Norwich Rehabilitation & Nursing Center
December 28, 2017 Certification Survey

Standard Health Citations

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 29, 2017
Corrected date: February 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey, the facility did not ensure 1 of 3 residents (Resident #58) reviewed for advance directives had the right to formulate advance directives. Specifically, Resident #58's Medical Orders for Life Sustaining Treatment (MOLST) was completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to lack capacity for decision making) and there was no documentation a concurring physician determined the resident's lack of capacity. Findings include: Resident #58 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/16/2017 admission Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, and was limited to total assist with activities of daily living (ADLs). The 11/9/2017 social services progress note documented the resident was confused and a MOLST was completed with the HCP. The 11/9/2017 comprehensive care plan (CCP) documented the resident had advance directives and cognitive deficits. Interventions included to provide simple choices, encourage participation in plan of care, explain all procedures and review advance directives at a minimum of quarterly. The 11/13/2017 nurse practitioner (NP) orders documented the resident was a Do Not Resuscitate (DNR, no cardiopulmonary resuscitation). The 11/20/2017 MOLST documented the resident was to be a Do Not Resuscitate/Do Not Intubate (DNR/DNI, no cardiopulmonary resuscitation/no mechanical breathing), no artificial nourishment, and was to be on comfort measures. The MOLST was signed by the resident's HCP. There was no 2-physician documentation determining the resident's lack of capacity to sign his own MOLST. The 11/20/2017 admission history and physical documented the resident was admitted from the hospital, had progressive dementia, was unable to participate in his own healthcare decision making, his condition was severe and prognosis guarded, and the physician was to complete a MOLST form on his behalf using his healthcare proxy. The 11/20/2017 physician progress notes [REDACTED]. The note documented the physician was to write an order to have the form placed in the chart. The 11/20/2017 physician order [REDACTED]. When interviewed on 12/28/17 at 05:02 PM, registered nurse (RN) Unit Manager #2 stated Resident #58 did not have capacity to make decisions regarding his advanced directives, she did not see a lack of capacity form in his chart, and it should be there or in the physician communication book and the social worker was responsible for ensuring they were completed. When interviewed on 12/28/17 at 05:16 PM, the Director of Social Services stated the facility used the MOLST lack of capacity form (a 2-physician concurring form) if a resident did not have capacity. The chart should have a dual lack of capacity form if the physician documented the resident did not have capacity and the form needed to be completed. When interviewed on 12/29/17 at 11:01 AM, the primary physician stated if the resident lacked capacity to sign their MOLST and the HCP signed for them, a dual physician lack of capacity needed to be done and the form was overlooked for the resident. When interviewed on 12/29/17 at 02:42 PM, the Director of Nursing (DON) stated the physician determined a resident's capacity with the social worker or physician while assessing their level of capacity. If the resident did not have capacity, the surrogate or HCP signed the MOLST, and the facility needed a lack of capacity form signed by 2 physicians. The physician was to document in a progress note when the MOLST was completed with the HCP or surrogate. She expected the RN Unit Managers to review the physician progress notes [REDACTED]. The RN Unit Managers should remind the social worker if a lack of capacity form needed to be done. 10 NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedJanuary 9, 2018

F578
Element 1
Corrective action taken for Resident #58 includes the lack of capacity form being reviewed and signed by the attending physician and medical director.
Element 2
Other residents with potential to be affected by this deficiency were identified by the Director of Social Work completing an audit of 100% of all residents to determine if any other resident did not have a completed lack of capacity determination or incomplete MOLST. The attending physician and Medical Director were utilized to complete any missing signatures or orders.

Element 3
The systemic changes being made to ensure the deficient practice does not recur includes; revising the Social Workers admissions process to require all new admissions and re-admissions are monitored and verified for complete and accurate advance directive documents.
A new Advanced Directives Binder has been established that includes a checklist of all steps of the process. All new admissions and readmissions will be added to the log and checklist completed at the time of admission.
The Director of Social Work is responsible to complete the admission review and ensure that all witness signature are documented and physicians signatures are requested. The Medical Director is responsible for to ensure timely physician response.
Element 4
Corrective actions will be monitored via monthly audit of advance directives for 100% of all residents. Audits will be completed for 3 months and will continue under the direction of the QAPI committee if 95% compliance is not achieved. Audit outcomes will be reported to the quarterly QAPI committee. The Director of Social Work is responsible for the correction of this deficiency.

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

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 29, 2017
Corrected date: February 2, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented for 2 of 2 residents (Residents #332 and 333). Specifically, Residents #332 and 333 did not have turning and positioning documented every two hours as care planned. Findings include: 1) Resident #333 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 12/21/17 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; did not reject care; required extensive assistance of 2 persons for bed mobility and was at risk for pressure ulcers. The undated certified nurse aide (CNA) care guide (care instructions) documented the resident was to be turned and positioned every 2 hours while in bed. The 12/2017 turning and positioning schedule documented the resident was to be turned and repositioned every 2 hours while in bed. There were 203 blank areas out of 209 opportunities where turning and repositioning had not been documented from 12/14/17-12/29/17. During an interview on 12/29/17 at 12:29 PM, certified nurse aide (CNA) #1 stated the resident needed assistance with rolling in bed. The resident used the handrails to pull herself over with the assistance of staff. The CNA stated the resident was on a turn and repositioning schedule and it was supposed to be documented in the CNA care guide every 2 hours. During an interview on 12/29/17 at 1:00 PM, registered nurse (RN) Unit Manager #2 stated the resident was on a turning and repositioning schedule. She stated turning and positioning should be documented when it was done. During an interview on 12/29/17 at 1:17 PM, licensed practical nurse (LPN) #3 stated the resident was on a turning and repositioning schedule and was to be repositioned from side to side to keep her off her bottom related to the open area she had. She stated CNAs documented positioning on the turning schedule. 2) Resident #332 was readmitted [DATE] and had a [DIAGNOSES REDACTED]. The 12/21/17 comprehensive care plan (CCP) documented that the resident was at risk for developing pressure ulcers. Interventions included the resident was an extensive assist of two with bed mobility, a Hoyer lift (mechanical lift) for all transfers and an extensive assist of two with toileting. The 12/22/17 physician's orders [REDACTED]. The 12/09/17 certified nurse aide (CNA) care guide (care instructions) documented the resident was an extensive assist of two for rolling and repositioning. The 12/2017 turning and positioning schedule documented the resident's position was to be changed every two hours. There were 43 blank areas out of 103 opportunities, where turning and repositioning had not been documented from 12/21-12/29/17. The 12/2017 treatment administration record (TAR) documented the resident was to be turned and positioned every two hours. There were 3 of 24 unsigned shifts that turning and repositioning for the shift had not been documented from 12/22-12/29/17. During an interview on 12/29/17 at 12:29 PM, CNA #1 stated that staff kept the resident clean and dry, and she was transferred with a mechanical lift. He was aware of the turning and positioning schedule and where it was documented. During an interview on 12/29/17 at 1:00 PM, registered nurse (RN) Unit Manager #2 stated the resident was on a turning and positioning schedule to prevent skin breakdown. She stated turning and positioning should be documented when it was done. During an interview on 12/29/17 at 1:17 PM, licensed practical nurse (LPN) #3 stated the resident had no skin breakdown and staff turned and repositioned her. She stated the CNAs documented turning and position on the log in the book with the CNA care guides and on the kiosk. 10 NYCRR 483.70(i)

Plan of Correction: ApprovedJanuary 22, 2018

F842
Element 1
Corrective action for Resident # 333 includes; review of resident ?s care plan and cardex, no revision was required. Resident # 333's care givers were identified and re-educated regarding the resident's specific needs and their need to follow the plan of care.
A skin assessment completed by a RN to ensure the resident is absent of wounds. Per facility policy a skin assessment by RN will be conducted on a weekly basis for 4 weeks after admission. Additionally, weekly skin checks are completed by a LPN.
Corrective action for Resident # 332 includes; review of resident?s care plan and cardex, no revisions were required. Resident # 332's care givers were identified and re-educated regarding the resident's specific needs and their need to follow the plan of care.
A skin assessment was completed by a RN. Additionally, weekly skin checks are being completed by a LPN. The M.D. order for turning positioning was reviewed and determined, that to be consistent with existing facility practices, a M.D. order is not required. Turning and positioning can be determined with nursing care planning process.
Element 2
Other residents with the potential to be affected were identified via an audit of 100% of all residents requiring turning and positioning to ensure consistent process and approaches. Specifically audited items include: M.D. orders, TARs, careplan, cardex and kiosk documentation.
Element 3
The systemic changes being made to ensure the deficient practice does not recur includes; review of facility policy and current documentation systems to determine the most appropriate location of turning & positioning documentation. Decision was to use the existing hard copy document used by CNAs, but to clarify it by re-naming it Monthly Turning & Positioning Documentation Sheet.
A new practice of CNAs reviewing the turning and positioning documentation sheet during daily shift to shift report will be implemented to ensure all documentation is complete prior to the end of each shift. LPNs are responsible for daily monitoring of documentation.
All nursing staff will be re-educated regarding the need and expectation for timely and consistent documentation of turning and positioning.

Element 4
Corrective action will be monitored via weekly audits of 10% of all residents on turning and positioning. Audits will be conducted for 3 months until 95% compliance is achieved. Results will be reported to the quarterly QAPI committee. The Director of Nurses is responsible for the correction of this deficiency.

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 28, 2017
Corrected date: February 23, 2018

Citation Details

Based on observation, interview, and record review conducted during the recertification survey, the facility did not ensure all emergency exit exterior discharge paths went to a public way for 1 of 4 first floor external emergency exits (physical therapy room exit) and the areas lacked adequate signage. Specifically, the first-floor physical therapy emergency exit discharge path was not a hard-packed surface and there was no illuminated exit sign. Findings include: On 12/27/2017, between 3:00 PM and 3:15 PM, a surveyor observed a physical therapy room exterior door with emergency exit only signage on it. The external pathway outside this door opened into a courtyard and was a was grass/not hard packed surface of 20 feet, before it connected to the driveway. The exit sign was covered but working. During an interview on 12/28/2017 at 2:00 PM, the Director of Plant Operations stated approximately four years ago the illuminated emergency exit sign in the hallway outside the physical therapy room and the emergency exit sign in the physical therapy room were removed. The area outside the door was grass, not pavement. During an interview on 12/28/2017 at 2:15 PM, maintenance worker #4 (previously the Director of Plant Operations) stated a surveyor from a previous federal survey told him emergency exit sign in the hall outside the physical therapy room could be removed. At that time, he also removed the emergency exit sign in the physical therapy room. He stated the patio was not an exit and was not a hard-packed surface. 2012 NFPA 101 19.2.7, 7.7 CMS Survey and Certification Letter 05-38 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

Element 1
Existing exit sign over therapy room doorway was uncovered and bulbs re-installed.
Blacktop will be added to the exit discharge as a hard packed all weather travel surface at a later date due to winter weather preventing the work being done.
Snow removal will be completed on soft surface discharge until hard packed can be installed.
Element 2 &3
All other residents have the potential to be affected by this deficient practice. Two Contracting companies have been contacted to develop a proposal and quote to install a hard packed surface from exit to the driveway egress pathway. The contractors, Yaccano's Paving, and Webster's Paving and contracting companies were contacted on 1/24/2018. Quotes will be reviewed to ensure compliance and obtain date available to complete project.
All other emergency exits were checked and verified that hard packed surfaces are existing.
A policy change will include the monitoring of this additional exit by the maintenance staff and building supervisor during off shifts. Maintenance staff and all facility supervisors will be educated on this additional area to monitor.
Element 4
Corrective action will be monitored to ensure hard surfaces are maintained for all emergency exits by the maintenance staff and or facility supervisor during off shifts. The maintenance director or designee shall audit the shift monitoring sheets and report monthly to QAPI for next 3 months and until 100 % compliance is achieved. The QAPI committee will then evaluate the frequency of audits after 3 months or when 100 % compliance is achieved. The Plant Operations Director is responsible for the correction of this deficiency



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: December 28, 2017
Corrected date: February 23, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not properly maintain electrical installations for 1 isolated area (third floor lobby). Specifically, the third-floor lobby had daisy-chained electrical cords (device plugged into an extension cord that was plugged into another relocatable power tap). Findings include: On 12/27/2017 at 11:49 AM, a surveyor near the third-floor lobby, observed a string of holiday lights that was plugged into an unapproved extension cord that was plugged into a 6-prong relocatable power tap. During an interview on 12/28/2017 at 2:24 PM, the Director of Plant Operations stated he was not aware of the daisy-chained power taps near the third-floor lobby, and that extension cords were not allowed in the facility. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

Element 1
Corrective action includes removal of extension cord from the holiday decorations in the lobby.
Element 2
Other potential risks identified via a whole house audit.
Element 3
Measures put into place to prevent recurrence of this deficiency include:
Notification of residents and responsible parties at the time of admission that extension cords are not permitted.
All staff will be educated on not allowing extension cords in the facility. This training will be incorporated into the general new hire orientation process as well.
Auditing for extension cords will be added to the Room of the Day daily audits.
Element 4
Corrective action will be monitored by the Director of Plant Operations or department designee via reporting the outcome of the daily audits to the quarterly QAPI committee. A minimum of 95% compliance will be expected. Once 95% compliance or greater is achieved, the QAPI committee will evaluate and determine frequency of audits. The Director of Plant Operations is responsible for the correction of this deficiency.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 28, 2017
Corrected date: February 23, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not maintain all patient care related electrical beds in accordance with National Fire Protection Agency (NFPA) for two isolated rooms (resident room [ROOM NUMBER], and resident room [ROOM NUMBER]). Specifically, the facility did not maintain electrical cords on two resident beds. Finding include: On 12/27/2017 at 10:49 AM a surveyor, with the Director of Plant Operations in resident room [ROOM NUMBER], observed a section of the electrical cord to a bed and there was electrical tape wrapped around it. When the Director of Plant Operations removed the electrical tape the outside sheathing of the bed electrical cord was damaged. This bed was inspected 11/14/2017. On 12/27/2017 at 2:17 PM, a surveyor in room [ROOM NUMBER] observed a section of the electrical cord to a bed had torn/damaged sheathing with exposed wires. This bed was inspected 11/14/2017. During an interview on 12/28/2017 at 2:29 PM, maintenance worker #4 stated he did the resident room bed inspections and if he observed frayed/damaged wires he would have replaced the electric bed control and cord. 2012 NFPA 99: 10.5.3 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1
Corrective action includes replacement of the electric cords for beds located in rooms [ROOM NUMBERS].
Element 2
Other beds at risk for damaged electric cords were identified via visual observation of all beds in house.
Element 3
Measures put into place to prevent recurrence of this deficiency include;
Re-educate staff to report damage of equipment by recording in the maintenance repair books.
Preventative maintenance for beds per manufacturer guidelines will be completed by the Director of Plant Operations or department designee on an semi annual basis and will include a visual inspection to identify damaged cords.
General orientation and annual fire safety training will include use of maintenance repair books and reporting of damaged equipment.

Element 4
Corrective actions will be monitored by the Director of Plant Operations or department designee to ensure the deficient practice will not recur via audit, to include an audit of 10% of all beds on a monthly basis for a period of 3 months. A minimum of 95% compliance will be expected. Outcomes will be reported to the Quarterly QAPI committee. The Director of Plant Operation is responsible for the correction of this deficiency.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: December 28, 2017
Corrected date: February 23, 2018

Citation Details

Based on interview conducted during the recertification survey, the facility did not ensure the emergency generator remote annunciator was properly installed for the generator. Specifically, the emergency generator did not have an alarm annunciator remotely installed in an area that had 24-hour staff coverage. Findings include: On 12/27/17 at 01:52 PM, the generator annunciator was observed by a surveyor in the North A stairwell Exit located near the employee time clock. During an interview with the Director of Plant Operations on 12/27/17 at 10:09 AM, he stated he did not know how to get the panel to alarm to show the surveyor that it functioned. He was not aware if it alarmed anywhere else in the building. During a combined interview with maintenance worker #4 and the Director of Plan Operations on 12/27/17 at 12:03 PM, they stated neither of them had ever heard the remote annunciator go off. It was not in a 24-hour staff covered location as the area near the employee time clock would not have employees in the area 24-hours a day. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

Elements 1 & 2
Corrective action taken includes scheduling the vendor to relocate the emergency generator remote annunciator to the second floor nurses station. This new location has 24-hour staff coverage and will provide monitoring on a 24/7 basis.
Penn Power Company has been hired to relocate the new annunciator panel the week of (MONTH) 29, (YEAR).
Element 3
Measures put into place to prevent recurrence.
The remote annunciator will be tested by the Director of Plant Operations or his designee with the weekly generator testing and noted on the emergency generator test form.
The Director of Plant Operation or designee will educate all staff regarding action to be taken in the event the emergency generator remote annunciator sounds.
Element 4
Corrective action will be monitored from the weekly emergency generator testing reports. Audits from the weekly testing will be reported to QAPI committee monthly for the next 3 months and until 100% compliance is achieved. After 3 months and 100% compliance, the QAPI committee will evaluate and determine frequency of audits.
The Director of Plant Operations is responsible for the correction of this deficiency.

EP TESTING REQUIREMENTS

REGULATION: *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 28, 2017
Corrected date: February 23, 2018

Citation Details

Based on record review and interview during an Emergency Preparedness (EP) survey, the operator did not ensure there was EP testing performed at least annually. Specifically, the facility did not conduct EP exercises that were community-based at least annually. Findings include: During review of the EP plan on 12/27/2017, there was no documentation the facility participated in a full-scale exercise that was community-based. When interviewed on 12/27/2017 at 12:55 PM, the Administrator stated the facility had not conducted a community based exercise yet. They were working with the county mutual aid to organize a community-based exercise with other facility's starting in 1/2018. Moving forward community-based exercises will be on an at least annual basis. 42 CFR 483.73(d)(2)

Plan of Correction: ApprovedJanuary 24, 2018

Elements 1 & 2
Corrective action to correct this deficiency includes; administrative review of area wide disaster plan; administrator contacting the other local leaders to schedule a planning meeting and area wide drill. The meeting has been scheduled for 2/14/18.
Element 3
Measures being put into place to ensure the deficient practice does not recur includes the administrator's and designated staff's participation in year round disaster planning committee meetings.
Element 4
Corrective action will be monitored by including a review of any disaster drills that occurred during last quarter at the quarterly QAPI Committee meetings. 100% compliance of all drills conducted and a review of their after action reports to ensure a full scale community- based exercise was conducted. 100% compliance will be maintained for next 4 quarters of (YEAR). The frequency of the reviews will then be determined thereafter. The administrator is responsible for the correction of this deficiency.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 28, 2017
Corrected date: February 23, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the building was protected throughout by an approved automatic sprinkler system, in accordance with National Fire Protection Association (NFPA) 13, Standard for the Installation of Sprinkler Systems, for 1 isolated area (third floor lobby hall). Specifically, this area contained both quick-response sprinkler heads and standard response sprinkler heads where all sprinklers within a compartment shall be quick-response sprinkler heads. Findings include: On 12/27/2017 at 11:58 AM, a surveyor in the third-floor lobby hall observed two side wall quick-response sprinkler heads mixed with 14 standard sprinkler heads. On 12/27/2017, between 11:58 AM and 12:15 PM, a surveyor in the first-floor boiler room observed the facility's spare sprinkler boxes did not contain any quick-response side wall sprinkler heads. During an interview on 12/27/2017, between 11:58 AM and 12:15 PM, maintenance worker #4 (previously the Director of Plant Operations) stated the two quick-response sprinkler heads in the third-floor lobby hallway were added approximately five or six years ago. A surveyor during a past federal survey identified this hallway was missing sprinkler heads. 2012 NFPA 101 19.3.5.1, 9.7.1.1 2010 NFPA 13 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

Elements 1 & 2
Corrective action taken for this deficiency includes;
Sidewall quick response sprinkler heads in the front lobby have been replaced with standard response sidewall heads by the sprinkler system vendor.
All residents have been identified as a potential to be affected by this deficient practice. A full house audit will be conducted by 1/25/18 to inspect all other sprinkler heads condition and correct type of sprinkler head.
Element 3
Measures being taken to ensure the deficient practice does not recur includes;
The spare sprinkler head box will be inventoried and updated to include only replacement heads that match equipment currently being used in the facility.
A photograph of proper heads will be left in the box for vendor technician's quick reference.
Element 4
Audit of the spare sprinkler head box will be conducted by the Director of Plant Operations of department designee monthly and reported to the quarterly QAPI committee until 100% compliance rate is achieved. The QAPI committee will then review and determine the frequency of audits after 100% compliance. The Director of Plant Operations is responsible for the correction of this deficiency.

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: December 28, 2017
Corrected date: February 23, 2018

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 one isolated room (kitchen walk-in freezer). Specifically, a sprinkler head located in the kitchen walk-in freezer had a damaged deflector. The finding was: On 12/28/2017 at 11:50 AM in the walk-in freezer located in the kitchen, a surveyor observed a sprinkler head with a damaged deflector. Two metal tips of this sprinkler deflector were bent. During an interview on 12/28/2017, between 1:30 PM and 1:56 PM, maintenance worker #4 (previously the Director of Plant Operations) stated the sprinkler head in the kitchen walk-in freezer was added six years ago. He was not aware of this damaged sprinkler head. During an interview on 12/28/2017 between 4:00 PM and 4:36 PM, the Operations Manager stated he was not aware of the damaged sprinkler head in the walk-in freezer. 2012 NFPA 101: 19.3.5.1 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1
The correction action taken includes;
The sprinkler head in the walk-in freezer will be replaced by the sprinkler system vendor. The sprinkler head was ordered on [DATE] and will be replaced the week of 1/29/18. A protective cage will be added over the sprinkler head by the vendor.
Element 2
Other areas at risk will be identified via visual inspection of sprinkler heads.
Element 3
Measures being put into place to ensure there is no recurrence includes;
Education of dietary staff regarding the need to use caution when loading the refrigerator/freezer.
Remind staff to enter damage of sprinkler head into maintenance repair log.
The condition of all sprinkler head will be confirmed during annual cleaning by the maintenance staff immediately referred to the vendor if damage is identified.

Element 4
The corrective measures will be monitored by the Director of Plant Operations or department designee via visual observation of the freezer sprinkler head on a monthly basis for the next 3 months. the visual inspection will be recorded on a audit sheet. This audit will be reported to the QAPI committee monthly for the next 3 months and until 100% compliance is achieved. The QAPI committee will then evaluate and determine frequency of audit after 3 months and 100% compliance.

The Director of Plant Operations is responsible for the correction of this deficiency.



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: December 28, 2017
Corrected date: February 23, 2018

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 three isolated areas (third floor storage room by nursing lounge, second floor storage room by nursing lounge, and first floor kitchen). Specifically, there was a bundle of unsealed data wires that passed down from the third-floor storage room by nursing lounge into the second-floor storage room by nursing lounge into the first-floor kitchen. Findings include: On 12/27/2017 at 11:00 AM, a surveyor in the third-floor storage room by the nursing lounge observed an unsealed 1/2-inch hole in the floor with a bundle of data wires passing through it. On 12/27/2017 at 11:08 AM, a surveyor in the second-floor storage room by the nursing lounge observed an unsealed 1/2-inch hole in the floor with a bundle of data wires passing through it. During an interview on 12/28/2017 at 12:24 PM, maintenance worker #4 (previously the Director of Plant Operations) stated he thought if there was a tight seal of less than 1/8-inch fire stopping materials were not required for unsealed penetrations. The wires were installed five years ago. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

Element 1
The corrective action for this deficiency was taken on 12/28/17 to seal identified areas with a 4 hour rated sealant. Specifically the areas corrected include; data wires in third floor storage room by nursing lounge, data wires in second floor storage room by nursing lounge and the first floor kitchen.
Element 2
All resident have been identified as potential to be affected by this deficient practice.
To identify if other locations are at risk for similar penetrations, a full house audit will be done by maintenance staff to identify any vertical or horizontal openings in walls, floors or ceilings. If any areas are found, the proper sealant will be used to provide the required fire rating.
Element 3
Measures being put into place to ensure that the deficient practice does not recur include;
At the conclusion of their work, vendors and contractors will be asked to sign a statement verifying that they did not leave any penetrations.

Maintenance staff will inspect an affected area after each time a vendor or contractor does work in the building.
If, upon inspection, maintenance staff see penetrations, they will be responsible to repair them immediately, or ensure the vendor repairs them.
Any areas checked and repaired will be documented in a PM maintenance log book to track any and all work completed.
Element 4
The corrective actions will be monitored to ensure the deficient practice will not recur by audits;
after any new construction or repair to the building; 10% of all rooms in the facility will be audited monthly.
The audits will be reported monthly by the maintenance director or designee to QAPI committee for next 3 months and until 100% compliance is achieved. After 3 months and 100% compliance the QAPI committee will determine frequency of the audits.

The Director of Plant Operations is responsible for the correction of this deficiency.