Orchard Rehabilitation & Nursing Center
January 10, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(2):ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

REGULATION: (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, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed 1/10/17, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. One (Resident #149) of three residents observed for ADL's was not provided with their dentures prior to breakfast as planned. The finding is: 1. Resident #149 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/23/16 revealed the resident has severe cognitive impairment. During a family interview on 1/5/17 at 10:26 AM, the family member stated that sometimes the resident doesn't have her dentures in for breakfast. Observations on 1/6/17 at 8:18 AM and 1/10/17 at 8:14 AM revealed the resident's breakfast tray was on the over bed table in the resident's room and the resident did not have her dentures in place. Review of a physician's orders [REDACTED]. Review of the current Comprehensive Care Plan (CCP) dated 11/2/16 revealed a potential for dental or oral cavity health problem related to a [DIAGNOSES REDACTED]. Additionally, noted the resident takes her dentures out frequently and does not always put them in her denture cup. Interventions include: the CNA (certified nurse aide) will take dentures from the resident at bedtime, give them to the LPN (licensed practical nurse) to be locked up on the medication cart until the morning. Review of the Individual Plan Report (guide used by staff to provide care) dated 1/10/17 revealed instructions to ask the med (medication) nurse for dentures in the a.m. before breakfast. During an interview on 1/10/17 at 8:24 AM, LPN #6 Unit Manager (UM) stated the resident's dentures are kept in the medication cart and are given to the CNA in the morning. During an interview on 1/10/17 at 8:26 AM, LPN #7 Medication Nurse stated she gives the resident's dentures to the CNA in the morning. The CNA did not come to get them. During an interview on 1/10/17 at 9:15 AM, CNA #2 revealed it was her first day on the floor, she was bombarded and had to get five people up for breakfast. When asked if she read the care plan, the CNA stated that she had. 415.12(a)(3)

Plan of Correction: ApprovedFebruary 3, 2017

The following corrective action have been implemented for the deficiency cited:
A) Resident #149 was properly given her dentures
B) CNA # 2 was reeducated on time management and priority of ensuring residents dentures are provided prior to any meal
The following actions have been completed to identify other residents within the facility that have potential to be affected by this deficiency:
A) A full house audit prior to breakfast was conducted by nurse managers, DON, ADON, Staff Educator to ensure all residents requiring dentures for meals had them properly in place prior to meal

The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)All nursing staff have been reeducated/in-serviced on providing dentures, ensuring proper placement of dentures prior to any meal
B)An audit of all residents who require dentures within the facility will be conducted by Director of Nursing or designee weekly for one month, then monthly on an ongoing basis to ensure dentures are properly provided prior to meals.
C)The results of these audits will be presented and reviewed by the Quality Assurance Committee at the monthly QA meeting
The Director of Nursing will be responsible for implementation and ongoing evaluation of this corrective action

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

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 1/10/17, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Two (Residents #97 and 136) of five residents reviewed for unnecessary medications had issues involving the lack of documentation of the resident's behavior to support the use of antipsychotic medication as needed (PRN), and the lack of documented non-pharmacological interventions prior to the administration of antipsychotic medication. The findings are: 1. Resident #97 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 11/23/16 revealed the resident is cognitively intact, is understood and understands. Review of current Care Plan dated 1/6/17 revealed the resident uses [MEDICAL CONDITION] medication. Interventions include the following: - Attempt Non-Pharmacological Interventions: 1 on 1, activity, adjust room temperature, backrub, change position, give fluids, give food, redirect, remove resident from environment, return to room. - Provide physical and verbal cues to alleviate anxiety, give positive feedback, and assist with verbalization of source of agitation. Review of the Order Summary Report with the Date Range of 11/1/16 - 1/31/17 included the following physician order [REDACTED]. Inject 0.2ml intramuscularly (IM) STAT (immediately) for agitation. Review of the Medication Administration Record [REDACTED]. Review of a Progress Note dated 12/6/16 revealed there was no documented evidence that non-pharmacological interventions were attempted by the staff prior to the administration of an antipsychotic medication. Review of the Order Summary Report with the Date Range of 11/1/16 - 1/31/17 included the following physician order [REDACTED]. Inject 1 ml intramuscularly one time only for increased agitation for one day. Review of the MAR indicated [REDACTED]. Review of the 12/23/16 and 12/24/16 Progress Notes revealed there was no documented evidence that non-pharmacological interventions were attempted by the staff prior to the administration of an antipsychotic medication. Review of Order Summary Report with the Date Range of 11/1/16 - 1/31/17 included the following physician order [REDACTED]. Give 1 mg by mouth every 8 hours as needed for agitation/anxiety. Review of the MAR indicated [REDACTED]. Review of a Progress Note dated 12/31/16 revealed there was no documented evidence that the resident was experiencing agitation/anxiety. In addition, there was no documented evidence that non-pharmacological interventions were attempted by the staff prior to the administration of an antipsychotic medication. Review of the MAR indicated [REDACTED]. Review of the Progress Notes dated 1/5/17 and 1/6/17 revealed there was no documented evidence that non-pharmacological interventions were attempted by the staff prior to the administration of an antipsychotic medication. Interview with Licensed Practical Nurse (LPN #6) on 1/9/17 at approximately 11:27AM revealed, We don't usually do a prn (as needed) order for [MEDICATION NAME]. We try everything under the sun before we give the medication: quiet area, snacks; remove from room; toileting; going for a walk or distractions. There's no interventions documented in here (progress notes), this is not right. There should be non-pharmacological interventions attempted before giving a STAT or prn dose. 2. Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, understands and is understood. Further review of the MDS revealed that the resident's vision is severely impaired, there were no episodes of mood disturbance, [MEDICAL CONDITION] or behavioral symptoms and there was no rejection of care during the look back period. Observation of Resident #136 on 1/9/17 at approximately 11:30 AM revealed the resident was independently wheeling herself in the wheelchair from the unit hallway into a small common area in the center of the nursing unit. There were no staff in the immediate vicinity but four residents were sitting in wheelchairs or Geri-chair in a section of the common area that Resident #136 was approaching. Resident #136 became entangled in the footrest of another resident sitting in a reclining wheelchair as she was attempting to propel throughout the common area. The resident was observed to become slightly anxious and began to call out, asking where was she and what time it was. This surveyor was standing approximately three feet of Resident #136 when the resident became entangled with the other resident's foot rest. The surveyor offered verbal cues to the resident of her location, time and offer verbal cues for the resident to clear her obstructed path. Resident #136 followed the cues and proceeded with her activity without further concerns. Review of the Order Summary Report for the date range 4/25/16 to 1/31/16 and review of the Medication Administration Records (MAR) for October, (MONTH) and (MONTH) (YEAR) and (MONTH) (YEAR) revealed orders for the following [MEDICAL CONDITION] medications (medication used to manage behaviors, stabilize mood or treat psychiatric conditions): - 4/26/16 [MEDICATION NAME] (antidepressant) 20 mg,1 tab by mouth one time a day - 10/14/16 [MEDICATION NAME] (anti-anxiety medication) 5 mg,1 tablet by mouth 2 times a day for anxiety (discontinued 12/15/16) - 12/15/16 [MEDICATION NAME] (antipsychotic medication) 12.5 mg by mouth every 8 hours as needed for behaviors for 21 days (discontinued 1/2/17) - 1/2/17 [MEDICATION NAME] 25 mg by mouth at bedtime - 1/2/17 [MEDICATION NAME] 25 mg by mouth every 12 hours as needed for behavior disturbance Review of the electronic Medical Record (eMR) revealed Psychiatrist Progress Notes as follows: -7/29/16 Constantly calling out to go the bathroom but has no need when taken there. Continue [MEDICATION NAME] and increase [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and nerve pain) to 200 mg tid (three time a day) -8/12/16 Despite increase in [MEDICATION NAME] still yells, shouts, attention seeking. Denies being depressed except to state that she is depressed over her loss of vision, constantly calling to go to toilet although mostly has no need when taken there. Continue [MEDICATION NAME] and increase [MEDICATION NAME] to 300 mg tid. -9/2/16 still yells, shouts, attention seeking although she denies the above. Depressed over her loss of vision. Often calling to go to toilet but less so -11/4/16 Complaints of being frustrated. Yells, shout, attention seeking. Depressed over her loss of vision. Calling to go to toilet more than needed. Her medications include [MEDICATION NAME] 20 mg daily, [MEDICATION NAME] 300 mg tid, [MEDICATION NAME]. Plan: dc (discontinue) [MEDICATION NAME] GDR (gradual dose reduction). -12/5/16 [MEDICATION NAME] not discontinued because it is felt patient's behavior quite problematic and if discontinued will need something else to help. I do not feel [MEDICATION NAME] is effective. Patient acknowledged being angry often, still depressed over her vision. Denies being nervous but states she is sometimes frustrated. Plan: dc [MEDICATION NAME] GDR, increase [MEDICATION NAME] to 400 mg tid for nerve pain and affective lability, [MEDICATION NAME] 12.5 mg every 8 hours as needed for agitation for 21 days. -1/6/16 s/p (status [REDACTED]. Patient acknowledged being angry often for example with nurses, depressed over her vision but less so. Yells, shouts, attention seeking, calling to go to toilet more than needed. Plan Monitor s/p recent dc [MEDICATION NAME] GDR and increase [MEDICATION NAME]. Change standing [MEDICATION NAME] to 12.5 every 12 hours, dc [MEDICATION NAME] prn. Review of eMR Progress Notes revealed nursing notes as follows: -During (MONTH) (YEAR), 14 episodes of adverse behavior documented with nursing staff providing non-pharmacological interventions on 4 occasions - During (MONTH) (YEAR), 8 episodes of adverse behavior documented with no non-pharmacological interventions documented - During (MONTH) (YEAR), 32 episodes of adverse behavior documented with nursing staff providing non-pharmacological interventions on 8 occasions From (MONTH) 1 to 8, (YEAR), 12 episodes of adverse behavior documented with no non-pharmacological interventions documented. Review of the Comprehensive Care Plan (CCP), reviewed 11/1/16, revealed [MEDICAL CONDITION] medication use related to [DIAGNOSES REDACTED]. Interventions documented were: Monitor for side effects, MD medical doctor) to review on rounds; staff to administer medications; obtain consults prn and to educated resident/family/staff as needed. The CCP does not document the medication dose changes, additions or discontinuation of the resident's [MEDICAL CONDITION] medication. The CCP does not include non-pharmacological interventions to help control the resident's behavior prior to the use of antipsychotic medications. During an interview on 1/9/17 at 9:40 AM, the Director of Nursing (DON) stated that the facility does not maintain behavior logs with the use of [MEDICAL CONDITION] medications. The DON stated that nursing staff are to document resident behaviors in a nursing note. The DON stated that the Consultant Pharmacist maintains the meeting minutes for facility BMARC (behavior modification assessment record committee). During an interview with the Consultant Pharmacist on 1/9/17 at 10:44 AM, the Consultant Pharmacist Stated that he has just recently started attending the facility BMARC meetings but does not document meeting minutes for BMARC committee. During an interview on 1/9/17 at 11:35 AM, the Licensed Practical Nurse (LPN #1) Unit Manager (UM) stated she last remembered attending a BMARC meeting in (MONTH) (YEAR) and stated the Social Worker would be responsible for documenting BMARC meeting minutes and for developing the resident's care plan for [MEDICAL CONDITION] medication. The UM further stated that behavior charting is documented in the nursing progress notes and should include any interventions attempted to control the resident's adverse behaviors. During an interview with the Social Worker (SW #1) on 1/9/17 at 11:41 AM SW #1 stated that she did not have meeting minutes for the facility's BMARC but had a list of the residents that were reviewed at the 8/31/1/6 and 9/23/16 BMARC meetings. SW #1 stated Resident #136's medications were reviewed during the 9/23/16 BMARC meetings but the resident has not been reviewed by BMARC since that date. SW #1 further stated that the resident had a care plan meeting on 10/26/16 and the resident's use of [MEDICATION NAME] and [MEDICATION NAME] were discussed at that time. SW #1 stated the care plan updating is the responsibility of all team members. The SW #1 that is was probably a good idea to update the care plan to address the resident's current psychotic medications and non-pharmacological interventions. 415.12(l)(1)

Plan of Correction: ApprovedFebruary 9, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following corrective action have been implemented for the deficiency cited:
#1
A)Resident #97 was assessed by MD and had complete medication review to ensure current appropriateness of medications. Residents PRN [MEDICATION NAME] was discontinued. Residents care plan and record have been updated to include non-pharmaceutical approaches to deescalate behavior prior to any medication use.
#2
A)Resident #136 comprehensive care plan has been updated to include use of non-pharmacological interventions, and current medication regime has been reviewed by MD and appropriatness for continued antipsychotic medications have been documented.
The following actions have been completed to identify other residents within the facility that have the potential to be affected by this deficiency:
A)A complete review of all residents within the facility who receive any [MEDICAL CONDITION] medication was completed by pharmacy consultant, Director of Nursing, Unit Managers, Social Worker to identify appropriate indications of use including Diagnosis, behavior documentation, and indication for medication use.
B)The facility Medical Director reviewed and addressed recommendations found from the full house review. (step A)
C)Each resident identified as receiving [MEDICAL CONDITION] medications has had their comprehensive care plan updated to include non-pharmacological interventions for behavior management
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)Reeducation/in-service has been conducted by the Staff Education Nurse to all nursing staff (RN,LPN,CNA)regarding the use of non-pharmaceutical interventions for behavior management, proper and complete documentation of all interventions attempted prior to pharmaceutical intervention. In-service also reviewed behavior documentation for any resident receiving antipsychotic medications
B)The facility policy for BMARC has been reviewed and adjusted. Specifically, the facility will have this meeting monthly, attended by Consultant Pharmacist, Nursing Administration, Social Services, Medical Director. Meeting Minutes will be completed and maintained at the facility for prompt access. The minutes of the monthly BMARC meetings will be a required portion of the agenda for review with the monthly Quality Assurance Committee
C)Facility policy regarding use of PRN/STAT [MEDICAL CONDITION] medication (ie [MEDICATION NAME])has been revised to specifically indicate that orders can only be for a one time dose after all non-pharmaceutical interventions have been attempted without effect.
D)All medical providers (MD,NP,PA)with privileges to the facility as well as all licensed nursing staff have been in-serviced on above policy change (C)
E)Any use of additional pharmaceutical interventions other than a residents normal standing orders will be identified on the daily 24 hour report sheet and be presented to the interdisciplinary team during AM report for further investigation and recommendations. The resident record of any resident who received any additional, or one time [MEDICAL CONDITION] medication will be audited by DON or designee within 24 hours to ensure alternative measures have been consistently attempted prior to pharmaceutical intervention
F)Audits will be conducted monthly by nursing administration (DON, ADON, Staff Education RN, Unit Manager) of all residents records who routinely receive [MEDICAL CONDITION] medications to ensure behavior documentation, alternative measure attempts, pharmacist reviews with MD follow up are all timely and current.
G)The results of audits (E & F) will be provided and reviewed by the Quality Assurance Committee during the monthly QA meeting
The Director of Nursing will be responsible for the implementation and ongoing evaluation of this corrective action

FF10 483.45(c)(1)(3)-(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility?s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility?s medical director and director of nursing and lists, at a minimum, the resident?s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident?s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident?s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 1/10/17, the facility did not ensure that the Licensed Pharmacist reported drug regime irregularities to the attending Physician, and the Director of Nursing (DON), and these reports must be acted upon. Specifically, one (Resident #190) of five residents reviewed for unnecessary medications had an issue involving the lack of physician response and follow-up of the Consultant Pharmacist's recommendation regarding the resident receiving duplicate therapy of two antidepressants. The finding is: 1. Resident #190 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/17/16 revealed the resident was feeling down, depressed or hopeless two to six days and the resident received antipsychotic, antianxiety and antidepressant medications for the previous seven days. The resident has moderate cognitive impairment. Review of the Order Summary Report printed 1/10/17 revealed Active orders as of 7/31/16 included orders for Lexapro and Trazodone (medications used to treat depression). Review of the Medication Regimen Reviews (MRR) from 7/1/16 through 1/1/17 revealed there were no recommendations made by the Pharmacist. During an telephone interview with the Pharmacist on 1/9/16 at approximately 10:00 AM he stated that he made recommendations to the Physician in (MONTH) of (YEAR). The Consultant Pharmacist faxed the note dated 7/29/16 to the facility on [DATE], at the surveyor's request. Review of the Pharmacist's Note to the Attending Physician/ Prescriber dated 7/29/16 revealed The following medications represent duplicate therapy and regulations call for a documented rationale and monitoring necessary for potential additive effects: two antidepressants. An interview with the Director of Nursing (DON) on 1/10/17 at approximately 12:35 PM revealed she was unable to locate any documented evidence that the Physician had reviewed or acted on the recommendations. During an telephone interview with the Physician on 1/10/17 at 1:00 PM, the Physician stated that they have not met to discuss this as yet and discussion is pending. The Physician further stated that he did not document the rationale for or monitoring of the duplicate therapy. 415.18(c)(2)

Plan of Correction: ApprovedFebruary 6, 2017

The following corrective action has been implemented for the deficiency cited:
A) Resident #190 medication regime has been reviewed by the Medical Director and adjusted appropriately. MD documented the indications, risk, benefits for maintaining current regime at this time
The following actions have been completed to identify other residents within the facility that have potential to be affected by this deficiency:
A) A complete medical record audit of all residents receiving psychotropic medications (anti-anxiety, anti-depressant, anti-psychotic, hypnotic)has been completed to Identify:
-that the contracted pharmacist has reviewed and making recommendations.
-that there has been a review within the past 30 days by the contracted pharmacist
-That the residents physician (and DON) has reviewed and addressed the recommendations
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)The contracted pharmacist will provide a complete comprehensive monthly report to the facility Administrator/Director of Nursing indication residents reviewed during the month
B)The Director of Nursing or designee will audit all residents receiving psychotropic medications each month to ensure Doctor compliance with Pharmacists recommendations
C)Both A&B will be reviewed monthly during the facility Quality Assurance Committee Meeting

The Director of Nursing will be responsible for implementation and ongoing evaluation of this corrective action.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

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 1/10/17, the facility did not maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, one (Unit Two) of three Nursing Units had issues involving glucose meters (used to measure and display the amount of sugar (glucose) in your blood) that were not disinfected in accordance with manufacturer's recommendations and shared bathrooms that had unlabeled and uncapped personal care items stored improperly. Also, one (Resident #103) of three residents observed for infection control practices during personal care had issues with improper hand hygiene after providing personal care. In addition, the laundry room observed for infection control had four washing machines that were soiled and leaking. The findings are: 1. a. Observation on 1/06/17 at approximately 7:18 AM on Unit Two, revealed Licensed Practical Nurse (LPN #3) Medication Nurse returned to the medication cart with a blood glucose meter. Wiped the glucose meter for two seconds with a Sani Cloth Germicidal wipe and placed the glucose meter in the top drawer after approximately 20 seconds. The surveyor asked the LPN to open the drawer and after approximate 40 seconds from contact with the Sani Cloth, and the glucose meter was dry. At the time of the observation, LPN #3 stated that she had just checked Resident #131's glucose reading and needed to administer insulin. During a continued observation the LPN administered Humalog 4 units to Resident #131 and returned to the medication cart. On 1/6/17 at approximately 7:26 AM, LPN #3 stated she had one more insulin to administer to Resident A and obtained the glucose meter to complete the glucose check. The surveyor stopped the process. During an interview on 1/06/17 at approximately 7:27 AM, LPN #3 stated that glucose meters are cleansed with an antimicrobial cloth. Additionally, LPN #3 stated she did not know the specific amount of time for the cleansing process. During an interview on 1/06/17 at approximately 7:29 AM, LPN #1 Unit Manager stated that glucose meters are cleansed with an antimicrobial cloth, it usually takes one minute to air dry. However, the LPN #1 Unit Manager did not know the specific amount of time for the cleansing process. During an interview on 1/06/17 at approximately 7:38 AM, the Director of Nursing (DON) stated that glucose meters require cleansing with an antimicrobial cloth, and the glucose meter should dry in two to three minutes. However, the DON was not sure of the specific amount of time for the cleansing process. Review of the facility's undated policy entitled Non Disposable Medical Equipment revealed that the first step is to cleanse the surface with a Caviwipe to remove debris and bio-burden and discard. The second step to disinfect after cleaning and to follow the label instruction for appropriate contact times, allow to air dry and discard the towelette. Review of the product information for Sani Cloth Germicidal Disposable wipe revealed that to get disinfection, allow the treated surface to remain wet for a full two minutes and air dry. b. Observation on 1/6/17 at 7:54 AM on Unit Two revealed that LPN #2 completed blood glucose testing for a resident using the Assure Prism Multi blood glucose monitoring system. LPN #2 returned to the medication cart, disposed of the lancet (used to prick your skin to obtain a blood sample) and glucose test strip in the biohazard waste container on the side of the medication cart. While wearing gloves, LPN #2 obtained a Sani Cloth Germicidal wipe from the container on the medication cart and wiped the entire surface of the glucose meter for less than 10 seconds. LPN #2 placed the damp glucose meter on the surface of the medication cart and disposed of the Sani Cloth Germicidal wipe. During a continuous observation of the glucose meter that was on the top of the medication cart, the meter was moist with germicidal solution for less than one minute. During an interview with LPN #2 on 1/6/17 at 8:17 AM, LPN #2 stated that the surveyor had observed the last glucose meter testing for the morning. LPN #2 stated that she thought that the glucose meter should be cleansed for one minute after resident use. During an interview with the LPN #1 Unit Manager (UM) on 1/6/17 at 8:39 AM, the UM stated she thought that the glucose meter should be cleansed with a germicidal wipe for approximately 15-20 seconds and was not sure how long the glucose meter would stay moist after it was wiped. The UM stated she was not aware of the germicidal wipe manufacturer recommendations of length of time required for cleansing of contaminated surfaces. Review of the Assure Prism Multi Blood Glucose Monitoring System User Instruction Manual revealed the following: -The meter should be cleansed and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. 2. Resident #103 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/5/16 revealed that the resident has moderate cognitive impairment, understands and is understood. During an observation on 1/6/7 at approximately 10:10 AM, revealed a Certified Nursing Aide (CNA#3) completed a bed bath for the resident. The CNA completed pericare (washing of the genitals and anal area), washed the resident's buttock and did not remove the contaminated gloves. The CNA proceeded to: dress the resident in briefs and pants, adjusted the position of the resident's wheelchair; opened the top drawer of the dresser and got socks; dressed the resident in socks and shoes; lowered the resident's bed with the bed controller and handled the resident's pillow all while wearing the contaminated gloves. During an interview on 1/10/17 at approximately 8:00 AM, the DON stated that staff are to follow universal precautions when providing resident care. 3. Observations of Unit Two shared resident bathrooms on 1/4/17 from 8:30 AM to 10:30 AM; on 1/6/17 from 2:00 PM to 2:15 PM and on 1/9/17 from 11:00 AM to 11:30 AM revealed the following: - Resident room [ROOM NUMBER] - had multiple bottles of unlabeled soaps and deodorants, an unlabeled exposed toothbrush and toothpaste in an unlabeled kidney basin on a shared sink - Resident room [ROOM NUMBER] - had unlabeled skin moisturizer lotion and bottles of liquid soap on a shared sink and two to three clean briefs on the back of the toilet - Resident room [ROOM NUMBER] - had an unlabeled basket with multiple bottles of unlabeled skin moisturizer lotion, bottles of peri wash and an open container of Vaseline petroleum jelly on a shared sink - Resident room [ROOM NUMBER] - had two baskets with unlabeled soaps and skin moisturizer lotion, and an un-medicated body powder on a shared skin - Resident room [ROOM NUMBER] multiple bottle of soaps and deodorants, exposed toothbrush and toothpaste on a shared sink During an interview on 1/9/17 at 11:28 AM, LPN #1 Unit Manager (UM)stated that resident personal care items should be stored in a wash basin in resident drawers. The UM continued to state that in a shared bathroom resident care items should be labelled, containers of resident personal care items should not be left open and a basket or basin of resident care items should be labelled. During an interview with Housekeeper #1 on 1/10/17 at 9:26 AM, the Housekeeper stated that resident care items on the sink would be replaced to the back of the sink after cleaning the resident sink. During an interview with the Certified Nurse Aide (CNA #1) on 1/10/17 at 9:27 AM, CNA #1 stated that all resident personal care items should be stored in a basin in the resident's cupboard or dresser drawer and it was not okay to store personal care items on the back of the resident shared sink. 4. During an observation on 1/05/17 at approximately 11:20 AM, revealed that the four resident use washers in the laundry room were in an unclean condition and in use. Specifically, the front loaded machine doors and front casing had a white residue. Two of the four washing machines had copious amounts of white/brown residue. One washer had a water intake hose attached to the glass on the front loaded door which was leaking. There was a bucket was on the floor underneath the hose to catch the dripping water. During an interview on 1/15/17 at approximately 11:20 AM, the Housekeeping and Laundry Supervisor revealed that the facility staff is responsible to conduct routine maintenance on the washing machines and the facility contracts out more difficult repairs to a company. Additional observation on 1/9/17 at approximately 9:00 AM, revealed that the washing machines were in the same soiled condition and all were being utilized, with the one washing machine still leaking water on the floor. Additional observation on 1/10/17 at approximately 8:48 AM revealed all four washers were in a similar condition, with one machine leaking water with a bucket placed on the floor. During an interview on 1/10/17 at approximately 8:48 AM, the Housekeeping and Laundry Supervisor revealed that the facility staff had fixed the leaking washer and was not aware that it was still leaking water. During an interview on 1/10/17 at approximately 8:48 AM the Administrator stated that the resident use washers should be kept in a clean and operational manner and they would be fixed. 415.5(h)(2)

Plan of Correction: ApprovedFebruary 6, 2017

The following corrective actions have been implemented for the deficiency cited:
#1
A)LPN #2 & LPN #3 were both reeducated on proper sanitizing of glucometer as per recommendations.
#2
A)CNA #3 was reeducated on proper technique regarding pericare and changing of gloves
#3
A)Resident #217,#221,#225,#255,#257 had all unlabeled toiletry items removed and thrown out. All items for each resident were immediately replaced with new and properly labeled items, appropriately stored in a labeled personal wash basin.
#4
A)The four frontloading washing machines were immediately cleaned of all residue.
B)A vendor was contracted to repair the leaking water hose attached to the glass front of the one washer
The following actions have been completed to identify other residents that have potential to be affected by this deficiency:
#1
A)A complete house audit was done observing medication nurses for proper cleaning technique of glucometers by the Staff Educator Nurse
B) all glucometers within the facility were visually inspected for cleanliness
#2
A)The Staff Educator Nurse audited pericare on each nursing unit on each shift to further identify proper technique is being utilized. 30 audits (10 per unit) are completed. Audits will continue until all CNA staff have been visually audited over the next 30 days.
#3
A)Every resident room within the facility was audited for unlabeled toiletry items, proper storage of appropriately labeled toiletry items, no material stored inappropriately in resident bathrooms
#4
A)The four washers identified are the only washers the facility utilizes, therefore this deficiency affected the entire facility
The following systemic changes have been implemented to ensure continued compliance with the regulation:
#1
A)A facility wide nursing in-service regarding the proper technique and materials to appropriately clean and disinfect glucometers will be conducted by the facility Staff Educator Nurse
B)glucometer disinfectant will be added to the annual nursing skills assessment that all nurses must be observed properly completing for their annual evaluation
C)Random audit of proper disinfectant techniques involving all units on all shifts will be conducted by the Director of Nursing or designee monthly for three months The audit will be completed on every (6) glucometer in the facility monthly
D) the results of these audits will be provided and reviewed by the facility Quality Assurance Committee during the monthly meeting
The Director of Nursing will be responsible for implementation and ongoing evaluation of this portion (#1) of this corrective action
#2
A)The Staff Education Nurse will audit all CNA staff on each unit, each shift for proper procedure during peri care. Staff educator Nurse will complete these audits at a rate of 10 per week until all CNA staff has been reviewed and 100% compliance is achieved
B)Reeducation/in-service will be provided to all Nursing staff reinforcing proper techniques, hand washing, glove removal.
C)Results of the CNA audits will be tracked and reported upon during the facility monthly Quality Assurance Committee meeting
The Director of Nursing will be responsible for implementation and ongoing evaluation of this portion (#2) of this corrective action
#3
A)The Staff Education Nurse will conduct reeducation/in-service for all nursing & housekeeping staff reinforcing proper labeling & storage of resident toiletries.
B)Facility wide audit will be conducted monthly assessing each resident room for all individual items are labeled and appropriately stored.
C)The results of the room audits will be reported and reviewed at the monthly Quality Assurance Committee meeting
The Director of Nursing will be responsible for implementation and ongoing evaluation of this portion (#3) of this corrective action
#4
A)Reeducation/in-service will be provided to all Laundry department staff reviewing proper machine cleanliness.
B)A schedule for cleaning the facility washing machines has been implemented. Staff training and protocol for reporting concerns has been provided to all laundry department staff.
C)An audit has been created and will be completed weekly addressing the proper functioning and cleanliness of ALL washers in the laundry department.
D) the results of this audit will be provided and reviewed by the facility Quality Assurance Committee during the monthly meeting
The Director of Environmental Services will be responsible for implementation and ongoing evaluation of this portion (#4) of this corrective action.

FF10 483.80(d)(1)(2):INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

REGULATION: (d) Influenza and pneumococcal immunizations (1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident?s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident?s representative has the opportunity to refuse immunization; and (iv) The resident?s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident?s representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. (2) Pneumococcal disease. The facility must develop policies and procedures to ensure that- (i) Before offering the pneumococcal immunization, each resident or the resident?s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident?s representative has the opportunity to refuse immunization; and (iv) The resident?s medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident?s representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 1/10/17, the facility did not ensure that each resident was offered an Influenza and Pneumococcal Immunization, unless the immunization is medically contraindicated or the resident has already been immunized. Specifically, nine (Residents #1, 63, 68,117,119,149,151,190, and 218) of 10 residents reviewed for Influenza and Pneumococcal immunizations revealed the facility did not have documented evidence that each resident is offered and receives an influenza and/ or a pneumococcal immunization unless medically contraindicated or the resident has already been immunized. In addition, residents were not administered the pneumococcal vaccination in a timely manner. The findings are but not limited to: 1. Resident #149 has a [DIAGNOSES REDACTED]. Review of a Pneumococcal Pneumonia and Influenza Vaccination form revealed on 10/4/16 the responsible party gave consent for the resident to receive the Influenza vaccination and Pneumococcal vaccination. Review of the Medical Record revealed that the resident received the Influenza vaccination on 11/14/16. However, the resident had not received the Pneumococcal vaccination. There was no Physician's Order to receive the Pneumococcal vaccination. During an interview on 1/05/17 at approximately 1:02 PM, the Assistant Director of Nursing (ADON) stated that the resident's Influenza and Pneumococcal vaccination status was unknown and that the Licensed Practical Nurse (LPN) Unit Manager (UM) was checking into it right now. The ADON stated that the individual Nurse Managers on the units are responsible to monitor the resident's Influenza and Pneumococcal vaccination status and are to administer the vaccinations when indicated. During an interview on 1/9/17 at approximately 10:00 AM LPN #6 UM stated that the resident did not receive the Pneumococcal vaccination because there was no vaccine. The pharmacy delivery time after ordering a vaccine is usually one day. A review of Physician's Orders with the LPN UM on the computer system revealed that there was no order for the Pneumococcal vaccination. The LPN #6 UM further stated that she will obtain the order when the vaccine is administered. During an interview on 1/9/16 at approximately 12:00 PM the Medical Director (MD) stated that the facility has standing orders to administer the Influenza and Pneumococcal vaccinations. The status of the immunizations should be determined immediately upon arrival into the facility. When questioned about the lack of Physician's Orders for Influenza and Pneumococcal vaccination; the MD stated there should be standing orders on all the residents. 2. Resident #63 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/21/16 revealed the resident is cognitively intact and is understood and understands. Review of the admission Physician's Orders dated 12/14/16 revealed no orders for the Influenza of Pneumococcal vaccination. During an interview on 1/5/17 at approximately 1:02 PM, the ADON stated that the individual Nurse Managers on the units are responsible to monitor the resident's Influenza and Pneumococcal vaccination status and are to administer the vaccinations when indicated. The resident's vaccination status was not obtained until 1/5/17 when the surveyor asked about the resident's vaccination status. Review of the Immunization Audit Report dated 1/5/17 revealed the resident received the Influenza vaccination on 9/8/16 and the Pneumococcal vaccination on 9/3/15 3. Resident #151 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of admission Physician's Orders dated 12/6/16 revealed there were no orders for the Influenza of Pneumococcal vaccination. During an interview on 1/5/17 at approximately 1:00 PM with the ADON revealed that the resident was admitted from an assisted living center and the resident's vaccination status was unknown because the facility was still waiting for information regarding the resident's Influenza and Pneumococcal vaccination status. During an interview on 1/10/17 at approximately 7:39 AM, the Director of Nursing (DON) stated the facility does not currently have an Infection Control Nurse and the Administrative Nursing Staff are all assisting with infection control duties. 415.19 (a) (1)

Plan of Correction: ApprovedFebruary 6, 2017

The following corrective actions have been implemented for the deficiency cited:
#1
A)Resident #149. MD order has been obtained and the Pneumococcal vaccine administered
#2
A)Resident #63 vaccination record has been properly updated to show accurate date of receiving Influenza & Pneumococcal vaccinations
#3
A)Resident #151 vaccination status was obtained, updated and the resident received both Influenza and Pneumococcal vaccinations as per MD order
Additionally:
Residents #1,68,117,119,190,218 Have all had their medical record reviewed by Unit Manager and have received both the Influenza & Pneumococcal vaccines and have their individual vaccination record updated accordingly
The following actions have been completed to identify other residents within the facility that have the potential to be affected by this deficiency:
A)Every resident within the facility has had their medical record reviewed by perspective Unit Managers and their vaccination (Influenza & Pneumococcal)provided per MD order, vaccination record updated appropriately
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)The responsibility of Infection Control has been assigned to our Staff Educator RN to prevent misunderstanding of responsibility errors. The Director of Nursing will be responsible for these duties in the event the Staff Educator is unavailable.
B)A detailed tracking log has been developed to specifically track Influenza & Pneumococcal administration date, refusals, and this tool will be updated daily with the daily census changes to ensure every resident is reflected.
C)From (MONTH) 1st through (MONTH) 31st annually the above tracking log will be presented at reviewed by the Quality Assurance Committee during the monthly meeting.
D)The facility policy has been clarified to require individual MD orders for administration of Influenza and Pneumococcal vaccination
E)Compliance will be monitored through a monthly audit conducted by the Medical Records staff encompassing every residents record within the facility. This audit will be presented to the Quality Assurance committee on a monthly basis for review. Expectation and evaluation is 100% compliance either receiving vaccinations or documented declines related to medically contraindicated.
The Director of Nursing will be responsible for implementation and ongoing evaluation of this corrective action

FF10 483.35(g)(1)-(4):POSTED NURSE STAFFING INFORMATION

REGULATION: 483.35 (g) Nurse Staffing Information (1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law) (C) Certified nurse aides. (iv) Resident census. (2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. (3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. (4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and interview conducted during the Standard survey completed 1/10/17, the facility did not post the current resident census and the total number of actual hours worked by licensed and unlicensed nursing staff directly responisble for resident care on a daily basis, in a prominent place readily accessible to residents and visitors. The finding is: 1. Observations during the initital tour of the facility on 1/4/17 at approximately 9:20 AM revealed the required nurse staffing data was not posted in a prominent place readily accessible to residents and visitors. Additional observations were made throughout the survey by multiple surveyors on 1/4/17, 1/5/17, 1/6/17 and 1/9/17 between the hours of 8:00 AM and 3:00 PM to locate the nurse staffing data. During an interview on 1/9/17 at 9:30 AM, the facility Scheduler stated she has never posted a BIPA (Benefits Improvement and Protection Act) and did not know what information was required to be posted. Interview with the Director of Nursing (DON) on 1/9/17 at 9:40 AM revealed she realizes the licensed and unlicensed staffing hours need to be posted daily. The DON further stated that her start date at the facility was (MONTH) (YEAR) and thought that was the one thing she did not need to check into. Review of a facility Policy and Procedure entitled Posting Direct Care Daily Staffing Numbers dated 2006 revealed within two hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator.

Plan of Correction: ApprovedFebruary 6, 2017

The following corrective action has been implemented for the deficiency cited:
A) The facility Scheduler immediately began the practice of posting daily a complete BIPA report which includes
Facility name
current date
total actual hours worked by licensed & unlicensed staff (RN,LPN,CNA)
current census
B)A prominent place was identified for daily posting of the BIPA report (posting board in the main corridor)
The following actions have been completed to identify other residents within the facility that have the potential to be affected by this deficiency:
A)Entire facility was affected by this practice
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)Education/in-servicing provided to all nursing management staff (scheduler, supervisors, managers, administration) on the BIPA requirement and proper posting
B)The facility policy regarding BIPA posting has been reviewed, amended, and specifically detailed to enable a chain of responsibility for the shift postings
C)A daily audit of the BIPA posting will be conducted for 30 days to ensure compliance
D)the results of this audit will be reviewed with the Quality Assurance Committee during the monthly QA meeting
E)All BIPA postings will be retained as per policy for a period of 18 months from date of posting
The Director of Nursing will be responsible for implementation and ongoing evaluation of this corrective action

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Complaint Investigation (Complaint #NY 535) during the Standard survey completed on 1/10/17, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being. Specifically, four (Residents #23, 41, 93, 103) of 26 residents reviewed for quality of care had issues involving the lack of pain assessment for a resident receiving a routinely scheduled narcotic (Resident #41), the lack of an evaluation of pain when a pain medication was administered as needed (Resident #23); a resident not receiving pain medication as ordered by the Physician, failure to clarify the physician's orders [REDACTED].#93). In addition, the lack of a complete Physician treatment order for vascular wounds, the lack of a complete RN (Registered Nurse) assessment of the wounds and an incomplete treatment of [REDACTED].#103). The findings are but not limited to: 1. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/18/16 revealed the resident is cognitively intact, is understood and understands. Further review of the MDS revealed the resident received PRN (as needed) pain medication and non- medication interventions for pain. Review of the staff assessment for pain revealed the resident had vocal complaints of pain during the last five days and indicators of pain or possible pain were observed daily. Review of the Comprehensive Care Plan, review date 12/13/16 revealed the resident has pain related to surgery of the great toe and second toe of left foot. Interventions included to monitor, record and report to nurse the resident complaints of pain or requests for pain treatment. Review of the Medication Review Report revealed orders dated 9/12/16 to evaluate for pain every shift. Document verbal and nonverbal signs/ symptoms of pain every shift. Review of electronic Medical Record (eMR) Medication Review Report for the period of 11/1/16 to 1/9/17 and the Medication Administration Record [REDACTED]. This order was discontinued on 11/30/16. Further review of the Medication Review Report and the MARs for (MONTH) and (MONTH) (YEAR) revealed a physician's orders [REDACTED]. This order was discontinued on 12/19/16. An additional physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the MARs for (MONTH) and (MONTH) (YEAR) revealed instructions dated 9/12/16 for the nurse to evaluate for pain every shift and to document verbal/nonverbal signs and symptoms of pain every shift. Further review of the MAR for (MONTH) and (MONTH) (YEAR) revealed documentation of the resident's pain level at the time of administration of the [MEDICATION NAME] 10 mg throughout (MONTH) (YEAR) and continued to 12/19/16 at 8:00 AM. Continued review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR) revealed there was no further documentation of the resident's pain level from 12/19/16 through 1/6/17 despite the resident receiving [MEDICATION NAME] 10 mg by mouth every 6 hours. Review of the eMR Progress Notes from 12/1/16 through 1/5/17 revealed there was no evidence that the nurse documented the resident's complaints for pain or requests for pain treatment. Interview with the Licensed Practical Nurse (LPN #3) Medication Nurse on 1/6/17 at 12:31 PM revealed the nurse would obtain the resident's pain level with number value and document that pain level on MAR. LPN #3 further stated that a progress note is written if the resident has complaints of pain. Interview with the Unit Manager LPN #1 on 1/9/17 at 11:32 AM revealed the nurse is to obtain a pain rating for a resident receiving pain medication every shift. The Unit Manager further stated that all nurses should be aware of need to obtain the resident's pain rating. Review of policy entitled Administering Medications revised 12/12 revealed the following, As required or indicated for a medication, the individual administering the medication will record in the resident's medical record complaints or symptoms for which the drug was administered. 2. Resident #93 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Interview with the resident on 1/4/17 at 12:15 PM revealed she wasn't in any pain now because she has been getting her pain medicine regularly. The resident stated she receives [MEDICATION NAME] every 12 hours for pain and there was a time I didn't get it and should of. It was in August. The nurse Supervisor kept saying they didn't have it but it would be available in a few hours. In a few hours the resident stated she asked the next night supervisor for the [MEDICATION NAME] and she stated it still wasn't available. I expect to taper off of the [MEDICATION NAME] in the near future but I believe it could be dangerous to just abruptly discontinue it. Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. Review of electronic Progress Notes dated 8/16/16 and 8/17/16 revealed the system has identified a possible drug allergy for the following order: [MEDICATION NAME] Tablet 15 mg Narcotic. Give 15 mg by mouth every 12 hours for pain management. Additional review of the (MONTH) MAR indicated [REDACTED]. Interview with the Pharmacist on 1/9/17 at 12:00 PM revealed [MEDICATION NAME] ([MEDICATION NAME], Schedule ll narcotic pain medication) is not the same as [MEDICATION NAME] ER the nurses should have called the Physician regarding the alert and asked for a clarification. Additionally, the resident had PRN pain medication that could have been administered until they clarified the order. Review of the (MONTH) MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. The medication was administered twice on 8/19/16. The [MEDICATION NAME] ER 15 mg resumed on 8/18/16 at 9 PM. Review of an electronic Progress note dated 8/17/16 revealed HS [MEDICATION NAME] was unavailable at 9 PM supervisor spoke with resident that it would be here tonight. The Supervisor offered her PRN [MEDICATION NAME] to hold her over but resident refused, offered to call MD for something else on hand but resident refused wanting her usual [MEDICATION NAME]. Review of Omnicell Inventory list (audomated dispensing system that contains emergency medications) on hand) revealed [MEDICATION NAME] was available in the Omnicell. Interview with the Director of Nursing (DON) on 1/9/16 at approximately 9:30 AM stated she was unaware of the reason why the resident did not get the [MEDICATION NAME] on those particular days but would look into it. The DON stated there were no medication error reports regarding the lack of availability or administration of the [MEDICATION NAME] ER. It looks like they may have had an issue inputting the order. In Summary, the resident had an order for [REDACTED]. 3. Resident #103 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has moderate cognitive impairment, understands and is understood. Review of the current Care Plan dated 11/30/16 revealed the resident has fragile skin related to a [DIAGNOSES REDACTED]. Review of a wound consultant note written by the Nurse Practitioner (NP) dated 8/3/16 revealed the resident had the following wounds on the right leg: 1) Right lateral mid-calf full thickness ulceration 1.2 centimeter (cm) in Length(L) by (x) 1.5 cm in width (W) and 0.0 cm in Depth (D) with 100% slough (dead tissue) at the wound base with moderate non-serous drainage 2) Right lateral mid-calf full thickness ulceration 0.5 cm L x 2.5 cm W x 0.0 cm D with wound base - 100% granular (new tissue growth) 3) Right lateral distal calf full thickness ulceration 1.0 cm L x 1.5 cm W x 0.0 cm D with wound base - 100% granular 4) Right posterior proximal calf full thickness ulceration 2.0 cm L x 1.0 cm W x 0.0 cm D wound base - 100% slough 5) Right lateral distal calf full thickness ulceration 1.0 cm L x 1.0 cm W x 0.0 cm D wound base - 100% slough. Review of a wound consult note date 8/31/16 revealed wounds 1 & 5 were resolved and measurements and treatment were ongoing for wounds 2, 3 & 4. Review of wound consultant notes dated 9/21/16, 9/28/16 10/5/16 10/12/16, revealed the patient would not allow measurements, the resident had wounds 2, 3 & 4; however, they were not measured. There were no further wound consult notes until 11/2/16 which documented that the resident had multiple full thickness ulcerations on the right lower extremity and the resident would not allow measurements. Wound consult notes dated 11/9/16, 11/30/16, 12/14/16, 12/21/16 12/28/16 and 1/4/17 also documented that the resident had multiple full thickness ulcerations on the right lower extremity and the resident would not allow measurements. Additional review of the 12/14/16, 12/21/16, 12/28/16 and 1/4/17 wound consultant NP note indicated that the resident has improved multiple vascular venous ulcerations of the right lower extremity with plans to cleanse the wound with normal saline or wound cleanser, and apply [MEDICATION NAME] to affected areas twice a day. Review of physician's orders [REDACTED]. Review of the (MONTH) and (MONTH) Medication Administration Record [REDACTED]. During an observation on 1/09/17 at approximately 10:00 AM revealed the Licensed Practical Nurse (LPN #3) entered the room to complete the treatment on the resident's right leg wounds. The dressing on the right leg was not dated and signed. Prior to starting the treatment, the resident told the LPN to be gentle because the last treatment hurt like hell. LPN #3 removed the cling and there was one [MEDICATION NAME] dressing on the anterior (front) shin, right outer ankle and two on the posterior (back) calf. The LPN poured normal saline on all four [MEDICATION NAME] dressings prior to removing them. When the LPN removed the [MEDICATION NAME] each dressing was soiled with yellow-brownish drainage. The LPN did not cleanse the wounds after removing the dressing; however, each wound was wiped with a dry 4x4 gauze dressing. The LPN then used one wooden applicator to apply [MEDICATION NAME] 1% to a cluster of five visible ulcerations on the right shin, and to the two cluster of ulcerations/areas on the right posterior calf. The LPN then stated she was going to apply the kerlix (without applying [MEDICATION NAME] to the right outer ankle ulceration). The surveyor questioned the LPN treatment nurse about the right ankle ulceration. LPN #3 wiped the ankle ulcer with a 4x4, determined it was open and applied [MEDICATION NAME] cream 1 % with a separate wooden applicator. During an interview on 1/9/17 at approximately 10:20 AM, LPN #3 stated that she has completed the resident's leg treatments for the past month and the areas have been improving. LPN #3 also stated that the four general areas have been consistent and are followed by the wound consultant. During an interview on 1/10/17 at approximately 7:20 AM, the Director of Nursing (DON) stated that a facility RN accompanies the NP wound consultant for the weekly skin evaluations and the treatment is directed by the wound consultant. For this resident either the RN Assistant Director of Nursing (ADON) or the LPN Unit Manager accompanies the NP wound consultant. The DON stated that Resident #103 has an order to apply [MEDICATION NAME] cream 1% topically to open wounds on her bilateral lower extremities, every day shift, and cover with [MEDICATION NAME]. The DON stated the treatment order should include the directions for cleansing. If the wounds have yellow- brownish slough, then wound cleanser should be used. The DON stated that she last saw the resident's wounds on 12/7/16 and she measured the wounds on the right leg because the wound consultant was not in the facility that week. During an interview on 1/10/17 at approximately 7:42AM, the ADON stated she has accompanied the NP wound consultant and the NP does not measure the ulcerations/areas because there are too many multiple areas; she doesn't even attempt to measure them. The ADON stated that the treatment order should include cleansing instructions. During an interview on 1/10/17 at approximately 8:10 AM, the Licensed Practical Nurse (LPN #1) Unit Manger (UM) stated that usually she obtains treatment orders from the NP. LPN #3 UM stated she obtained and transcribed the 12/15/16 treatment order without clarifying instructions for the wound cleansing. In addition, the LPN #3 UM stated when she accompanies the NP, the NP does not measure the wounds because there are so many. During an interview on 1/10/17 at approximately 11:06 AM, the wound consultant NP stated that she conducts wound rounds on Wednesdays between 7:30 AM - 8:30 AM. The NP stated that the resident becomes very agitated when she tries to measure the wounds and she has had milk thrown at her and kicked by the resident, so she treads lightly. The NP stated that she writes her recommendations on a consult form and the nurses usually get the orders from them and she is certain she provided instructions to cleanse the wound along with the treatment. 415.12(c)(2)

Plan of Correction: ApprovedFebruary 6, 2017

The following corrective actions have been implemented for the deficiency cited:
#1 & #2
A)Resident #41,#23,#93 have had a RN Pain assessment completed and MD made aware of current findings. Pain management interventions/medications have been adjusted accordingly
#3
B)Resident # 103 had a complete body assessment by the consultant wound NP and the Director of Nursing. All wounds have been properly identified, measured, and classified. Treatment orders have been clarified by residents physician to include instructions for proper cleaning, treatment and dressing of each wound
The following actions have been completed to identify other residents within the facility that have the potential to be affected by this deficiency:
#1 & #2
A)Each resident within the facility has had a complete pain review assessment conducted by RN and current findings reported to the appropriate resident physician for intervention where appropriate
#3
B)Each resident with a pressure ulcer, wound has been assessed by the Director of Nursing and Nurse Managers as well as the Consultant wound NP. Each resident, each wound has been identified and completely measured.
C)All residents within the facility receiving any wound care has had the MD treatment order reviewed to ensure the order has complete instructions for cleaning, treating, dressing as individually indicated
The following systemic changes have been implemented to ensure continued compliance with the regulation:
#1
A)All RN,LPN,CNA nursing staff have been reeducated/in-serviced on verbal/non-verbal indications of pain by Staff Educator. Policy of prompt reporting indications of resident pain reinforced to all nursing staff.
B)All RN,LPN nursing staff in-serviced on available inventory of pain management medications contained in the facility Omnicell. The inventory of the Omnicell has also been reviewed by the facility Medical Director to increase availability and alternatives of various pain medications.
C)Each resident within the facility will continue to have complete pain assessment by RN designee monthly x 3 months with the results of these audits being reported to the facility monthly Quality Assurance Committee.
D)Each new admission will have a pain assessment completed within 3 hours of admission to the facility with MD notification for interventions
E)Each new admission to the facility will be interviewed by the Director of Nursing or designee within 24 hrs of admission to ensure any pain management interventions are satisfactory and timely. The Director of Nursing will report resident feedback from her interviews to the monthly Quality Assurance Committee.
#3
A)The policy/practice within the facility has been amended to utilize a wound team weekly for wound assessments. The consultant NP is wound certified as facility staff currently are not. This wound team will consist of (consultant wound NP, DON or designee, Nurse Manager of residents unit, Registered Dietician and Therapy Department Designee) each ensuring that wound assessments are complete and accurate. Each discipline will address their specific area of focus ensuring wounds are being addressed multidisciplinary.
B)A detailed report of each resident, each wound will be provided by the wound team and reported to the facility Quality Assurance Committee monthly. Nutritional support and therapy review will be included in the assessments of this report.
C)The Staff Education Nurse will provide reeducation/in-servicing on wound care, proper application of treatments, dressings to all RN,LPN staff.
D)The Staff Education Nurse will audit nurses during actual wound treatments to residents, ensuring proper cleaning,
application of treatment, dressing has been appropriately completed as per MD order. Every staff nurse will be audited over the next 30 days until successfully completing this duty. Results of these audits will be reported to the facility Quality Assurance Committee until 100% is achieved, then audits will become semi annual and ongoing.

The Director of Nursing will be responsible for implementation and ongoing evaluation of this corrective action plan

Standard Life Safety Code Citations

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Life Safety Code survey completed on 1/10/17, the building ' s fire alarm system was not properly maintained. Issues included sensitivity testing that was not conducted on the building ' s smoke detectors at least every other year and sensitivity testing that was not conducted on smoke detectors within one year of their installation. This affected the the fire alarm system installed throughout the entire building including three (Unit's #1, 2, 3) of three resident units. The findings are: 1. Review of Fire Alarm Inspection Reports on 1/5/17 revealed the following: - The building ' s fire alarm system was inspected and tested on [DATE], 5/24/16, and 11/13/15. Sensitivity testing was not conducted on any of the building's smoke detectors during these inspections. - Sensitivity testing was conducted on smoke detectors located on Unit 3 and a portion of Unit 2 on 5/21/15. Three smoke detectors failed their sensitivity testing at that time. - Review of a Service Request report from the outside contractor that conducted the 5/21/15 inspection of the building's fire alarm system revealed the three smoke detectors that failed their sensitivity testing on 5/21/15 had been replaced on 5/26/15 and sensitivity testing was not conducted on the replaced smoke detectors at that time. - The last time sensitivity testing was conducted on all of the building ' s smoke detectors was on 11/5/14 and 5/7/14. Interview with the Maintenance Director on 1/5/17 at approximately 11:05 AM revealed he had spoken to a representative of the contractor that inspected and tested the building's fire alarm system and sensitivity testing was not conducted on the three smoke detectors that were installed on 5/26/15. Further interview with the Maintenance Director at this same time revealed sensitivity testing was not conducted on every smoke detector in the facility in (YEAR) or (YEAR) The last time sensitivity testing was not conducted on the all of the building ' s smoke detectors was on 11/5/14 and 5/7/14. Continued record review revealed smoke detectors on Unit 1 and Unit 3 were sensitivity tested on [DATE], and smoke detectors on Unit 1 and Unit 2 were sensitivity tested on [DATE]. Per the 2010 edition of the National Fire Protection Association, NFPA 72: National Fire Alarm and Signaling Code: Smoke detector ' s sensitivity testing shall be checked within one year after their installation and smoke detector sensitivity testing shall be checked every alternate year thereafter. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 9.6.1.3 2010 NFPA 72: 14.4.5.3.1, 14.4.5.3.2 2000 NFPA 101: Chapter 19

Plan of Correction: ApprovedFebruary 3, 2017

The following corrective actions have been completed for the deficiency cited:
A)Service contractor was immediately contacted and every smoke detector within the facility was tested for sensitivity on 1/16/17.
All detectors within sensitivity range this latest inspection.
The following actions have been completed to identify other residents within the facility that have potential to be affected by this deficiency:
A)The entire facility had potential to be affected by this deficiency
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)Entire full facility testing of smoke detector sensitivity will be scheduled within two years of the latest successful inspection (1/16/17)
B)Policy has been developed and our service contractor made aware that any replacement detectors will have sensitivity test completed upon instillation.
C)Smoke detector sensitivity testing dates including last facility test date and next scheduled full facility testing date will be added to the Maintenance Directors monthly report and will be provided for review to the facility Quality Assurance Committee for the monthly meeting
The Director of Maintenance will be responsible for implementation and ongoing evaluation of this corrective action

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 1/10/17, fire drills were not properly conducted. Issues included fire drills that were not conducted under varied times and conditions. This affected the entire building including three (Units 1, 2, 3) of three resident units. The findings are: 1. Review of Fire Drill Evaluation forms on 1/4/17 revealed second shift (3:00 PM to 11:00 PM) fire drills that were conducted between 2/26/16 and 12/30/16 were not conducted under varied conditions, nor at varying times on the following dates: 4/4/16 9:45 PM Resident room [ROOM NUMBER] 7/3/16 9:30 PM Resident room [ROOM NUMBER] 8/6/16 8:58 PM Side 1 Center Hall/Social Work office 10/12/16 9:45 PM Resident room [ROOM NUMBER] Interview with the Maintenance Director on 1/4/17 at approximately 3:34 PM revealed the Registered Nurse (RN) Night Supervisor had conducted the Second Shift Fire Drills. Interview with the Maintenance Director on 1/5/17 at approximately 10:43 AM revealed the facility conducted second shift fire drills between 3:00 PM and 11:00 PM and the facility had not conducted any other Second Shift Fire Drills between 2/26/16 and 12/30/16 besides the drills that were conducted on 4/4/16, 7/3/16, 8/6/16, and 10/12/16. Further interview with the Maintenance Director at this time revealed he was not aware the fire drills were conducted so close together in time and location. Review of the facility's floor plan on 1/6/17 revealed the Side 1 Center Hall/ Social Work office was located three resident rooms away from Resident room [ROOM NUMBER]. Observation on 1/6/17 at approximately 1:05 PM revealed the Side 1 Center Hall/ Social Work office was located approximately 58 feet away from Resident room [ROOM NUMBER]. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.7.1.6, 4.7, 4.7.4 2000 NFPA 101: Chapter 19

Plan of Correction: ApprovedFebruary 9, 2017

The following corrective actions have been implemented for the deficiency cited:
A)The Maintenance Director conducted a second shift fire drill on both unit 2 & 3 (the two units that did not receive a drill during (YEAR)) on two separate dates to ensure staff responded appropriately.
The times were 3:00 PM & 7:00 PM
The following actions have been completed to identify other residents within the facility that have potential to be affected by this deficiency:
A)The entire facility was affected by this practice
The following systemic changes have been implemented to ensue continued compliance with this regulation:
A)The practice of utilizing the off shift Nursing Supervisor to conduct a fire drill has been eliminated. Only the maintenance director or maintenance staff designee will conduct future fire drills. All maintenance staff have been thoroughly in-serviced on requirements of conduction fire drill once per shift per quarter, at various times under a variety of conditions. (various times, alternating units, various staff)
B)The Maintenance Director will determine time, and location of future fire drills to ensure variety of locations involving the entire facility and times are covered
C)The fire drill log will be presented at the monthly Quality Assurance meeting and reviewed each month on an ongoing basis. QA committee will ensure that log accurately reflects fire drills are being completed once per shift per quarter at various times under varying conditions.
D)Nursing Administration/management (DON,ADON, Staff Education RN,Unit manager, Supervisor)have also been in-serviced on requirements of having drills once per shift, per quarter, at various times under varying conditions and will audit all future fire drills conducted by Maintenance Director or Maintenance department designee. These audits will be presented to the Quality Assurance Committee on a monthly basis at the monthly QA meeting in addition to the fire drill log.
The Maintenance Director will be responsible for implementation and ongoing evaluation of this corrective action

K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 1/10/17, an oxygen cylinder was not properly secured. Issues included an oxygen cylinder that was not protected from potential abnormal mechanical shock, from falling. This affected one (oxygen storage/ oxygen trans-filling room) of one oxygen storage/ oxygen trans-filling room. The findings are: 1. Observation on 1/4/17 at approximately 11:38 AM revealed one E sized oxygen cylinder, in a two wheeled cart, was suspended approximately one foot above the concrete floor, at an approximately 45 degree angle, between two other two wheeled carts in the oxygen storage/ oxygen trans-filling room. Further observation at this time revealed one of the two wheeled carts that the oxygen cylinder was suspended from, contained one E sized oxygen cylinder and the other two wheeled cart contained one H/K sized oxygen cylinder. Continued observation at this time revealed the suspended oxygen cylinder was obscured from view by four, approximate 100 pound liquid oxygen canisters. Interview with the Maintenance Director at the time of the observation revealed he was not sure who had stored the oxygen cylinder in this manner. Per the 2012 edition of the National Fire Protection Association, NFPA 99: Health Care Facilities Code: Oxygen cylinders shall be protected from damage by abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 11.6.2.3, 11.6.2.3(1) 2000 NFPA 101: Chapter 19

Plan of Correction: ApprovedFebruary 3, 2017

The following corrective actions have been implemented for the deficiency cited:
A)The suspended E oxygen tank in the oxygen storage room was immediately removed and properly stored
The following actions have been completed to identify other residents within the facility that have potential to be affected by this deficiency:
A)A full facility audit was conducted to identify any improperly stored oxygen cylinders
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)All facility staff have been reeducated/in-serviced on proper oxygen storage.
B)The oxygen storage area will be audited daily X3 months by maintenance director or designee to ensure compliance
C)A facility wide audit will be conducted weekly X3 months to identify any improper oxygen storage beyond the designated storage area.
D)The results of these audits will be reported and reviewed by the facility Quality Assurance Committee during the monthly QA meetings

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: March 10, 2017

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 1/10/17, smoke barrier walls were not properly maintained. Issues included smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30 minute fire resistance rating, and were not designed to resist the passage of smoke, due to unselaed and improperly sealed penetrations. This affected two (Units #1, 2) of three resident units and the smoke barrier wall located at Activities Assistant's Office/ Activities Storage Room. The findings are: 1. Observation on Unit 1 on 1/9/17 at approximately 9:33 AM revealed an approximate one half inch, circular, unsealed penetration through the smoke barrier wall in Resident Room #173. Interview with the Maintenance Director at the time of the observation revealed the resident's wardrobe had recently been moved and the penetration through the wall was from the anchor bolt that was used to secure the wardrobe to the wall. 2. Observation above the ceiling tiles on Unit 1 on 1/9/17 at approximately 9:37 AM revealed an approximate five foot long section of four inch long by two inch wide penetrations between the gypsum board smoke barrier wall and the corrugated roof deck were filled with pink colored fiberglass insulation that was not sealed with a fire rated material. Further observation revealed these penetrations were located through the smoke barrier wall that separated the Unit 1 corridor from the Minimum Data Set (MDS) office. Continued observation at this time revealed an approximate ten inch long by ten inch wide penetration through the smoke barrier wall was filled with mineral wool that was not sealed with a fire rated material. Review of the facility's floor plan, with the Maintenance Director, at this time of observations revealed this was a smoke barrier wall. Interview with the Maintenance Director at this same time revealed this was a smoke barrier wall and the areas must have been missed when the Maintenance Department was inspecting the building ' s smoke barrier walls. 3. Observation above the ceiling tiles on Unit 2 on 1/9/17 at approximately 10:06 AM revealed an approximate six inch long by two inch wide unsealed penetration through the smoke barrier wall located above the corridor smoke barrier doors near Resident Room #227. Further observation at this time revealed the unsealed penetration was located in front of a steel beam that ran perpendicular to the smoke barrier wall. 4. Observation above the ceiling tiles on 1/9/17 at approximately 10:32 AM revealed an approximate three inch long by one inch wide penetration, through the smoke barrier wall, above the corridor smoke barrier doors, located by the Activities Assistant ' s Office/ Activities Storage Room, was filled with pink colored fiberglass insulation that was not sealed with a fire rated material. Further observation at this time revealed the penetration was located above an insulated pipe that was installed through the smoke barrier wall. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2 2000 NFPA 101: Chapter 19

Plan of Correction: ApprovedFebruary 3, 2017

The following corrective action has been implemented for the deficiency cited:
#1
A)The one half inch circular penetration through the smoke barrier wall on unit one was appropriately sealed
#2
A)The five foot long 4 inch by 2 inch penetration between the gypsum board wall and the corrugated roof deck on unit 1 corridor has been properly sealed with fire rated material. The 10 inch wide area penetration filled with mineral wool was appropriately sealed with fire rated material
#3
A)The six inch long by two inch wide penetration above room #227 has been appropriately sealed with fire rated material
#4
A)The three inch long by one inch wide penetration above the smoke barrier doors by the Activities Assistant office has been appropriately sealed
The following actions have been completed to identify other residents within the facility that have potential to be affected by this deficiency:
A)The Maintenance Director has completed inspection of all fire barrier walls throughout the facility to further identify any penetrations
The following systemic changes have been implemented to ensure continued compliance with the regulation:
A)The maintenance director has developed a detailed audit clearly outlining all fire barrier walls within the facility, and dividing the facility into 4 areas(3 nursing units, lobby & dining area)
B)The maintenance staff will audit each area fire wall completely monthly x 3 months then quarterly on an ongoing basis
C)Maintenance staff conducting these audits will alternate areas each time to allow a variety of different maintenance staff to assess the different areas. (dividing the facility into 4 separate audits and having different staff alternate sides will promote more thorough inspection results)
D)All Maintenance staff have been reeducated/in-serviced on fire code relating to smoke barrier penetrations and properly sealing with fire rated materials
E)All Maintenance staff have been reeducated/in-serviced on properly sealing anchor holes in walls when the move residents furniture
F)The results of these monthly audits will be reported and reviewed to the Quality Assurance Committee during the monthly QA meeting
The Director of Maintenance will be responsible for implementation and ongoing evaluation of this corrective action