plan will be reviewed and adjusted by the Interdisciplinary Team.
4. The corrective action will be monitored by the Assistant Director of Nursing.
Weekly audits will be completed by the Nurse Managers verifying 5 residents:
Are receiving showers or baths according to their preferences.
Each resident?s preference is addressed in the resident?s individualized care plan.
Residents will be audited on a rotating basis
The results of these audits will be reported on at our next two quarterly Quality and Resident Safety Committee meeting by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee, a recommendation will be made to the continuation and reporting of these audits.
5. The Director of Nursing is responsible for the correction of this deficiency.
Completion date: (MONTH) 7, (YEAR)

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review completed during the Standard survey completed on 1/10/18 the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Two (Residents #65 & 66) of three residents observed for pressure ulcers had issues. Specifically, Resident #66 had a new pressure area develop which went unreported by the Certified Nursing Assistant (CNA) which delayed treatment and Resident #65 had a pressure treatment which was not in place for two hours. In addition, the lack of barrier cream applied after perineal care (#65, 66). The findings are: 1. Resident #66 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 12/12/17 revealed that the resident is cognitively intact, understands and is understood. In addition, the MDS documented the resident required extensive staff assistance for personal hygiene and that the resident has two Stage IV pressure ulcers and one unstageable pressure ulcer, which were all present on admission. Review of the computerized comprehensive care plan (CCP) initiated on 9/12/17 revealed the resident was admitted with pressure ulcers of the right and left buttock, right heel, left ankle and second toe with planned interventions for the use of an alternating air mattress administer treatments as ordered, turn and position every two hours. Observation on 1/9/18 at 7:24 AM revealed Certified Nursing Aide (CNA #3) and CNA #2 entered the room to perform morning care for the resident. CNA #2 washed the buttocks and hips and the surveyor noted the Allevyn (absorbent dressing) dressing dated 1/8/18 was intact on the right buttock; however, the left buttock had multiple areas of excoriations and two-three large scabs; CNA #2 did not apply any barrier cream when the cleansing and drying of the buttocks was completed. During an interview on 1/9/18 at 3:26 PM the Licensed Practical Nurse (LPN #4) Team Leader stated that the day LPN #3 Team Leader did not report any new concerns or skin issues for the resident to him. Additional observation on 1/9/18 at 4:08 PM with the Registered Nurse (RN #1) Nurse Manger revealed the areas of skin breakdown on the left buttock were new and were not there when she completed the last weekly skin assessment one week ago. The RN NM stated during the observation that the CNA should have informed the LPN Team Leader, who should have informed her. 2. Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands, is understood and was identified at risk of developing pressure ulcers. Review of the CCP updated 1/4/18 revealed the resident had a Stage III pressure ulcer on the sacrum (area above the tail bone on the right and left buttocks). CCP interventions include plan to apply barrier cream with incontinent care and to provide treatment as ordered to skin impairments. Review of a Skin/ Wound Note, written by the Registered Nurse (RN #1) Unit Manager (UM) dated 1/5/18 revealed the wound on the resident's sacrum measured 5.0 centimeters (cm) long by 1.5 cm wide with 0.2 cm depth. The RN UM documented that the wound is now a full thickness wound with 10 % (percent) yellow slough (soft, moist dead tissue) and 90 % pink tissue. Review of Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) dated 1/2018 revealed the 1/4/18 physician's orders [REDACTED]. Observation on 1/8/18 at 11:25 AM revealed two CNAs #1 and 4 provided fecal incontinence care during after the completion of a bed bath. When the resident was rolled to her right side, the resident was noted to be oozing soft brown stool and the sacral pressure ulcer was observed without a dressing. The resident continued to be positioned side to side by the two CNAs to place a slide sheet under the resident; the resident was boosted up in bed; pillows were place under the resident's arms; and CNA #1 combed her hair. Barrier cream was not applied to the resident after incontinent care and the sacral dressing remained off. Continued intermittent observation on 1/8/18 from 11:57 AM to 1:13 PM revealed the resident remained in bed. During an interview on 1/8/18 at 1:13 PM, LPN #1 Medication/Treatment Nurse was asked to provide the resident's sacral pressure ulcer treatment. The LPN stated that she had asked CNA #1 if the resident's dressing was okay and the CNA stated Yes. Observation on 1/8/18 at 1:48 PM revealed the sacral dressing remained off and LPN #1 cleansed the sacral pressure ulcer and provided the Santyl ointment treatment as ordered by the physician. Interview with CNA #1 on 1/9/18 at 10:59 AM revealed that she was aware that Resident #65's pressure ulcer dressing was off after morning care on 1/8/18 and that she told LPN #1 that the dressing was off. The CNA stated that she did not apply the barrier cream to the resident's skin after incontinent care because the nurse was supposed to do the treatment. 415.12(c)(2)

Plan of Correction: ApprovedFebruary 19, 2018

F686 Treatment/Services to Prevent/Heal Pressure ulcer
1. For resident #65, the treatment was completed by the nurse when it was brought to the nurses attention. Barrier cream was applied by the Certified Nursing Assistant.
For resident # 66, an assessment was completed by the Registered Nurse for the new pressure area. Barrier cream was applied by the Certified Nursing Assistant.
2. All residents have the potential to be affected by these deficient practices. All residents had skin checks completed by the LPN team leaders. Any unreported pressure ulcers that were found will have an assessment completed by an RN with notification to the resident?s medical provider for a treatment order.
All residents requiring barrier cream have been checked by RNs/supervisors to be sure Certified Nursing Assistants are applying barrier cream per care plan.
3. All residents who have dressings covering their wounds will have a statement added to the resident?s care plan that states to - notify the nurse if dressing is loose or off.
All Certified Nursing Assistants will be inserviced by ADON/Nurse Manager/Supervisor on:
--The requirement of completing all resident care per care plan including the application of barrier cream.
--The importance of immediately notifying the nurse if a dressing is loose or not on a wound
--The importance of immediately notifying the nurse of any new open areas found on residents.
ALL LPNs will be inserviced by ADON/Nurse Manager/Supervisor on:
timely completion of all treatments, including when told by staff member that a dressing is loose or not on a wound
proper procedure and documentation for all wound treatments
skin monitoring and reporting of any new pressure ulcer areas immediately to the charge nurse/RN
All RNs will be inserviced by ADON on:
Wound assessment requirements
Timely notification to the medical provider for obtaining a treatment order
4. The corrective action will be monitored by the Assistant Director of Nursing.
Weekly audits will be completed by the Nurse Manager on 2 residents with pressure ulcers to be sure an assessment has been completed and treatments/dressings are completed per medical provider order. Residents will be audited on a rotating basis.
Weekly audits will be completed on 2 CNAS by NM/supervisor to be sure proper application of barrier cream is completed per resident?s care plan. CNAs will be audited on a weekly rotating basis.
Weekly audits will be completed on 2 residents per unit (4 residents total) by nurse manager/ supervisor after the nurse manager / supervisor has completed a thorough skin check on each of the 4 total residents. Nurse manger / supervisor will then audit the documentation from nursing in the electronic medical record to determine if a skin concern was reported or identified in a timely manner.
The results of these audits will be reported on at our next two quarterly Quality and Resident Safety Committee meeting by the Director of Nursing. After the second quarterly Quality and Resident Safety Committee meeting, a recommendation will be made to the continuation and reporting of these audits.
5. The Director of Nursing is responsible for the correction of this deficiency.
Completion date: (MONTH) 7, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 1/10/18, a door with a self-closing device was not properly maintained. Issues included, a hazardous area door was equipped with a self-closing device that allowed the door to be held in a fully open position and was not arranged to automatically close the door upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system, and loss of power. This affected one (Second Floor) of three resident use floors. The finding is: Observation on the Second Floor, on 1/4/18 at approximately 9:50 AM, revealed the soiled utility room's corridor door was equipped with a hold open device that allowed the door to be held in a fully open position. This device was not arranged to automatically close the door upon activation of the required manual fire alarm system, local smoke detectors, automatic sprinkler system, and loss of power. Interview with the Facilities Manager, at the time of the observation, revealed the door should not have been equipped with this style of a hold-open device. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2000 NFPA 101: 19.2.2.2.7, 7.1.2.8.2

Plan of Correction: ApprovedFebruary 8, 2018

K 223 Doors with Self Closing Devices

What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
The soiled utility room door identified during survey that had a self closing device that allowed the door to be held in a fully open position was immediately corrected.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
All doors that exist throughout the rest of the facility that should be tied into the fire and smoke alarm system and should close automatically were examined for and any concerns and will be corrected.

What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
Education will be done by the Supervisor of Plant Operations to the appropriate maintenance team members regarding hazardous area doors, self-closing devices, and how they are tied into the fire/smoke alarm system.
A monthly audit of 2 self-closing doors per unit (4 total per month) will be conducted by the supervisor of plant operations / designee to ensure that they are tied into the smoke and fire alarm system and close properly. Concerns identified during the audit will be addressed immediately.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
Results from auditing will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Supervisor of Plant Operations

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 1/10/18, exit doors equipped with delayed-egress locking arrangements were not properly maintained. Issues included, a stairway exit door and a fire door exit were equipped with electromagnetic delayed-egress locks that did not open within the time stated by instructional signs on the doors and did not produce an audible alarm or start the delayed-egress process once attempts were made to open the doors. This affected one (Second Floor) of three resident use floors. The findings are: 1a.) Observation on Second Floor, on 1/4/18 at approximately 9:29 AM, revealed the fire/exit door located at the end of the corridor near Resident room [ROOM NUMBER] was equipped with an electromagnetic delayed-egress locking mechanism. The following observations were made when the delayed egress mechanism was tested : - instructional signage on the door read as follows: Keep pushing, this door will open in 15 seconds, alarm will sound. - on the first attempt, when the Facilities Manager tried to open the door, the door's electromagnetic lock did not release and allow the door to open until 23 seconds had passed. - on the second attempt, when the Facilities Manager tried to open the door, the door's electromagnetic lock did not release and allow the door to open until 29 seconds had passed. -Interview with the Facilities Manager, at the same time of the observations, revealed he would have the door adjusted immediately. b) Observation on Second Floor, on 1/4/18 at approximately 10:13 AM, revealed the Stairway E exit door, located near Resident room [ROOM NUMBER], was equipped with an electromagnetic delayed-egress locking mechanism. The following observations were made when the delayed egress mechanism was tested : - instructional signage on the door read as follows: Push until alarm sounds. Door can be open in 15 seconds. - on the first attempt, when the Facilities Manager tried to open the door, no audible alarm sounded in the area of the door - after 28 seconds had passed the door could not be opened. - on the second attempt, when the Facilities Manager tried to open the door, no audible alarm sounded in the area of the door and after 28 seconds had passed the door could not be opened. - Interview with the Facilities Manager at the time of the observation revealed the door should have been toning and he would be contacting an outside contractor to inspect and test the doors. Interview with the Facilities Manager on 1/8/18 at approximately 1:18 PM revealed he and the Administrator had tested the delayed egress doors located on the Second and Third Floors approximately one month ago and the facility had no documentation for the tests. Further interview with the Facilities Manager at this time revealed the facility did not have any logs for the testing of the delayed egress doors located on the Second and Third Floors and the delayed egress doors were not being tested on a regular basis. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2000 NFPA 101:19.2.2.2.4(2), 7.2.1.6.1.1

Plan of Correction: ApprovedFebruary 8, 2018

K 222 Egress doors
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
Delayed Egress locking mechanism and lack of audible alarm of specific areas identified during survey were corrected.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
All areas where delayed egress audible alarm exit doors exist throughout the rest of the facility were examined for and any concerns and will be corrected.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
Education will be done by supervisor of plant operations to the appropriate maintenance team members regarding proper operation of egress doors and operation of locking mechanisms.
A weekly audit will be conducted by the supervisor of plant operations / designee of all doors with delayed egress to ensure proper functioning. Concerns identified during the audit will be addressed immediately.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
Results from auditing will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Supervisor of Plant Operations

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 1/10/18, electrical equipment was not properly maintained. Issues included electrical junction boxes were open and uncovered and the ground prongs (a metal prong that is designed to divert electrical current into the ground instead of back into a piece of equipment in case of a short circuit) were missing from the plugs on flexible cords of electrical equipment. This affected two (Second and Third Floors) of three resident use floors. The findings are: 1a) Observation above the ceiling tiles on the Third Floor, on 1/5/18 at approximately 11:30 AM, revealed an open uncovered electrical junction box located in the corridor, near the fire door by Resident room [ROOM NUMBER]. b) Observation above the ceiling tiles on the Third Floor, on 1/5/18 at approximately 11:49 AM, revealed an open uncovered electrical junction box located in the corridor, near the smoke barrier doors by Resident room [ROOM NUMBER]. Interview with the Facilities Manager at the time of the observation revealed he was not aware of any current electrical work being done in the building. c) Observation above the ceiling tiles on the Second Floor, on 1/5/18 at approximately 12:27 PM, revealed an open uncovered electrical junction box located in the corridor, near the smoke barrier doors, by Resident room [ROOM NUMBER]. d) Observation above the ceiling tiles on the Second Floor, on 1/5/18 at approximately 12:37 PM, revealed an open uncovered electrical junction box located in the corridor, near the smoke barrier doors, by Resident room [ROOM NUMBER]. e) Observation above the ceiling tiles on the Second Floor, on 1/5/18 at approximately 12:46 PM, revealed an open uncovered electrical junction box located in the corridor, near the smoke barrier doors, by Resident room [ROOM NUMBER]. 2a) Observation on the Second Floor, on 1/5/18 at approximately 12:28 PM, revealed the ground prong was missing from the plug on the flexible power cord for the electrical bed located in Resident room [ROOM NUMBER]. b) Observation on the Second Floor, on 1/8/18 at approximately 2:59 PM, revealed the ground prong was missing from the plug on the flexible power cord for the air mattress pump for the bed located closest to the door in Resident room [ROOM NUMBER]. c) Observation on the Third Floor on 1/8/18 at approximately 12:12 PM revealed the ground prong was missing from the plug on the flexible power cord for the air mattress pump for the bed located closest to the door in Resident room [ROOM NUMBER]. d) Observation on the Third Floor on 1/8/18 at approximately 12:23 PM revealed the ground prong was missing from the plug on the flexible power cord for the air mattress pump for the bed located closest to the door in Resident room [ROOM NUMBER]. Interview with the Facilities Manager at the time of the observation revealed he was not aware the ground prongs were missing from the electric beds or air mattress pumps. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.1, 6.1.1, 1.3, 1.3.2.1, 6.3.2, 6.3.2.1, 2011 NFPA 70: 110.3(A)(1), 110.3 (A)(8), 400.3, 400.24, 250.138(A), 314.25, 314.72(C)

Plan of Correction: ApprovedJanuary 31, 2018

K 911 Electrical Systems
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
1) Junction boxes without covers for specific areas identified during survey were corrected.
2) Ground plug prongs on bed frames and air mattress pumps for specific areas identified during survey were corrected.

How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
1) All Junction boxes that exist in the ceiling throughout the rest of the facility will be examined for and any concerns and will be corrected.
2) All Ground plug prongs on mattresses and bed frames will examined for and any concerns and will be corrected.

What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
1) Education will be conducted by the supervisor of plant operations to all maintenance workers on ensuring that covers are installed and /or replaced on all junction boxes. A monthly audit will be conducted by maintenance designee above the ceiling of one area per unit per month to determine if any junction boxes are missing covers and concerns will be corrected. Areas specifically focused on will be those where above ceiling electrical work was known to have been performed.
2) Education to all applicable nursing and environmental staff will be conducted by the Manager of Health and Safety regarding if any plug prongs are noted to be missing when they are in rooms, that they will notify their immediate supervisor so that maintenance can be contacted to repair. An audit will be conducted on a monthly basis by Administrator / designee of 2 rooms per unit per month to determine if any concerns exist with missing plug prongs on electric bed frames or mattress air pumps and concerns identified during the audit will be addressed immediately.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
Results from auditing will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Administrator


K307 NFPA 101:GAS AND VACUUM PIPED SYSTEMS - OTHER

REGULATION: Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 7, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 1/10/18, medical gas valves were not properly maintained. Issues included medical gas zone valves boxes (boxes containing shut-off valves for the building's piped in oxygen system) were not accessible at all times due to physical obstructions. This affected two (Second and Third Floors) of three resident use floors. The findings are: 1a.) Observation on the Second Floor, on 1/8/18 at approximately 12:29 PM, revealed a sit-to-stand style lift was stored in the corridor, in front of and obstructing the oxygen zone valve box located between Resident Room's #703 and 704. Further observation revealed the valves located in the box were for the building ' s piped-in oxygen system that supplied oxygen to Resident Rooms #700 through 709. Interview with the Facilities Manager, at the time of the observation, revealed the lift should not have been stored in front of the medical gas valves. b) Observation on the Third Floor, on 1/9/18 at approximately 11:17 AM, revealed a soiled linen receptacle was stored in the corridor, in front of and obstructing the oxygen zone valve box located between Resident Room's #806 and 807. Further observation revealed the valves located in the box were for the building's piped-in oxygen system that supplied oxygen to Resident Rooms #800 through 809. Further observations on the Third Floor, on 1/9/18 at approximately 12:32 PM, 2:11 PM, and 2:30 PM revealed a patient care cart was stored in the corridor in front of and obstructing the oxygen zone valve box located between Resident Room's #806 and 807. c) Observation on the Third Floor on 1/10/18 at approximately 7:33 AM revealed a sit-to-stand style lift was stored in the corridor in front of and obstructing the oxygen shut of valves located between Resident Room's #806 and 807. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 5.1.4.8.4

Plan of Correction: ApprovedJanuary 31, 2018

K 902 Gas and Vacuum Piped Systems
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
Areas where oxygen zone valves were blocked that were identified during survey were corrected.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
All zone valves in facility were examined for potential obstructions and any concerns and will be corrected.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
Education will be conducted to all facility staff by the Health and Safety Manager regarding not obstructing or blocking oxygen zone shut off valves.
A weekly audit will be conducted by Administrator / designee of all areas where zone valves are located to ensure obstructions do not exist and concerns identified during the audit will be addressed immediately.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
Results from auditing will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Administrator

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: January 10, 2018
Corrected date: March 7, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 1/10/18, components of the building's automatic sprinkler system were improperly installed and the building was not protected by a complete, supervised automatic sprinkler system. Issues included; sprinkler heads were obstructed, sprinkler piping was not hung from the building's structure, and areas of the building were not protected by a supervised automatic sprinkler system. This affected three (First, Second, and Third Floors) of three resident use floors. The findings are: 1a.) Observation on the Second Floor on 1/4/18 at approximately 8:39 AM revealed a pendent style sprinkler head was obstructed by an exit sign, installed from the corridor ceiling near the Resident Care Manager's office. b) Observation on the Third floor on 1/5/18 at approximately 9:27 AM revealed a pendent style sprinkler head was obstructed by an exit sign, installed from the ceiling near the Nurse Manager's office. Interview with the Facilities Manager on 1/5/18 at approximately 11:20 AM revealed the exit signs that were obstructing the sprinkler heads would be moved. Further interview with the Facilities Manager at this time revealed the sprinkler heads had been installed after the exit signs had been installed. 2a) Observation on the Fifth Floor landing in Stairway E ,on 1/5/18 at approximately 10:41 AM, revealed a sprinkler head was not installed at the top of stairway. Further observation at this same time revealed Stairway E served the First, Second, Third, Fourth, and Fifth Floors. b) Observation on the First Floor landing in Stairway D, on 1/5/18 at approximately 10:46 AM, revealed a sprinkler head was not installed at the bottom of stairway. Further observation at this time revealed Stairway D served the First, Second, Third, Fourth and Fifth Floors. Interview with the Facilities Manager at the time of the observation revealed he was not aware sprinkler heads were not installed at the bottom of Stairway D and the top of Stairway E. 3a) Observation above the ceiling tiles on the Third Floor, on 1/5/18 at approximately 11:18 AM, revealed an orange colored plastic sprinkler pipe was hung from an electrical conduit in the soiled utility room. b) Observation above the ceiling tiles on the Second Floor, on 1/5/18 at approximately 12:46 PM, revealed an orange colored plastic sprinkler pipe was hung from an electrical conduit in the corridor near Resident room [ROOM NUMBER]. Interview with the Facilities Manager, at the same time of this observation, revealed an outside contractor had installed the sprinkler piping in 2013 when the facility upgraded the building's automatic sprinkler system. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2000 NFPA 101: 19.3.5.1, 9.7.1, 9.7.1.1(1) 2010 NFPA 13: 8.5.5.2.1, 8.5.5.2.2, 8.6, 8.6.5.2.2, Table 8.6.5.2.2, 9.2.1.3, 9.2.1.3.1

Plan of Correction: ApprovedFebruary 8, 2018

K 351 Sprinkler System?Installation
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
1) Sprinkler heads that were obstructed by exit signs during survey will be corrected.
2) Sprinkler heads that were identified as missing and required new installation will be corrected.
3) Areas where sprinkler piping was hung from electrical conduit identified during survey will be corrected.
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
1) All areas where sprinkler heads exist throughout the rest of the facility are to be examined to ensure that no obstructions exist and concerns will be corrected.
2) All areas within facility will be examined to ensure sprinkler heads are installed in all stairways and other required areas and any concerns will be addressed.
3) Above ceiling areas to be examined to determine that no plastic sprinkler pipe is hung from electrical conduit and any concerns will be corrected.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
The manager of facility services or his designee will conduct:
1) A monthly audit of 2 floors per month to determine if any obstructions of sprinkler heads exist and any concerns identified during the audit will be addressed immediately.
2) No further audit for missing sprinkler heads or orange sprinkler piping hanging from electrical conduit as will be a one-time audit; however the areas where new sprinkler heads are to be installed in 2 stairway locations will be examined to ensure that no concerns exist with the installation process.
3) Education will be done by the Supervisor of Plant Operations to the appropriate maintenance team members regarding identifying obstructions of sprinkler heads and ensuring that orange sprinkler piping should not be hung from electrical conduit.

How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
Results from auditing will be presented and discussed at the Quality Assurance / Performance Improvement meeting for a duration of 6 months (or the next 2 quarterly meetings); and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 7, (YEAR)
Responsible person: Supervisor of Plant Operations

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2018
Corrected date: March 10, 2018

Citation Details

Based on observation, interview, and record review during the Life Safety Code survey completed on 1/10/18, the building's automatic sprinkler system was not properly tested . Issues included, the fire pump was not run under emergency power conditions. This affected three (First, Second, and Third Floors) of three resident use floors. The finding is: On 1/4/18, a review of the Fire Pump inspection and testing report dated 4/21/17 revealed: - the reports contained no documentation the facility's fire pump had been run under emergency power conditions. - the following was written on page eight of the report: Please note: Periodic tests of transfer switches and emergency generators may be necessary in accordance with National Fire Protection Association NFPA 110 Standard for Emergency and Standby Power Systems but are not part of this inspection. Interview with the Facilities Manager on 1/5/18 at approximately 7:51 AM revealed the facility's fire pump had not been run under emergency power conditions. Observation in Building #1 on 1/5/18 at approximately 10:38 AM revealed a fire pump was located in the building's Basement. Interview with the Facilities Manager at the time of the observation revealed the fire pump was part of the automatic sprinkler system for the Skilled Nursing Facility located in Building # 5 and the facility's emergency generator's supplied power to the fire pump. Per the 2011 edition National Fire Protection Association (NFPA) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems Chapter 8 - Fire Pumps: 8.3.3.4, For installations having an automatic transfer switch, the following test shall be performed to ensure that the overcurrent protective devices (i.e., fuses or circuit breakers) do not open: (1) Simulate a power failure condition while the pump is operating at peak load (2) Verify that the transfer switch transfers power to the alternate power source (3) Verify that the pump continues to perform at peak load (4) Remove the power failure condition and verify that, after a time delay, the pump is reconnected to the normal power source. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5 2011 NFPA 25: 8.3.3.4, 8.3.4.1, 8.3.4.2

Plan of Correction: ApprovedFebruary 13, 2018

K 353 Sprinkler system?Maintenance and Testing
What corrective action(s) will be accomplished for the areas found to have been affected by the deficient practice:
How will you identify other areas having the potential to be affected by the same deficient practice and what corrective action will be taken:
The facility?s automatic sprinkler system will be properly tested as the fire pump will be running under emergency power conditions.
What measures will be put in place or what systemic change you will make to ensure that the deficient practice does not reoccur:
The fire pump will be annually running under emergency power conditions during the scheduled times of fire pump testing. Documentation from the Fire pump inspection and testing report will reflect that the fire pump was running under emergency power conditions. An audit will be conducted by the supervisor of plant operations / designee during the next fire pump flow test.
How will the corrective action(s) be monitored to ensure the deficient practice will not reoccur, i.e. what quality assurance program will be put into practice.
Results from the fire pump flow test will be presented and discussed at the (MONTH) (YEAR) Quality Assurance / Performance Improvement meeting and further continuation of this process to be determined by discussion among the QA/PI team.
Date for correction: (MONTH) 10, (YEAR)
Responsible person: Supervisor of Plant Operations