Willow Point Rehabilitation and Nursing Center
September 28, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(a)(b):ADLS DO NOT DECLINE UNLESS UNAVOIDABLE

REGULATION: (a) Based on the comprehensive assessment of a resident and consistent with the resident?s needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: (1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section, ? (b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: (1) Hygiene -bathing, dressing, grooming, and oral care, (2) Mobility-transfer and ambulation, including walking, (3) Elimination-toileting, (4) Dining-eating, including meals and snacks, (5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2017
Corrected date: November 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews conducted during the recertification survey, it was determined the facility did not ensure the ability to perform ADLs did not diminish for 1 of 2 residents (Resident #29) reviewed for activities of daily living (ADLs). Specifically, Resident #29 was not assisted timely with toileting and did not have his call bell within reach. Findings include: Resident #29 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, could respond adequately and understood simple, direct communication. The resident required extensive assistance of one person for transfers, toileting, dressing, and hygiene. The comprehensive care plan (CCP) revised 7/24/2017, documented the resident: - had ADL self-care deficits related to dementia and bilateral [MEDICAL CONDITION]; - was alert and confused, able to use the call bell, and spoke clearly; - had the potential for skin impairment related to decreased mobility and incontinence; - had functional bladder incontinence and drank large amounts of coffee during the day; and - was at risk for falls and had a history of [REDACTED]. Interventions on the 7/24/2017 revised CCP included: - anticipate and meet the resident's needs; - provide toileting assistance upon rising, before/after meals, and as needed; - provide incontinence care every two hours and as needed; and - ensure the call light was within reach and encourage the resident to use it for assistance as needed. The undated Kardex report (direct care instructions) documented the resident's call light was to be within reach and to encourage the resident to use it. The resident required assistance of one person for toileting and was to be toileted upon rising, before and after meals, at bedtime, and was to be provided incontinence care every two hours and as needed. On 9/29/2017, the following was observed: - At 9:25 AM, the resident was in bed, the call light was out of his reach, and was hanging on the bed frame under the head of the bed. The resident asked the surveyor for assistance as he could not find his call light and had to use the bathroom. - At 9:26 AM, the resident's call light was activated. - At 9:27 AM, certified nurse aide (CNA) #5 entered the resident's room and left within 2 minutes. - At 9:45 AM, the resident called out from his bed he needed to use the bathroom and told the surveyor he had not been toileted yet. - At 9:46 AM, the call light was activated. - At 9:56 AM, the call light was turned off by an unidentified staff member. - At 10:13 AM, licensed practical nurse (LPN) #8 approached CNA #5 and told her the resident needed to use the bathroom. During an interview with CNA #4 on 9/29/2017 at 9:50 AM, she stated the resident used his call light sometimes, could make his needs known, used the toilet, was incontinent at times, and he should be toileted after breakfast. When interviewed on 9/29/2017 at 10:02 AM, CNA #5 stated she responded to the resident's call light earlier and he said he had to use the bathroom. She stated she did not take him to the bathroom, did not offer the urinal, as he sometimes did not really have to go when he called. She stated if he called again she would take him, he had not called again, and no one reported to her he had called. She stated the resident did not always use his call light, she was aware it was out of reach, and he was last toileted between 7:30 - 8:00 AM. When interviewed on 9/29/2017 at 10:30 AM, LPN #6 charge nurse stated the resident made his needs known by calling out to staff, he should have his call light in reach, and if he stated he had to use the bathroom, he should have been taken at the time or offered a urinal. The resident could walk to the bathroom with a walker and staff assistance and he should have been taken to the bathroom after breakfast. She stated 45 minutes was not an acceptable time for answering a call for toileting assistance. When interviewed on 9/29/2017 at 11:20 AM, LPN #8 stated she approached CNA #5 an hour prior because she was giving the resident his medications and he stated he needed to use the bathroom. She recalled the resident's call light was on prior to going into his room and it was off when she entered his room. During a follow up interview with CNA #5 on 9/29/2017 at 12:15 PM, she stated the resident's incontinence briefs were wet when she took him to the bathroom at 10:13 AM. 10 NYCRR 415.12(a)(1)(iii)

Plan of Correction: ApprovedDecember 4, 2017

1. Resident #29
CNA #5 was counseled by LPN #8 regarding her responsibility to toilet residents timely and to ensure the call bell is within reach.
2. All residents have been identified as potentially being affected by the same practice.
3. The Administrator, Medical Director, and Director of Nursing will continue to review and revise as needed policies and procedures related to resident ADLs.
Facility Clinical Care Coordinators or designees will monitor for compliance with ensuring resident call bells are within reach and that residents are toileted timely upon request. Immediate corrective action, including staff education, will be implemented as needed.
Education was provided to all part and full time staff regarding facility policies and procedures on ADL care. Educational emphasis was placed on ensuring call bell is within reach of resident, that residents are toileted timely upon request, and that all staff are responsible to answer lights and if unable to provide care that they notify the appropriate staff.
4. The facility developed an audit tool to monitor compliance with facility policies and procedures related to call bell placement and timeliness of toileting.
Facility Supervisors or designee will audit 1 resident on each unit during each shift daily for 3 months and report findings to the Director of Nursing. Corrective action will be implemented as indicated.
Director of Nursing or designee will report audit findings to Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: The Director of Nursing

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2017
Corrected date: November 17, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure food was stored and prepared under sanitary conditions for the main kitchen. Specifically, the main kitchen had standing water located under and around cook surfaces. Findings include: On 9/26/2017, between 10:41 AM and 11:21 AM, a kitchen tour was conducted with the Food Service Manager. The surveyor observed the hose reel next to the kettle was leaking water onto the ground. The surveyor then observed a two-inch-deep section of standing water that was slowly flowing down the slope of the main kitchen floor and pooling on the floor of the staff bathroom. During an interview on 9/27/2017, between 10:41 AM and 11:21 AM, the Food Service Director stated the hose reel next to the kettle leaks water whenever it is turned on, and it was turned on during the time of survey. She stated the hose reel should have been turned off because it was only used by staff to spray clean the main kitchen and that did not happen until later in the day. She stated she did not use the main kitchen staff bathroom and was not aware of the water pooling in that room. During an interview on 9/27/2017 at 6:00 PM, the Plant Operations Director stated the water dripping/leak in the main kitchen was not brought to his attention until he received a verbal work order request, and it was immediately corrected by insulating the water pipes and replacing the braided line. He could not determine the location of the leak because the kitchen was a wet area. 10NYCRR 415.14(h)

Plan of Correction: ApprovedDecember 4, 2017

1. The hose reel next to the kettle was repaired to prevent additional leakage and the standing water was cleaned.
2. All kitchen areas have been identified as potentially being affected by the same practice.
3. All part and full time dietary staff were re-inserviced on need for floors to be free of standing water.
4. The facility developed an audit tool to monitor compliance with federal and state regulations related to standing water.
The Food Service Manager will audit the kitchen weekly for three months for evaluation and follow-up. Corrective action will be implemented as indicated.
The Food Service Director or designee will report audit findings to Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Food Service Director

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2017
Corrected date: November 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview conducted during the recertification and abbreviated survey (NY 115), it was determined the facility did not consistently provide a safe environment and adequate supervision for 1 of 3 residents reviewed for accidents. Specifically, Resident #31 was missing from the facility and authorities were not notified timely. Findings include: The facility's policy for missing residents dated 5/2014, documented when a resident was determined to be missing from the unit: - The Unit Manager or Supervisor was notified; - The unit called a Code Grey (missing resident) using the intercom system; - The Unit Manager or Nursing Supervisor notified Administration and Nursing Administration; - A thorough search was coordinated and a command center was set up for all searchers to report to; - The family was notified by the nursing supervisor or social services; and - If the resident was not found the town police and county security departments were to be notified. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognitive status was intact and he required assistance with transfers, dressing, toilet use and personal hygiene. The medical history and physical (H&P) note dated 4/5/2017, documented the resident was admitted to the facility after a hospitalization for an episode of unconsciousness. The resident had ESRD and was non-compliant with his dialysis and diabetes and blood pressure medications. A nursing progress notes dated 4/9/2017 at 11:54 PM and 4/10/2017 at 12:19 AM, documented the resident called 911 thinking he was having a stroke. On assessment, his gaze was unfocused and a neurological examination was incomplete due to his left sided weakness and headache. The resident then vomited; his blood sugar was 76; and he complained of having a panic attack. The resident left the facility via ambulance at 12:05 AM and was transferred to the Emergency Department. The nurse practitioner (NP) note dated 4/10/2017, documented the resident developed anxiety symptoms over the weekend and dialed 911. The resident had a history of [REDACTED]. A urine specimen was ordered to test for cocaine to make sure he did not receive any from visitors over the weekend. The registered nurse (RN) progress note dated 4/11/2017 at 11:59 AM, and the NP's note dated 4/11/2017, documented the urine screen was positive for cocaine and the RN and NP spoke to the resident about his test results. The resident denied any illegal drug use since admission and denied any of his weekend visitors gave him drugs. The resident stated he wanted to leave AMA (against medical advice), the NP explained the risks and benefits to the resident, and he agreed to stay at the facility and have supervision when visitors were at the facility. There was no documented evidence Resident #31's CCP or certified nurse aide (CNA) care card (Kardex, care instruction) was updated to include the resident's desire to leave the facility AMA. The physicians order dated 4/12/2017, documented to give the resident Ativan 0.5 milligrams (MG) 1 every 4 hours as needed for panic attacks. The 4/13/2017 medication administration record (MAR) documented Resident #31 received a dose of Ativan at 7:29 PM. RN #20's progress note dated 4/13/2017 at 11:57 PM, documented the resident was observed in his room at 7:25 PM during medication pass and was given Ativan as requested. The resident was seen walking in the hall and said he was going to the TV room and was observed sitting down in the TV room. At 9:11 PM, the resident was not in his room when the nurse went to administer his insulin. RN #20 documented he checked the TV room, questioned the resident's roommate, and told the charge nurse (LPN #21). RN #20 checked the porch and the parking lot and the certified nurse aide (CNA) did a room to room check. The supervisor (LPN #17) was notified and the NP was updated. Calls were made to the resident's cell phone and his girlfriend's cell phone with no answer. RN #20's progress note dated 4/14/2017 at 12:39 AM, documented the resident was out of the facility without permission and had not returned. The LPN progress note dated 4/14/2017 at 11:08 AM, documented the resident remained out of the facility and was considered officially discharged AMA at 9:11 PM on 4/13/2017. The undated facility summary report of the investigation, written by the Associate Director of Nursing (ADON, RN #16), documented the resident was last observed on the unit at 7:25 PM after he received his medication and staff were unable to locate him at 9:56 PM. The summary documented the LPN Supervisor was notified, a Code Grey (missing resident) was initiated, the facility and grounds were searched, attempts were made to contact the resident and his significant other, and the Administrator and DON were notified. The summary documented on 4/14/2017 the ADON notified the facility's security department and stated the resident had left the faciity on [DATE] against medical advice. She asked security to check his last known address to see if he was there. The summary documented the resident left the facility independently on 4/13/2017 during the evening shift without notifying anyone. The summary report documented the resident failed to return and left the facility AMA. The incident report from the security department dated 4/14/2017 at 8:12 AM, documented the ADON reported the resident was missing from the facility and he was last seen on 4/13/2017 at approximately 9:00 PM. The security department conducted a thorough search of the facility, grounds, and a nearby cemetery. A mini command center was set up. The investigation included contacting local police departments, the Sherriff's Department, NYS(NAME)Rangers, local hospitals, established medical providers, bus and cab companies, and the resident's acquaintances. The resident was located at a friend's house at 1:00 PM on 4/14/2017. When interviewed by security, the resident stated he walked out of the facility at 9:00 PM on 4/14/2017 without telling staff, received a ride from a stranger and was dropped off at a store and bought beer. He then went to a bar, obtained cocaine and marijuana and went to his friend's house. The report documented during the conversation with security the resident stated he wanted to harm himself and emergency services were notified and he was taken to the hospital. A statement dated 4/17/2017 by the LPN Supervisor, documented when the resident was missing, staff searched the unit and she searched the facility grounds for 8 minutes and did not find him. She checked his room and noticed all his belongings were still there. She called a Code Grey and had the units do a head count. The NP, Medical Director, DON, and Administrator were notified. The Administrator told her there was nothing more that needed to be done and they could wait and see if the resident returned. The LPN Supervisor typed a time line of the events for the Code Grey on 4/13/17 starting at 9:56 PM and ending at 10:30 PM. She left the time line for the DON and ADON to see in the morning. When interviewed on 4/25/2017 at 9:30 AM, RN #16 (ADON) stated she was made aware the resident left the facility when she came to work the morning of 4/14/2017. She stated she did not know if the resident was care planned regarding his ability to leave the facility on his own or with a responsible party. She stated when the staff determined the resident was not in the facility a search of facility and grounds was conducted and the resident was not located. She stated the Administrator was notified when the resident left and he determined the resident left AMA. She stated she notified the facility security department at approximately 8:00 AM the following morning on 4/14/2017 and informed them the resident left AMA the previous evening. She stated she reviewed the investigation and concluded the resident left the facility AMA and that was not an elopement. When interviewed on 4/25/2017 at 10:02 AM, the Director of Nursing (DON) stated when the resident was missing, a search was conducted in the facility. She stated the facility security department was notified the following day that the resident had left AMA the previous evening. She stated she was notified of the missing resident and in conjunction with the Administrator they determined the resident left the facility AMA as he could make his own decisions. She stated she did not consider the incident an elopement. When interviewed on 4/25/2017 at 4:07 PM, LPN #21 stated she was working on the unit the evening of 4/13/2017 and when RN #20 told her the resident was missing, she checked his room. She stated the resident left all his belongings including his backpack that he took everywhere. The supervisor was notified and a Code Grey was started. She said she tried to call the number for his significant other and other numbers in his medical record. She stated she called the NP as the resident left without a responsible party and did not have a physician order [REDACTED]. When the NP was asked if the police should be called, she said it was up to the Administrator. When interviewed on 5/5/2017 at 11:41 AM the Administrator stated he determined the resident left AMA as he was alert and oriented, took his phone and charger and left without telling anyone. He stated the residents belonging were in his room and were packed up and given to facility security the following day after the incident. He stated the nurse assigned on the unit used the Code Grey protocol (missing person) to ensure he was not in the building and once the facility was searched we knew he left. He stated he notified security the following day to alert them the resident left the facility the previous evening and to inform them the resident was discharged from the facility, and was not to return. When interviewed on 12/29/2017 at 12:17 PM the Administrator stated if a resident left the facility without staff knowledge, the resident was considered a missing resident, the facility elopement policy would be initiated, and the police would be notified. 10NYCRR 415.12(h)(1)(2)

Plan of Correction: ApprovedDecember 4, 2017

1. Resident #31 no longer resides within the facility.
2. All residents have been identified as potentially being affected by the same practice.
3. The Administrator, Medical Director, and Director of Nursing will continue to review and revise as needed policies and procedures related to missing residents.
The Director of Nursing or designee will monitor for compliance with missing resident policy and procedure. Policy updated to include that facility will conduct one drill per shift per month and staff assignments during a Code Grey.
Education was provided to all scheduled staff and agency staff regarding facility policies and procedures on missing residents and discharges against medical advice. Educational emphasis was placed on ensuring that when a resident cannot be located that a code grey is called and if after a search of the facility the resident cannot be found then the authorities will be contacted.
4. The facility developed an audit tool to monitor compliance with facility policies and procedures related to missing residents.
The Director of Nursing or designee will conduct 1 code grey drill per shift per month and will report findings to the Administrator. Corrective action will be implemented as indicated.
Director of Nursing or designee will report audit findings to Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Nursing

FF10 483.25(e)(1)-(3):NO CATHETER, PREVENT UTI, RESTORE BLADDER

REGULATION: (e) Incontinence. (1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. (2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that- (i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. (3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2017
Corrected date: November 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews conducted during the recertification survey, it was determined the facility did not ensure appropriate urinary treatment and services were provided for 1 of 4 residents (Resident #30) reviewed for infections. Specifically, when Resident #30 showed signs of urinary distress, fluids were not encouraged, testing was not ordered timely, and the resident went to the hospital with a urinary tract infection [MEDICAL CONDITION]. Findings include: Resident #30 was admitted to the facility on [DATE] for short-term rehabilitation following an aortic (heart) valve replacement, and other [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was intact. She required extensive assistance with transfers and toileting, and supervision with eating. The hospital discharge summary dated 8/28/2017, documented the resident had an aortic valve replacement, deconditioning, and an elevated white blood cell count (WBC, indicative of infection) on 8/25/2017. The urinalysis showed a large number of leukocytes (blood cell, indicative of infection), an elevated urine WBC count and a large number of bacteria. The resident was started on [MEDICATION NAME] (antibiotic) for 14 days for treatment of [REDACTED]. The comprehensive care plan (CCP) dated 9/5/2017, documented the resident was at risk for dehydration and the goal was to promote adequate hydration. Interventions included encouraging fluids at and between meals, providing additional fluids during the unit hydration pass, monitoring for signs and symptoms of dehydration, monitoring intake and output, and a minimum fluid intake of 1500 cc (cubic centimeters) daily. The CCP also documented the resident required assistance with toileting, was incontinent of bladder and continent of bowel. The nursing progress note dated 9/7/2017 at 10:18 AM, documented the nurse practitioner (NP) was updated on the resident's vomiting and decreased appetite, and ordered to discontinue the [MEDICATION NAME]. The nutritional note dated 9/12/2017 at 8:46 AM, documented the resident had very low intakes, often refused meals, and averaged 700-900 cc/day. She was started on [MEDICATION NAME] to increase her appetite and the plan was to continue to encourage meals and fluids. The nursing progress note dated 9/19/2017 at 8:25 AM, documented the NP was updated on the resident's status including nausea, cloudy urine, poor appetite and fluid intake. A new order was given to send a urine to the laboratory, and consult the [MEDICATION NAME] for weight loss and nausea. The nursing progress note dated 9/19/2017 at 2:37 PM, documented the resident had a large amount of red stool. The NP was in to examine and ordered [MEDICATION NAME] (nausea medication), Vitamin C, and iron to be discontinued. The nursing progress note dated 9/19/2017 at 5:41 PM, documented the NP was updated on the presence of blood in the stool and the character of the urine obtained. An order was given to send the resident to the hospital. The nursing progress note dated 9/19/2017 at 6:50 PM, documented the resident was transported to the hospital at 6:00 PM and the resident's family was notified. The resident's urine specimen was transported to the hospital with the resident, vital signs were stable and the resident had noticeable pallor (pale appearance). The nursing progress note dated 9/20/2017 at 3:40 AM, documented the resident was admitted to the hospital for generalized weakness and UTI. The resident's family member contacted the surveyor on 9/28/2017 at 6:41 AM and stated: - On 9/17/2017, two certified nurse aides (CNA) told the family the resident's urine had been cloudy for a number of days. The family member discussed this with the nurse on duty and was told they did not do urine testing on the weekend. - On 9/18/2017, the family member called the nursing station and was told the urine test was done, and results would not be available until 9/19/2017. The person on the phone also stated from the smell of the urine they thought the resident had a UTI. - On 9/19/2017 at 5:00 PM, the family member visited and when asking about the urine testing, was told the test had not been done. During a record review on 9/28/2017, there was no evidence the resident had any urinary symptoms prior to 9/19/2017, the day the resident was sent to the hospital. During interviews on 9/29/2017 at 10:00 AM and 12:15 PM, licensed practical nurse (LPN) #2 stated she was the charge nurse on the unit. She stated if a CNA was concerned about a resident's urine, she would look at the urine, get vital signs, check the resident's history, and call the physician. She stated there was always a physician on call and specimens could be sent on weekends. She stated a CNA mentioned the resident had strong urine on the Friday (9/15/2017) before she was sent to the hospital and she checked the resident's urine. She stated she thought she documented the urine characteristics and notified the physician. She stated she did not think the resident had a UTI and had strong urine due to her limited fluid intake. When interviewed again, LPN #2 stated she did not do an examination or vital signs on 9/15/2017 and probably did not document. She stated it was at the change of shift and she verbally passed the urinary concerns on the next shift. During an interview on 9/29/2017 at 11:02 AM, CNA #15 stated she was the resident's primary CNA for day shift and was off for 5 days, returning to work on 9/18/2017. She stated the resident's urine was strong and foul smelling, and she reported it to the nurse that day. She stated she did not know when the order for the urine specimen was obtained. During an interview on 9/29/2017 at 11:30 AM, LPN #13 stated on 9/22/2017 the resident's family member told her the resident's signs and symptoms of a UTI were not acted on timely at the nursing home. She stated she started an investigation and found LPN #2 looked at the resident's urine on 9/15/2017 and thought it was dark due to low fluid intake. She stated protocol was not followed as fluids should have been encouraged, vital signs monitored, and the physician notified. During an interview on 9/29/2017 at 12:05 PM, the attending physician stated an assessment was to be done anytime there were urinary concerns. He stated when the resident's urine appeared strong or foul, vital signs including temperature should be taken, the abdomen should be checked for tenderness or distension, fluids should be encouraged, and the physician should be notified. He stated even if the resident was not symptomatic, he would expect vital signs and an examination to be done, and all concerns to be documented. During a telephone interview on 9/29/2017 at 12:40 PM, CNA #11 stated she worked on 9/17/2017 and told registered nurse (RN) #12 the resident's urine was foul. She stated the nurse did not ask her to get a specimen and she did not know if the nurse contacted the physician. She stated the resident's family was in that day, and she told them she was concerned about the resident's urine and her decline in walking and eating. 10NYCRR 415.12(d)(1)

Plan of Correction: ApprovedDecember 4, 2017

1. Resident #30 no longer resides within the facility.
2. All residents have been identified as potentially being affected by the same practice.
3. The Administrator, Medical Director, and Director of Nursing will continue to review and revise as needed policies and procedures related to UTI care path, and ?Changes in Condition Status? policy.
Facility Clinical Care Coordinators or designees will monitor for compliance with urinary treatment and services to ensure the nurses document a response to a STOP AND WATCH for UTI symptoms in the EMR, and documentation that facility care path for UTI is followed to include notification of the dietician/designee and the physician as required. Facility implemented INTERACT tool called STOP AND WATCH within ?Changes in Condition Status? policy for improved communication between staff to ensure new signs and symptoms of acute illness are addressed timely.
Education was provided to all part and full time staff regarding facility policies and procedures on facility UTI care path to include signs and symptoms of UTI and ?Changes in Condition Status? policy and procedure. Educational emphasis was placed on specific signs and symptoms of UTI and ensuring that all signs/symptoms of UTI are reported to the nurse.
4. The facility developed an audit tool to monitor compliance with facility policies and procedures related to urinary treatment and services.
Facility Clinical Care Coordinators or designees will audit 100% of all STOP & WATCHES for signs and symptoms of UTI monthly for three months.
Director of Nursing or designee will report audit findings to Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Nursing

FF10 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: (c) (3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident?s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident?s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (b)(5) of this section. (c) (4) Timing of the notice. (i) Except as specified in paragraphs (b)(4)(ii) and (b)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (b)(1)(ii)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (b)(1)(ii)(D) of this section; (C) The resident?s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (b)(1)(ii)(B) of this section; (D) An immediate transfer or discharge is required by the resident?s urgent medical needs, under paragraph (b)(1)(ii)(A) of this section; or (E) A resident has not resided in the facility for 30 days. (c) (5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident?s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. (c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. (c)(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2017
Corrected date: November 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated survey (NY 115), for 1 of 5 residents (Resident #32) reviewed for admission, transfer and discharge, the facility did not ensure all residents were safely discharged . Specifically, Resident #32 was cognitively impaired, unable to administer her own medications, and was discharged with medications with someone other than her Health Care Proxy (HCP). Findings include: Resident #32 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderate cognitive impairment, and required limited assistance with most activities of daily living (ADLs). The resident's health care proxy (HCP) form dated 7/16/2003, documented the resident's HCP lived out of state and was involved with the resident's plan of care. The comprehensive care plan (CCP) dated 12/1/2016, documented the resident had a knowledge deficit related to medications and impaired cognitive function related to dementia. The resident's plan was to be discharged out of state with her HCP and there was an active discharge plan in place. The nursing progress note dated 12/6/2016 at 10:59 AM, documented the resident's care plan had been reviewed. The resident had short term memory impairment, staff were to provide memory cues and reminders, and her family member (not the designated HCP) was attentive and visited often. The discharge plan was for the resident to move out of state with her HCP and travel plans were in the process of being arranged. Social work assistant (SWA) #10's progress note dated 12/16/2016 at 3:20 PM, documented the resident had short term memory impairment, she was unable to self-medicate and she needed supervision at home. The resident's visiting family member had some memory issues and was not a reliable care giver per the HCP. The physician did not support the resident's discharge at that time due to her cognitive impairment and lack of community support. The note documented the HCP was updated with the information. At 5:01 PM, SWA #10 documented the resident was discharged against medical advice (AMA) with someone other than the HCP, and the other person was not considered reliable. The HCP was notified and an Adult Protective referral was made. The licensed practical nurse (LPN) progress note dated 12/16/2016 at 6:12 PM, documented the resident stated she was leaving with someone other than the HCP. The nurse told the resident the discharge was considered AMA and the facility was not responsible once she left the building. The resident verbalized understanding and signed the Release of Responsibility form. The Administrator was notified and stated the facility could not hold the resident against her will. The note documented the resident was followed out to her vehicle and given a supply of her medications. The undated facility Release of Responsibility form documented the resident understood she was discharging herself from the facility. Resident #32 signed the form and dated it (MONTH) 26, 1962. When interviewed on 4/27/2017 at 2:27 PM, SWA #10 stated the resident was admitted to the facility for short term rehabilitation, she lived alone in the community, had some cognitive impairment and was unable to administer medications. She stated facility protocol was for a resident to complete the release of responsibility form and once completed, the Administrator determined if the resident was to be discharged . When interviewed on 4/25/2017 at 2:45 PM LPN #17 stated she recalled when the resident left the facility AMA and she was present when the resident signed the paperwork. She stated the Administrator and the Assistant Director of Nursing (ADON) were notified the resident wanted to leave the facility, they determined she could make her own decisions and the facility was unable to stop her from leaving. She stated the resident left the facility with someone other than the HCP, the resident agreed to take her medications with her and we provided them to her when she left. She stated the facility agreed to call Adult Protective Agency on Monday 12/19/2017 after she was discharged on Friday 12/16/2016. When interviewed on 5/5/2017 at 9:27 AM, LPN # 23 stated she provided the resident with her medications on the evening the resident left the facility because insurance had already paid for them. She was unable to remember what the resident's cognitive status was at the time she left the facility and did not think the resident was capable to self-medicate while at the facility. When interviewed on 9/29/2017 at 8:55 AM, LPN #2 stated the HCP had to be notified prior to the resident leaving the facility when a resident was cognitively impaired. She stated the resident would not be able to sign a release of responsibility form and the resident's medications would not be given if she was unable to self-medicate while at the facility. When interviewed on 9/29/2017 at 12:17 PM, the Administrator stated the facility would contact the HCP if a resident had cognitive impairment, was unable to self-medicate and wanted to leave the facility with someone other than the HCP. He stated the resident would not be discharged , the police would be notified and medications would not be provided to the resident. 10NYCRR 415.3(h)(1)(iii)(a-c)

Plan of Correction: ApprovedDecember 4, 2017

1. Resident # 32
The identified resident no longer resides at the facility.
2. All residents have been identified as potentially being affected by the same practice
A full house review of all AMA discharges was reviewed from 7/1/2017 to 9/30/2017 to ensure that all discharges designated AMA were signed by either the resident or the resident?s representative.
3. The Administrator, Director of Social Services, Medical Director and Director of Nursing will continue to review and revise, as needed, policies and procedures related to discharge against medical advice and elopement. Policy on Discharge Against Medical Advice updated to include that when a resident or legal representative expresses desire to leave AMA that the supervisor will be notified, that the Social Worker will notify APS that day, or the next business day if after hours, and that residents will discharged with medications per physician order. Capacity to sign self out will be determined based on BIMS score, ability to verbalize understanding of risks of leaving AMA, if they are alert and oriented x3, and/or if they signed their own admission agreement.
The Director of Social Services or her designee will be responsible to review all discharges to determine the discharge against medical advice was signed by either the resident or their legal representative.
The Director of Social Services will monitor for compliance with the above protocols. Immediate corrective action will be implemented as needed.
Education was provided to all part and full time staff regarding discharges against medical advice. Educational emphasis was placed on ensuring all discharges against medical advice are signed by the resident or their legal representative.
4. The facility developed an audit tool to monitor compliance with federal and state regulations regarding discharge against medical advice.
The Director of Social Services will audit 100% of AMA discharges monthly for three months and report findings to the Administrator. Corrective action, including re-education will be implemented immediately.
The Director of Social Services of designee will report audit findings to the Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow up with a compliance goal of 95%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Social Services.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 29, 2017
Corrected date: November 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined for 1 of 18 reviewed for quality of care (Residents #6), the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well-being. Specifically, Resident #6 had physician orders [REDACTED]. Additionally, the resident's physician ordered fluid restriction was not clear and documented 2 different restrictions in the medical record. Findings include: Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognitive status was intact, he required extensive assistance with his activities of daily living (ADL's) and he had shortness of breath. The comprehensive care plan (CCP) dated 8/22/2017, documented the resident had a fluid restriction of 1800 cc daily and staff were to monitor weights, laboratory values and [MEDICAL CONDITION]. The CCP documented additional fluids were not recommended due to the resident's cardiac status. On 8/22/2016, the weight report documented the resident weighed 160.6 pounds. The admission History and Physical report dated 8/26/2017, documented the resident had [MEDICAL CONDITION], he was uncompensated (worsening signs of heart failure), and staff were to monitor the resident closely and maintain his fluid restriction of 1800 cc (cubic centimeters). The physician's orders [REDACTED].#6 received [MEDICATION NAME] 20 mg daily for [MEDICAL CONDITION]. the resident's fluid restriction was to be maintained at 1800 cc, he was to be weighed daily and the physician was to be notified if the resident's weight increased by 2 pounds. The weight report documented the resident was weighed as follows: - on 8/28/2017, 165.4 pounds (4.8-pound increase from 8/26/2017); - on 9/4/2017, 166.6 pounds; and - on 9/11/2017, 168 pounds (2.6-pound increase from 8/28/17). There was no documented evidence the resident was weighed daily and no documented evidence the physician was notified of the weight gain as ordered. The RN progress note dated 9/2/2017 at 11:36 documented the resident had respiratory difficulty, shortness of breath, a productive cough with a moderate amount of clear thin secretions, received oxygen via nasal cannula at 3 liters, and his oxygen saturation level was at 83%. The RN progress note dated 9/3/2017 at 2:23 PM documented the resident had respiratory difficulty, had shortness of breath upon exertion and a productive cough with a moderate amount of clear thin secretions. The LPN progress note dated 9/8/2017 at 8:02 AM documented the resident did not look well, was slow to respond, and not normal for the resident. His oxygen saturation level was at 62% and his lung sounds had bilateral rubbing sounds. His skin was ashen in color and the resident was returned to bed, an x-ray was obtained and the resident was started on an antibiotic for pneumonia and [MEDICAL CONDITION] (low oxygen levels). The RN progress note dated 9/10/2017 at 12:35 PM documented the RN responded to an urgent need as the resident was unresponsive in the hallway. Resident #6 was returned to his room and placed in bed, he was slow to respond, his oxygen saturation level was at 63%, and he was transferred to the hospital and then readmitted to the facility with a [DIAGNOSES REDACTED]. The RN progress note dated 9/16/2017 at 2:00 PM documented the resident had a fall and hit his head. His oxygen saturation level was at 78%, his oxygen level continued to decline, the resident became lethargic and was sent to the hospital for evaluation. A nursing progress note dated 9/17/2017 at 11:52 PM, documented the resident's oxygen saturation was 58%, (normal range 95-100%) he was slumped in the chair, he was responsive only to sternal rub, his skin was gray, lips were blue tinged, and lung sounds were diminished in the left lower lobe. The resident was sent to the hospital for further evaluation. The hospital discharge records dated 9/22/2017, documented the resident was admitted with clinical signs of overload with acute decompensated heart failure, elevated kidney functions and liver enzymes (blood tests), [MEDICAL CONDITION] and bilateral crackles in the lungs. The resident was being discharged back to the facility after his hospitalization and discharge instructions recommended a fluid restriction was to be maintained at 1500 cc. The nurse practitioner (NP) re-admission history and physical dated 9/22/2017, documented the resident weighed 153 pounds. Recommendations included a 1500 cc fluid restriction. The physician's orders [REDACTED]. The 9/22/2017 CCP and the resident care guide (direct care instructions) documented the resident was on a fluid restriction of 1800 cc and 1500 cc. The CCP documented the resident's weights were to be monitored. The care guide did not document the resident was to be weighed. The weight report dated 9/22/2017, documented the resident had weights as follows: - on 9/22/2017, 153 pounds. - on 9/24/2017, 164.2 pounds There was no documented evidence the resident was assessed or the physician notified when the resident gained 11.2 pounds in 2 days. When requested on 9/26/2017 the facility did not provide a fluid restriction policy. During an interview on 9/29/2017 at 8:30 AM, certified nurse aide (CNA) #1 stated she was the resident's primary aid, she provided his daily care and reviewed the resident's care instructions daily for changes. She stated the resident coughed a lot, had trouble catching his breath and was not on a fluid restriction. She offered and provided fluids throughout the day, she did not monitor the amount of fluids he received and he was to be weighed daily related to his [MEDICAL CONDITION]. When shown the resident's care guide documenting both 1500 and 1800 cc fluid restriction, CNA #1 stated she did not realize the resident was on a fluid restriction and she was unable to identify which fluid restriction was current. During an interview on 9/29/2017 at 8:55 AM, licensed practical nurse (LPN) #2 stated when a resident was admitted on a fluid restriction the physician orders [REDACTED]. The order was documented on the medication administration record (MAR), in the medical record, on the CCP and in the resident's care guide. She stated she was unable to recall the resident's fluid restriction or weight schedule. She stated the Unit Manager was responsible to ensure the resident's medical record was updated with the correct fluid restriction per the physician's orders [REDACTED]. After review of the resident's physician's orders [REDACTED].#2 stated the resident's fluid restriction was not in the physician's orders [REDACTED]. During an interview on 9/29/2017 at 10:22 AM, Assistant Unit Manager registered nurse (RN) #3 stated he was responsible to ensure all medical records were updated to ensure the resident received appropriate care. He stated he was unable to recall if the resident had a fluid restriction, he had not assessed the resident for [MEDICAL CONDITION] while at the facility and was not sure when he was to be weighed. He stated if the resident had a fluid restriction he should be weighed weekly unless the physicians order was more specific. He stated if Resident #6 had a weight increase of several pounds the physician should have been notified. He stated staff were made aware of fluid restriction utilizing the resident care guide and the CCP. After reviewing the resident's physician's orders [REDACTED].#3 stated the CCP and the care guide both documented 1800 and 1500 cc fluid restriction, and there was no documented physician's orders [REDACTED]. He stated the last physician's orders [REDACTED]. He stated there was no documentation the resident was weighed daily and no documentation the physician was notified of the significant weight gain, and it should have been documented. During an interview on 9/29/2017 at 11:40 AM, the Medical Director stated if a resident was on a fluid restriction he expected staff to monitor and document daily on a resident. He stated the resident's physician order [REDACTED]. He stated the resident was not weighed per his order and he was concerned the increase in weight led to the exacerbation of [MEDICAL CONDITION]. He stated he was not aware the 1500 cc order had not been clarified upon readmission to the facility after the resident's hospital admission. When re-interviewed on 9/29/2017 at 2:00 PM, the Medical Director stated he was aware of the resident's admission to the hospital due to decompensation of [MEDICAL CONDITION]. He stated the hospitalization could have been avoided if the resident's weight was obtained per order and if the weight gain was reported to the physician. 10NYCRR 415.12

Plan of Correction: ApprovedDecember 4, 2017

1. Resident #6 was weighed and results were reported to the physician. Physician was also contacted to clarify order regarding resident?s fluid restriction.
2. All residents have been identified as potentially being affected by the same practice.
A full house review of all residents on fluid restrictions was completed to ensure consistent documentation of physician ordered fluid restrictions.
A full house review of all residents with orders for daily weights was completed to ensure physicians orders were followed.
3. The Director of Nursing, Medical Director, and Registered Dietician will continue to review and revise, as needed, policies and procedures related to fluid restrictions and daily weights.
Facility Clinical Care Coordinators or designees will monitor for compliance with fluid restrictions and orders for daily weights. Immediate corrective action, including staff education, will be implemented as needed.
Education was provided to all part and full time staff regarding facility policies and procedures on weight monitoring and fluid restrictions. Educational emphasis was placed on following physician?s orders for daily weights and consistent documentation of fluid restrictions.
4. The facility developed an audit tool to monitor compliance with facility policies and procedures related to Fluid Restriction and daily weights.
Facility Clinical Care Coordinators or designee will audit 100% of residents on fluid restriction weekly for 3 months and report findings to the Director of Nursing, and will audit 100% of residents with orders for daily weights and report findings to the Director of Nursing. Corrective action will be implemented as indicated.
Director of Nursing or designee will report audit findings to Quality Assurance/Process Improvement Committee monthly for three months for evaluation and follow up with a compliance goal of 90%. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective actions. Ad Hoc meetings will be convened as needed.
5. Responsibility: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 17, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the recertification survey, the facility did not properly maintain electrical installations for 3 isolated areas (south unit resident room [ROOM NUMBER], south unit resident room [ROOM NUMBER], and south unit resident room [ROOM NUMBER]). Specifically, south unit resident room [ROOM NUMBER] and south unit resident room [ROOM NUMBER] had patient care related electrical equipment plugged into unapproved six prong outlet adapters, and south unit resident room [ROOM NUMBER] had utilized an extension cord that was plugged into a six prong outlet adaptor. Findings include: 1. Patient Care Related Electrical Equipment On 9/26/2017 at 4:14 PM, a surveyor in the south unit room [ROOM NUMBER] observed an oxygen concentrator, a portable oxygen unit, and a nebulizer machine plugged into the same unapproved six prong outlet adapter. On 9/26/2017 at 5:49 PM, a surveyor in the south unit room [ROOM NUMBER] observed a portable oxygen unit plugged into an unapproved six prong outlet adapter into an unapproved power tap. During an interview on 9/27/2017 at 2:55 PM, the Plant Operations Director stated he was not aware of the patient care related electrical equipment plugged into unapproved six prong outlet adapters, and that all nursing and housekeeping staff are trained and aware that this was not allowed. 2. Improper Use of Extension Cord On 9/26/2017 at 4:53 PM, a surveyor in the south unit resident room [ROOM NUMBER] observed a television that was plugged into an extension cord that was plugged into a 6 outlet relocatable power tap (daisy chained). During an interview on 9/27/2017 at 2:55 PM, the Plant Operations Director stated the resident's family must of brought in the unapproved extension cord, and the facility's resident equipment policy states that these cords are not allowed. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 31, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Six prong outlet adapters were removed from rooms [ROOM NUMBERS]. Extension cord and six prong outlet adapter was removed from room [ROOM NUMBER].
2. Corrective action will be completed on or before 11/9/17
3. Education was provided was all part and full time staff on NFPA 10.2 requirements. Educational emphasis was placed on all medical equipment must be plugged directly into a wall outlet, and not to daisy chain extension cords into relocatable power taps.
4. The facility developed an audit tool to monitor compliance with NFPA requirements related to power cords and extensions. The Facilities Manager or designee will audit 20 random rooms per month to ensure medical devices are plugged directly into a wall outlet and that no power strips are daisy chained. Audit findings will be reported to the Quality Assurance Committee monthly for three months for evaluation and follow up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Facilities Manager

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 17, 2017

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not develop maintenance policies and provide records of all testing and repairs of all patient-care electrical equipment in accordance with National Fire Protection Agency (NFPA) 99 for electric beds, and electric lifts. Specifically, the manufacturer maintenance requirements were not followed for electric beds, and electric lifts. Findings include: 1. Electric Lift During review on 9/27/2017 of the electric lift user manual, a surveyor observed a maintenance safety inspection checklist that indicated monthly inspection/adjustment of the electric lifts. During review on 9/27/2017 of the electric lift maintenance log, electric lifts were maintained quarterly. During review on 9/27/2017 of the facility's mechanical lift preventative maintenance policy, electric lifts were to be inspected quarterly by the maintenance staff. When interviewed on 9/28/2017 at 11:43 AM, the Administrator stated he was not aware this lift was required to be maintained on a monthly basis, and added that the other two types of lifts within the facility had quarterly and annual maintenance requirements. 2. Electric Bed During review on 9/27/2017 of the electric bed user manual, a surveyor observed a preventative maintenance inspection chart that indicated semi-annual review of the electric beds. When interviewed on 9/28/2017 at 3:54 PM, the Administrator stated he was not aware the facility lacked an electric bed maintenance policy. He also stated the electric beds were maintained when work orders were completed, and that housekeeping checks the electrical beds monthly but there was no documentation to verify that. 2012 NFPA 99: 10.5.2.1, 10.5.6 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 31, 2017

1. Policies and procedures were developed for the preventative maintenance of electrical equipment. Preventative maintenance schedules for all facility electric lifts and beds was created within AMMS system based on manufacturer?s specifications.
2. Corrective action will be completed on or before 11/9/17.
3. Education was provided to all maintenance staff on facility policies and procedures related to preventative maintenance of electrical lifts and beds. Educational emphasis was placed on ensuring all patient care electrical lifts and beds have preventative maintenance schedules based on manufacturer?s specifications. Education will continue through 11/9/17 at which time all scheduled maintenance staff will have received this education.
4. The facility developed and audit tool to monitor compliance with facility policies and procedures related to preventative maintenance schedules for electric lifts and electric beds. The facilities Manager or designee will audit 100% of preventative maintenance schedules of electric lifts and electric beds monthly. Audit findings will be reported to the Quality Assurance Committee monthly for six months for evaluation and follow up. At the end of the six-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Facilities Manager

K307 NFPA 101:EXIT SIGNAGE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 17, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure exit signs were displayed in accordance with National Fire Protection Association (NFPA) 7.10 requirements for 1 isolated location (first floor south dining room). Specifically, the first floor south dining room lacked an exit sign. Findings include: On 9/26/2017 at 3:49 PM, a surveyor in the first floor south dining room observed there was a door that was labeled a fire door, that led to an emergency exit door. The surveyor could not find an exit sign to indicate that this door led to an emergency exit door. During an observation and concurrent interview on 9/28/2017 at 12:44 PM, the Plant Services Director stated the missing exit sign was not present when he was hired in (MONTH) (YEAR), and that there should be an exit sign near this door because the door in question was labeled a fire door. 2012 NFPA 101: 19.2.10.1, 7.10 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 31, 2017

1. An exit sign will be installed in the first-floor dining room for facility to comply with NFPA 7.10 requirements.
2. Exit sign will be installed on or before 11/9/2017.
3. Education was provided to all maintenance staff on NFPA 7.10 requirements. Educational emphasis was placed on exit sign placement. Education will continue through 11/17/17 at which time all scheduled maintenance staff will have received this education.
4. The facility developed an audit tool to monitor compliance with NFPA requirements related to exit signage. The Facilities Manager or designee will audit 2 fire zones monthly to ensure exit signage is in place as required. Audit findings will be reported to the Quality Assurance Committee monthly for three months for evaluation and follow up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Facilities Manager

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 17, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the fire rating of 2 isolated hazardous area doors were maintained (basement soiled linen storage room, and kitchen dry storage room). Specifically, these two doors lacked self closing devices. Findings include: On 9/27/2017 at 12:00 PM, a surveyor observed the basement soiled linen storage room door did not self close when tested , and was lacking a self closing device. This hazardous room was over 100 square feet in size and contained multiple bins of soiled linen. On 9/27/2017 at 12:57 PM, a surveyor observed the kitchen dry storage room corridor access door did not self close when tested , and the self closing device was not operable. This hazardous room was over 100 square feet in size. During an interview on 9/27/2017 at 12:57 PM, the Plant Operations Director stated he was not aware the kitchen dry storage room corridor access door did not self close, and was not aware of how long the self closing device was not operable. During an interview on 9/27/2017 at 5:13 PM, the Plant Operations Director stated he was not aware the basement soiled linen storage room door did not self close, and was not aware that the door lacked a self closing device. 2012 NFPA 101 19.3.2.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 31, 2017

1. Self-closing devices were installed on the doors to the basement soiled linen storage room and the kitchen dry storage room corridor.
2. Corrective action will be completed on or before 11/9/17.
3. Education provided to all maintenance staff on NFPA 8.4 requirements. Educational emphasis was placed on ensuring all doors to hazardous areas are self-closing.
4. The facility developed an audit tool to monitor compliance with NFPA requirements related to self-closing doors. The facilities Manager or designee will audit all doors requiring self-closing devices within 2 fire zones per month. Audit findings will be reported to the Quality Assurance Committee monthly for three months for evaluation and follow up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Facilities Manager

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 17, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems, for four isolated rooms (south 217A storage room, south 252 custodial closet, south 152 custodial closet, and west activities storage room). Specifically, the above mentioned rooms had sections of ceiling tiles missing that would allow smoke to rise past the sprinkler heads, not allowing the sprinkler heads to function as planned. Findings include: On 9/26/2017 at 5:00 PM, a surveyor in the south 217A storage room observed a 3 inch x 1 foot section of missing ceiling tile. On 9/26/2017 at 6:04 PM, a surveyor in the south 252 custodial closet observed there were missing sections of ceiling tile. This included a 2 foot x 2 foot section, a 1 foot x 2 foot section, a 1 foot x 1 foot section and a 1 foot x 5 foot section. On 9/26/2017 at 6:10 PM, a surveyor in the south 152 custodial closet observed there were missing sections of ceiling tile. This included a 1 foot x 2 foot section, a 1 foot x 2 foot section, and a 1 foot x 5 foot section. On 9/27/2017 at 3:50 PM, a surveyor in the west activities storage room observed a 2 foot x 2 foot section of missing ceiling tile. During an interview on 9/27/2017 at 2:40 PM, the Plant Operations Director stated the tiles in the south custodial closets were removed in June/July (YEAR) as part of a security camera installation project. He stated he was not aware of the missing ceiling tiles in the south 217A storage room and the west activities storage room. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 31, 2017

1. Ceiling tiles replaced in south 217A storage room, south 252 custodial closet, south 152 custodial closet, and west activities storage room.
2. Corrective action will be completed on or before 11/9/17.
3. Education was provided to all full and part time staff on NFPA 9.7.5 requirements. Educational emphasis was placed on ensuring all ceiling tiles are in place. Education will continue through 11/17/17 at which time all part and full-time staff will have received this education. Facility policy and procedure on workplace orders was reviewed and all full and part time staff received education. Education will continue through 11/17/17 at which time all part and full-time staff will have received this education.
4. The facility developed an audit tool to monitor compliance with NFPA requirements related to sprinkler system maintenance and testing. The Facilities Manager or designee will audit 20 random rooms per month for missing ceiling tiles. Audit findings will be reported to the Quality Assurance Committee monthly for three months for evaluation and follow up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Facilities Manager

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 17, 2017

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for one isolated area (third floor south custodial closet). Specifically, the third floor south custodial closet had an unsealed vertical penetration. Findings include: On 9/26/2017 at 5:40 PM, a surveyor in the third floor south custodial closet observed an unsealed two inch hole with data wires going into the floor below. The surveyor could see the light from the second floor south custodial closet below. During an interview on 9/27/2017 at 2:30 PM, the Plant Operations Director stated he was not aware of the unsealed two inch hole in the floor, and that all data wires passing through the floor were there before he was hired. He also stated preventative maintenance of the facility was done on a monthly and semi-annual basis. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedOctober 31, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Third floor south custodial closet vertical penetration was closed with fire stop putty and caulk.
2. Corrective action will be completed on or before 11/9/17.
3. Education provided to all maintenance staff on NFPA 8.6 requirements. Educational emphasis was placed on ensuring all vertical penetrations are sealed with fire stop putty.
4. The Facilities Manager or designee will audit all areas status [REDACTED]. Audit findings will be reported to the Quality Assurance Committee monthly for three months for evaluation and follow up. At the end of the three-month period the committee will evaluate the need for additional monitoring or other corrective action. Ad Hoc meetings will be convened as needed.
5. Responsibility: Facilities Manager