Buffalo Center for Rehabilitation and Nursing
March 1, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.24(c)(1):ACTIVITIES MEET INTERESTS/NEEDS OF EACH RES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 3/1/17, the facility did not provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Five (Residents #62, 140, 161, 168, 243) of five residents reviewed for activities had issues including the lack of documentation that activities of interest are offered to residents who are cognitively impaired (Residents #62,140,168, 243) and lack of documentation that a cognitively intact resident attended activities or was provided in room activities (Resident #161). The findings include but are not limited to: 1. Resident #140 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/24/16 revealed the resident has severe cognitive impairment. The customary routine and activity assessment was completed by staff without family involvement and all sections are answered no. During an interview on 2/23/16 at 9:50 AM a family member stated they did not know if the facility provided any kind of activities for the resident and that the resident is always in bed. Review of the Comprehensive Care Plan revealed a focus area of Activities. The goal was the resident would attend/ participate in at least two activity programs per week during this review. Interventions included inviting/ escorting resident to activities, special events, and parties of choice/ interest; providing resident with reminders/ encouragement as needed; providing resident with personal 1:1/ bedside visits and provide equipment/ supplies necessary for in room participation. During intermittent observations from 2/22/17 through 3/1/17 during hours 6:45 AM to 5:30 PM the resident was noted to be in her bed. Occasionally eyes open, television was on in the room, however resident did not appear to be watching the television. There was no radio or other music devices in her room. Review of the Activity Attendance Records dated (YEAR) revealed no documentation that the resident attended any activities in (MONTH) or February. Review of a second undated Activities Attendance Record, identified as from (YEAR) - per Activities Leader, revealed no documentation that the resident attended any activities from (MONTH) through December. During an interview on 2/28/17 at 12:08 PM, the Activities Leader revealed that the Activity Director's last day at the facility was yesterday. The Activities Leader further stated, Resident #140 stays in her room a lot. When asked if any room visits are done for this resident the Activities leader stated No, I'm not going to lie. During further interview on 3/1/17 at 9:48 AM when asked if there is anything the Activities Department could be doing with the resident, the Activities Leader stated, The only thing I can think of is music, maybe, I wish I could do more with her. 2. Resident #161 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. The resident's mood interview revealed the resident was feeling bad about herself for 12 to 14 days of the look back period; had little interest or pleasure in doing things and was feeling down, depressed or hopeless for seven to 11 days of the look back period; and had trouble concentrating on things for two to six days of the look back period. Intermittent observations of the resident throughout the survey from 2/22/17 to 3/1/17 revealed the resident was sitting in her wheelchair watching television in her room or waiting in the lobby to be taken outdoors to smoke. Review of the Comprehensive Care Plan revised 6/29/16 revealed the resident is independent in selecting activities to attend. The interventions included to assist the resident in finding programs of interest and encourage resident suggestions regarding program choices; invite and escort resident to activities, special events and parties of choice and interest. Review of the Recreation Quarterly assessment dated [DATE] revealed the resident preferences were self- directed or independent pursuits, one on one or large group activities. The resident participation was listed as a passive observer or chooses not to participate. The resident requires invitations or reminders to attend activities. Review of the (YEAR) and (YEAR) Activity Attendance Records revealed the resident had decreased attendance at activities after (MONTH) (YEAR). The resident attended two activities during (MONTH) (YEAR), attended no activities during (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) and attended three activities in (MONTH) (YEAR). There is no evidence that the resident was offered independent or one on one activities; or that the resident was offered and refused to attend activities. During an interview on 2/23/17 at 8:22 AM, Resident #161 stated that the activities offered at the facility were repetitive. The resident stated that she used to attend the mental game activities but it had become the same thing over and over. The resident stated that there were not enough activities for someone functioning at a higher cognitive level. During an interview with the Activity Leader on 2/28/17 at 9:02 AM, the Activity Leader stated that he has worked on Resident #161's floor occasionally and would try to talk the resident into attending activities. The Activity Leader stated he was not sure if the resident was offered activities such as puzzles or magazines that she could complete independently. The Activity Leader further stated he knew that the resident would go outdoors to smoke a lot. Facility records document that the resident was outdoors to smoke twice daily; smoking two cigarettes each time. Review of facility policy entitled Activity Program dated 1/27/17 revealed, The activity program is designed to encourage maximum individual participation and are geared to meet individual resident's needs and preferences. 3. Resident #243 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the resident's Comprehensive Care Plan revealed a goal to participate in at least two activities per week with target date of 5/2/17. Review of the Activity Attendance Records for the past five months revealed the resident attended one activity in October, none in November, one in (MONTH) and none in (MONTH) or February, (YEAR). Interview with Activity Aide #1 on 2/28/17 at 2:15 PM revealed the Activities Director's last day at work was yesterday and she was not replaced as yet. Activities Aide #1 stated there is no formal program for the fourth floor Dementia Unit and that the resident's that can come down to activities are usually brought downstairs. Interview with Activity Aide #2 on 2/28/17 at 2:30 PM revealed she does go to the fourth floor Dementia Unit and provides sensory stimulation for some of the residents when there was time. Observation of the residents on the fourth floor Dementia Unit throughout survey from 2/27/17 through 3/1/17 revealed no activities were scheduled nor were individual activities offered. 4. Resident #168 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revealed a goal that the resident would participate in two activities per week with a target date of 4/25/17. Review of the Activity Attendance Records for (YEAR) revealed the resident met this goal only four of the 12 months with no activities recorded in February, (MONTH) or September, (YEAR). Observation of the residents on the fourth floor Dementia Unit throughout survey from 2/27/17 through 3/1/17 revealed no activities were scheduled nor were individual activities offered. 5. Resident #62 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revealed a goal of two activities per week with a target date of 3/10/17. Review of the Activity Attendance Records for (YEAR) revealed no documented attendance in January, February, March, June, October, December, (YEAR). In (YEAR), there was one documented activity in (MONTH) and none in February. Interview with Activity Aide #1 on 2/28/17 at 2:15 PM revealed she has offered sensory stimulation to the resident but he does not like it and refuses. Interview with Activity Aide #2 on 2/28/17 at 2:30 PM revealed he has brought the resident down for different activities but the resident will request to go back upstairs. 415.5(f)(1)

Plan of Correction: ApprovedApril 13, 2017

Resident Activities assessments were reviewed and revised to fully identify the interests and the physical, mental and psychological well-being of the following residents: #62, #140, #161, #168, and #243.
An IDCPT meeting will be held for all residents to review current Activities interventions; interventions will be updated to ensure residents interests are being acted on. Input from Residents and families will be included, when possible.
All Residents have the potential to be affected.
A review of the activities program was conducted by the Regional Director of Activities, and revised accordingly for all Residents; a formal activities program was developed and implemented for all active in house residents.
The Regional Director of Activities educated all activities employees regarding changes to the activities program, and the need to ensure that all interests and physical, mental and psychological well-being of each resident is met.
The Director of Activities/Designee will conduct weekly audits x4, of 4 residents per wing, on each floor, and then monthly audits x6 of 2 residents per wing on each floor.
Results of the audits will be forwarded to the QA Committee monthly for review and input.
Responsible Party: Administrator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/1/17, the facility did not ensure that residents who are unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene. One (Resident #108) of three residents observed for morning care had issues involving a certified nurse aide (CNA) who did not wash hands and change gloves after providing fecal incontinence care. The finding is: 1. Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/16/17 revealed the resident has severe cognitive impairment, and is always incontinent of bowel and bladder. The resident requires physical help in bathing, requires total assistance with toileting, and extensive assist with dressing. Review of the Kardex (care plan used by CNAs to direct care) dated 2/28/17 revealed the resident is totally dependent for incontinent care. During an observation of morning care on 2/27/17 at 8:08 AM, CNA #2 provided bowel incontinence care. CNA #2 used a washcloth to clean and another washcloth to rinse the resident, then dried the resident's buttocks with a towel. CNA #2 then applied a clean incontinence brief on the resident, and a T-shirt and pants. CNA #2 did not remove her gloves and wash her hands prior to applying the clean brief and clothing. During an interview on 2/27/17 at 11:23 AM, when asked if she usually provides incontinent care and uses the same gloves to put a new brief and clothes on residents CNA #2 responded, Yeah, probably, I'm not going to lie. I just figured if my gloves weren't really soiled, and I rolled everything up and not touch it that that would be ok. During an interview on 3/1/17 at 10:59 AM when asked if she would expect CNA #2 to change her gloves after providing incontinence care, Registered Nurse (RN) #1 Unit Manager responded, Yes. Review of a facility policy entitled Handwashing/ Hand Hygiene last revised 1/2017 revealed to wash hands with soap after the following situations including: before and after assisting a resident with toileting/ brief change or perineal care. Also hand hygiene is to be completed after removing gloves. 415.12(a)(3)

Plan of Correction: ApprovedApril 7, 2017

The CNA that provided morning care to resident #108 on 2/27/17 was counseled by the RN Unit Manager on that date. Facility hand washing/ hand hygiene protocol was reviewed with CNA at this time. Resident # 108 received thorough and appropriate incontinence care during the afternoon of 2/27/17 with no further issues noted.
All Residents have the potential to be affected.
The RN educator will complete a Certified Nursing Assistant audit of 100% of CNAs of all 3 Units and all 3 shifts for providing care to Residents and ensuring hand washing is occurring per facility policy.
The Policy and Procedure titled Handwashing was reviewed by the DON.
All CNA staff will be educated on the above policy by the RN Educator regarding hand washing policy with special emphasis on hand washing following incontinence care.
The RN Educator/Designee will conduct an Audit 20% of all CNA?s weekly x4, then monthly x3. Audits will ensure that CNAs are washing hands as per facility policy.
Results of the audits will be forwarded to the QA Committee Monthly for review and input.
Responsible Party: DON

FF10 483.90(i)(3):CORRIDORS HAVE FIRMLY SECURED HANDRAILS

REGULATION: (i)(3) Equip corridors with firmly secured handrails on each side; and

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Standard Survey completed on 3/1/17, the facility did not ensure that corridors were equipped with firmly secured handrails on each side. This involved two (Unit Two, Four) of four resident use floors. The findings are: 1. Observation on 2/22/17 at approximately 12:12 PM revealed an eight-foot section of handrail was missing in the corridor on Unit Two, A Wing, beyond resident room A212. Further observations revealed there were four, screw sized holes in the wall where the handrail brackets were once mounted. 2. Observation on 2/27/17 at approximately 12:13 PM revealed an approximate four-foot section of handrail was missing on Unit Four, B Wing, between resident rooms B417 and B418. The holes on the wall, where the hand rail brackets appeared to be previously mounted, were patched with white drywall compound. A computer bracket (without computer) was mounted in the same space where the handrail should have been. 3. Observation on 2/27/17 at approximately 1:07 PM revealed approximately 14 feet of handrails were missing on the Unit Two, C Corridor. The 14 foot area began at the end of the corridor, closest to the Nurses' Station, and extended to a room that was undergoing construction renovation. The missing handrails then extended to the newly renovated Clean Work Room. Interview with the Director of Maintenance on 2/27/17 at approximately 11:30 AM revealed the corridor walls where the handrails had been removed, are to be removed in the next three weeks as part of the facility's renovation project. 415.29

Plan of Correction: ApprovedMarch 27, 2017

Handrails were replaced on 2nd floor A and C wings, and 4th floor B wings.
All resident areas were audited for handrails, and any areas missing handrails were addressed.
The Director of Maintenance educated the Maintenance Department on the necessity of hand rails throughout resident areas.
A monthly hand rail audit x6 will be conducted by the Maintenance Director.
Any issues noted will be immediately addressed.

Results of the audits will be forwarded to the QA Committee for review and input.
Responsibility:
Administrator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/1/17, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, one (Resident #26) of four residents reviewed for dignity was observed wearing a sweater with two large holes in the knit of the sweater throughout an entire day. In addition, one of one Main Dining Room observed for dignified dining was used for the storage of chairs, pictures, two pianos, four treatment carts, a ladder and multiple other items throughout the length of the survey. This involved Resident #35. The findings are: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/21/16 revealed the resident has moderate cognitive impairment, understands and is understood. The resident requires extensive assistance of one person for dressing and personal hygiene During an observation of the resident on 2/27/17 at 10:54 AM, the resident was sitting in a wheelchair in the open area around the nurse's station. The resident was wearing a pull-over knit sweater with two large holes on the front of the sweater. One hole at the bottom of the sweater was approximately three inches in diameter, the second hole was located at the upper chest area and was approximately two inches in diameter. The resident was unshaven, had bushy [MEDICAL CONDITION] the back hair line was at the base of his neck. Additional observations of the resident on 2/27/17 at approximately 4:30 PM revealed the resident was wearing the same sweater with holes, remained unshaved and continued to have overgrown hair. At the completion of an observation of morning care on 2/28/17 at 8:22 AM, the resident stated he was not aware that he was wearing a sweater with holes in it on the previous day. The resident stated that he wears whatever is in his closet. The resident also stated that he could use a shave and hair cut when CNA #1 offered to shave the resident after breakfast. Observation of the resident's clothing closet at that time revealed another knit pullover sweater on a hanger in the resident's closet with one hole in the center of the sweater, approximately two inches in diameter. During an interview with the Director of Social Work (DSW) on 02/28/17 at 9:31 AM, the DSW stated that if the resident does not have family then the social worker would take responsibility of the psychosocial needs of the resident and would obtain clothing items when needed. The DSW stated that the resident has an elderly wife that does not come in to visit the resident and does not respond to telephone calls about the resident. The DSW stated the facility is the resident's Representative Pay (receives the Social Security or SSI benefits for anyone who cannot manage or direct the management of the benefits, with the responsibility to use the benefits to pay for the current and future needs of that person) and checked with the business office and was told the resident has $6,000 available in his facility account. The DSW stated that she has not been told by the nursing staff that the resident needed clothing but will now replace the sweaters with holes with new clothing items. The DSW also stated that the hairdresser was in the facility that day and she would be sure to schedule the resident for a haircut and shave, as he was not on the list of resident to see the hairdresser. Review of the policy entitled Quality of Life/Dignity, dated 9/12 revealed that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 2. Observation of the Main Dining Room lunch meal service on 2/22/17 from 12:45 PM through 1:45 PM reaved a portion of the dining room was being used as storage area. The back of the dining room contained four unused treatment carts, multiple pictures,10 plus chairs stacked on top of each other, book cases, cupboards, a ladder and multiple other items. During the dining experience on 2/22/16 at 12:50 PM a staff member was observed removing the six foot ladder while residents were in the dining room eating lunch. Observations of the main dining room during meals on 2/23, 2/24, 2/27, 2/28, and 3/1 revealed a portion of the main dining room remained used as a storage area during meals. Interview with the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator who was monitoring the breakfast meal on 3/1/17 at 9:00 AM stated the equipment goes somewhere else, but it's been stored there for a while. Resident #35 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- an assessment tool) dated 11/18/16 revealed resident understands and is understood. During an interview on 3/1/17 at 9:31 AM Resident #35 stated that she eats all her meals in the Main Dining Room and she doesn't like looking at all that junk in the dining room while she eats. 415.5(a)

Plan of Correction: ApprovedApril 7, 2017

Resident # 26 clothing wardrobe was audited on 3/21/17 and items of clothing with holes and or tears were discarded. Resident # 26 received a shave and haircut on 2/28/17.
Items of clothing for resident # 26 will be replaced as necessary, monies will be obtained from resident?s facility account.
Resident # 35 was reassured on 2/28/17 that storage items would be removed from the main dining room; several items were removed on this date with scheduled follow up to remove all items.
All storage items were removed from the Main Dining room by the maintenance department on 3/24/17.
All Residents have the potential to be affected.
Nursing/ Social Work staff will conduct a full house audit of all resident clothing. Any items of clothing noted to have holes or damage will be discarded. Social work department will then obtain any necessary replacements.
The maintenance department will conduct a full house audit to ensure that items are not stored in resident areas, and maintenance work is not conducted near residents during meal times.
The policy and procedure titled Quality of life/dignity (Dignity and respect) was reviewed and revised by DON/Administrator.
All nursing and social work staff will be educated on the above policy by the RN educator regarding resident dignity and the need to replace any resident clothing that has stains or holes.
The RN educator will also educate the Maintenance department in regards to appropriate areas for storage of unused equipment, and environmental work not being done near residents during resident meal times.
Social work/designee will complete 5 random weekly audits of resident clothing for a period of 3 months. These audits will ensure that resident clothing items are clean and free of tears, holes and wear.
The Maintenance Director will complete weekly audits x4 then monthly x6 to ensure dining areas are free of equipment, and work is not being done near residents during meal times.
Results of the audits will be forwarded to the QA Committee monthly for review and input.
Responsible Party: DON/Administrator

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure that drugs and biological's used in the facility are stored and labeled in accordance with currently accepted professional principles, including the expiration date when applicable. Two (Units 2,3) of three nursing units observed for medication storage had issues, specifically pre-poured medications stored in the top drawer of the medication cart, expired liquid medications in the medication room refrigerator (Unit 2), and outdated vials of insulin stored in a medication cart (Unit 3). Residents #57, 140, 195, 263, 301, and 307 were involved. The findings include but are not limited to: 1. Observation of the Unit 2 medication refrigerator on [DATE] at approximately 10:50 AM revealed an opened, used bottle of liquid Prilosec (treats heartburn) belonging to resident #263 with an expiration date of [DATE]. Resident #263 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS a resident assessment tool) dated [DATE] revealed the resident has severe cognitive impairment and rarely understood or understands. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During interview on [DATE] at approximately 10:51 AM, Licensed Practical Nurse (LPN #2) stated, I gave the resident Prilosec from that bottle and then returned it to the refrigerator. I didn't realize the expiration date. 2. Observation of the Unit 2 - Hall B medication cart on [DATE] at approximately 10:58 AM revealed pre poured medications in two different medication cups. The first cup contained the following medications for Resident #301: - Ativan (controlled substance, anti-anxiety medication) - Hydralazine (used to treat high blood pressure and heart failure) - Folic acid (supplement) - Lisinopril (used to treat high blood pressure) - Spironolactone (used to treat high blood pressure, and fluid retention) - Vitamin B1 (supplement) - Vitamin D 3 (supplement) - Las (diuretic, medication used to promote urine excretion) - Core (used to treat heart failure and high blood pressure) The second cup contained the following medications for Resident #307: - Iron (supplement) - Calcium (supplement) - Magnesium (supplement) - Synchronic (thyroid replacement medication) During interview on [DATE] at approximately 11:00 AM, LPN# 10 stated one cup of pills belonged to resident #301 which included a controlled substance Ativan, (this was verified by Register Nurse (RN #5) on [DATE] at approximately 11:15 AM) and the other cup belonged to Resident # 307. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Observation of the Latvian blister pack for Resident #301 on [DATE] at approximately 11:02 AM revealed there was 13 pills remaining. Review of the Control Substance Record for the Latvian dated [DATE] revealed the count of 14 pills remaining, was not signed off as administered at 7:42 AM. During an interview on [DATE] at 11:05 AM, LPN #2 stated resident #301 had gone out to an appointment and requested to take her medications upon returning to the facility. LPN #2 then stated, I should have thrown away the medications in the cups and wasted the Ativan. Controlled substances should always be double locked and never stored in the top drawer. I forgot to sign out the pill in the Narcotic book. During continued interview on [DATE] at approximately 11:20 AM, LPN #2 stated that Resident #307 refused her pills and I saved them. I was going to back and give them later. I should have just thrown them away. During interview on [DATE] at approximately 11:21 AM, Registered Nurse (RN #5) stated I would expect if the patient refuses to take medications that the pills are discarded, and if it's a controlled substance the pill needs to be wasted, not saved until the patient returns. 3. Observation of the Unit 3 Hall C Medication Cart on [DATE] at approximately 1:25 PM revealed a used vial of Humulin R Insulin with an opened date of [DATE] belonging to Resident #140 and a used vial of Humalog Insulin with an opened date [DATE] belonging to Resident #57. a.) Resident #140 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, rarely/never stands or understood. Review of the MAR indicated [REDACTED]=) 2 units; 251- 300 = 4 units; 301- 350 = 6 units; 351- 400 = 8 units; 401- 450 = 10 units subcutaneously every 6 hours for DM. During interview on [DATE] at approximately 1:30 PM, LPN # 7 stated I gave 2 units this morning, and set it aside in the drawer to remind myself to reorder the insulin. I should have notified the Supervisor. It's good for 28 days once opened. b.) Resident #57 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and understood. Review of the MAR indicated [REDACTED]. During interview on [DATE] at approximately 1:35 PM, LPN # 7 stated she refused her insulin this morning, but I gave her the Humalog yesterday. I will call the pharmacy. During an interview on [DATE] at approximately 1:45PM Registered Nurse (RN #1) stated she expects the Nurses to check the opened dates on the vials of insulin, Insulin is good for 28 days once opened. 415.18(e)(4)

Plan of Correction: ApprovedApril 13, 2017

LPN # 2 and LPN # 10 received written medication errors and counseling on 2/28/17 and 2/23/17 for pre-pouring of medications.
Residents # 63,# 140 and #57 were monitored and had no ill effects from receiving expired medications. The MD was notified of the above residents receiving expired medications with no new orders.
Medications for residents # 307 and #301 were discarded after noting that they were stored inappropriately. Residents # 307 and #301 subsequently received medications as ordered that were not inappropriately stored.

LPN # 7 and LPN # 2 were counseled by the RN UM regarding the need to double check all medications and Insulins for expiration date prior to giving.
All outdated liquid medications and Insulin were discarded on 2/28/17.
All residents have the potential to be affected.
A full house audit of all liquid medications and Insulins was completed by the RN Administrative staff on 3/1/17. No expired medications were noted.
The policy and procedure titled Medication Administration & Storage was reviewed and revised by the DON/Administrator.
The RN Educator will conduct re-education for all licensed nurses regarding medication administration, medication expiration dates and storage. The facility policy will be reviewed at that time. Pre-pouring of medications will be discussed along with the need to double check all medications for expiration prior to administering.
The RN Educator/Designee will conduct 10 medication pass competencies of all nurses across all shifts weekly x 4 and then monthly x 3. These audits will ensure that medications are administered and stored as per facility policy.

Results of the audits will be forwarded to the QA Committee Monthly for review and input.
Responsible Party:
DON

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: May 12, 2017

Citation Details

Based on observation and interview conducted during the Standard survey completed on 3/1/17, the facility did not store, prepare, distribute, and serve food under sanitary conditions. One (Main Kitchen) of one kitchen and one (dish machine room) of one dishwashing rooms observed for sanitary conditions had issues involving dirty floors and equipment, pooling water, unlabeled food containers, and improper utensil use and storage. In addition, the dish machine room was not maintained in clean and sanitary condition. The findings are: 1. Observations on the ground floor, in the main kitchen on 2/22/17 from 8:50 AM through 9:35 AM revealed the following: a) A spatula and ice cream scoop in use were being stored on resident diet sheets on the countertop. b) The top of the steamer unit was soiled with black bits of debris. c) Under the two bay sink and attached shelving the floor was wet with standing water during the breakfast meal tray line. d) A 25 pound plastic tote with a red cover was stored in the main kitchen. Further observation revealed this tote was not labeled and contained rice. Continued observations revealed a maroon colored bow with no handle was in use, as the scoop for the rice. The bowl was in complete contact with the rice inside the tote. e) A 25 pound plastic tote with a blue cover was stored in the main kitchen. Further observation revealed this tote was not labeled and contained what appeared to be flour. Continued observations revealed a maroon colored bowl with no handle was in use, as the scoop for the flour. The bowl was in complete contact with the flour inside. f) The floor throughout the main kitchen was soiled, sticky and had spilled and dried food substances on it. 2. During an observations on the ground floor in the dish washing machine room with the Director of Maintenance on 2/24/17 at approximately 11:55 AM revealed the following: a) When one of the two 55-gallon trash receptacles were moved, a large swarm of flies flew out and gathered in flight above the cans. An interview with the Director of Maintenance at this time revealed that both of these trash cans were recently purchased to replace the old cans that were discarded because dietary had trouble keeping the cans clean. b.) The area under the dish washing machine and attached shelving had pooling of water, approximately ½ inch deep. Interview with the Director of Maintenance revealed the pooling water is coming from an old grease trap that is located under the floor. c) The walls in the dish washing machine room were found soiled with food debris. 415.14(h) 14-1.42 14-1.43(e) 14-1.80(b) 14-1.110(c) 14-1.110(d) 14-1.110(e) 14-1.111 14-1.113 14-1.130 14-1.140 14-1.160 14-1.170

Plan of Correction: ApprovedApril 6, 2017

The Food Service Kitchen and Dish rooms were fully cleaned and sanitized.
The steamer was scrubbed and sanitized. The utensils found were washed and sanitized and then placed in the designated storage areas.
The rice and flour bins were labeled, and scoops were placed in a caddy mounted on the wall.
The two-bay sink in the kitchen was repaired.
The 55-gallon trash receptacles were removed.
The grease trap in the floor was permanently disabled and floor was leveled so there is no further pooling water; in addition a new grease trap was installed.
All Residents have the potential to be affected.
An initial food service sanitation audit was conducted to identify areas of concern. Issues identified were addressed immediately.
The FSD revised the cleaning schedules to incorporate: cleaning utensils and proper storage, proper labeling, mopping after meals and as needed throughout the day, and cleaning of equipment and appliances.
The FSD in-serviced all food service employees regarding sanitation standards and practices.
The Maintenance Director educated the FS employees on the 32-Gallon receptacle requirement.
The FSD will audit the kitchen and dish room on a weekly basis x4, and then monthly x6 to ensure that all sanitation standards and practices are being met.
Any issues noted will be immediately addressed.

Results of the audits will be forwarded to the QA Committee Monthly for review and input.
Responsibility:
Administrator




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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure that the resident environment remains as free from accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Two (Residents # 26, 123) of three residents reviewed for accidents had issues with an improper transfer of a resident from a chair to toilet (#26) and a loose side rail on a resident's bed (#123). In addition, three (Second, Third, Fourth) of four resident use floors had issues with rooms under construction that were unprotected; doors that were unlocked to construction zones; a construction room not separated from the personal care room (Second Floor); and broken and jagged computer kiosk mounting brackets installed above handrails. The findings are: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident has moderate cognitive impairment, understands and is understood. The resident requires extensive assistance of two persons for bed mobility and transfer and is totally dependent on two persons for toileting. The resident is not steady when transitioned from a seated to standing position and when moving on and off the toilet; and requires the assistance of another person to be stabilized. During an observation of morning care on [DATE] at 8:22 AM, the Certified Nurse Aide (CNA #1) washed the resident's upper body while the resident was lying in bed. After putting a sweater on the resident, CNA #1 assisted the resident to transfer out of bed to a wheelchair at the bedside. The CNA needed to assist the resident to a standing position by holding the resident's upper arm as the resident rose to his feet and pivoted into the wheelchair. CNA #1 then wheeled the resident into the bathroom and assisted the resident to stand and pivot to the toilet. The CNA again steadied the resident by holding on to the resident upper arm and lowered the resident's brief as the resident stood in front of the toilet. Once the resident was sitting on the toilet, CNA #1 placed clean pants on the resident's lower legs and secured a clean brief around the resident's legs. After allowing the resident sufficient time to use the toilet, CNA #1 had the resident stand in front of the toilet as she completed peri care. The resident stood for approximately one minute as CNA #1 washed and rinse the perineal area (the area between the rectum and genitalia). Resident #26's lower body was shaking and the resident was crying and moaning out as CNA #1 attempted to reassure the resident that the CNA was almost finished with providing care. CNA #1 adjusted the resident lower body clothing and had the resident transfer back to the wheelchair by standing and pivoting into the chair, while the CNA held the resident's arm. Review of the Comprehensive Care Plan (CCP), revised on [DATE] revealed that the resident has had actual falls related to gait and balance problems. Interventions include ADL (activities of daily living) assistance per ADL care plan. Further review of the CCP revealed the resident requires assist with Activities of Daily Living related to limited mobility and impaired balance. Interventions include toileting and transfers with the extensive assist of two staff member and use of a rollator walker during transfer. Review of the CNA Kardex (used by the CNA to provide care) with the print date of [DATE] revealed instructions that the resident requires extensive assist of two staff members with a rollator walker. Instructions for toileting the resident stated extensive assistance of two persons. During an interview on [DATE] at 1:23 PM, CNA#1 stated that the resident was one assist and further stated she does not need anyone to assist with his care. The CNA stated, He does pretty good standing. I don't need any help. During an interview with the Physical Therapist (PT) Director of Rehabilitation Services on [DATE] at 9:06 AM, the Director of Rehabilitation stated that the resident's last PT assessment completed on [DATE] determined that the resident required minimal to moderate assistance with transfer but remained assistance of two persons with transfer on the nursing unit. The Director of Rehabilitation further stated that the Occupational Therapy assessment completed on [DATE] documented that the resident required the minimal assist of two persons for toilet transfer and that task would include transfer to and from the toilet, cleaning after toileting, and clothing adjustment. During an interview with the Registered Nurse (RN #2) Unit Manager (UM) on [DATE] at 9:43 AM, the UM stated that Resident #26 should receive the assistance of two persons for transfers. When asked if there was another staff member available to assist CNA #1 with the resident's transfers. The UM stated, The staff do what they need to do to get the residents' care done. They really care about these residents. 2. Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact and requires extensive assistance of one person for bed mobility. During observation on [DATE] at 11:45 AM, the resident's left quarter side rail (window side of bed) was in the up position and was loose. Review of the Therapy Requisition form dated [DATE] revealed the resident had positioning side rails on his bed at home and needs them for bed mobility. Review of the RN: Side Rail assessment dated [DATE] revealed side rails were recommended due to resident request, the rails do not impede freedom of movement, provide security for the resident, and will assist the resident turning from side to side in bed. Review of an MD order dated [DATE] revealed bilateral side rails for increased mobility/ independence. During an interview on [DATE] at 10:09 AM, the RN #1 Unit Manager stated I can have maintenance fix it, after she observed the resident's left side rail and moved it around. The rail moved approximately three inches in all directions. During this observation the resident was seated in his wheelchair and stated yes when asked if he uses the side rail to turn in bed. During further interview, the RN #1 Unit Manager stated she doesn't know if maintenance or nursing checks them routinely. During an interview on [DATE] at 10:17 AM, the Maintenance Director stated that maintenance puts the side rails on the bed, but if they are loose, nursing would put a work order in so we can tighten them. The Maintenance Director further stated that he does not think he received a work order for this side rail. Review of the policy Bed Safety and Entrapment Prevention last revised (MONTH) (YEAR) revealed Nursing staff will report any concerns to the Maintenance Department for re- assessment including rails that are loose and can be pulled away from the side of the bed. 3. Observations on the Second Floor on [DATE] at approximately 11:59 AM revealed the corridor door closest to the Personal Care Room, had three red colored signs on the door that stated: Danger Restricted Area, Danger Hard Hat Area and Danger Construction Area Keep Out. Continued observation at this time revealed the door to the room was unlocked, accessible and under construction. The room was not occupied at this time. Observations on the Second Floor on [DATE] at approximately 3:20 PM revealed the same corridor door closest to the Personal Care Room, had three Danger signs, was accessible and unlocked. The room was not occupied at this time. Observations with the Director of Maintenance, on the Second Floor on [DATE] at approximately 11:25 AM revealed the same corridor door, closest to the Personal Care room, with the three Danger signs was again unlocked. Observations inside this room revealed the ceiling assembly and associated grid work was removed, revealing sprinkler piping, building service cables, junction boxes and fire safety components. Walls that had separated this room from the Physical Therapy room were in various stages of demolition. This room, while under construction, was also serving as a storage area of construction debris (observed in one 55-gallon trash receptacle and one mobile wheeled trash receptacle), construction tools and equipment, and new equipment to be installed. The room also contained 26 boxes of medical records. The Director of Maintenance stated at this time the medical records were being sorted and were going to be moved into a locked room, in the rear of this room until Monday (,[DATE]). Then the records will be relocated to offsite storage area. Continued observation at this time revealed there was an open archway from the room under construction that opened directly into the Personal Care (beauty shop) room. There was no physical separation from the Personal Care room from the construction zone. An interview with the Director of Maintenance at this time revealed the Personal Care room was still being used approximately one day per week, but would eventually be relocated as part of the renovation project. Continued interview with the Director of Maintenance revealed residents receiving therapy do ambulate down this corridor, but are never unattended by Physical Therapy Staff. The residents who use the Personal Care room would never be unattended by the Salon staff. Continued interview with the Director of Maintenance at this same time revealed construction may have started about one month ago and stopped about three weeks ago when the contractors discontinued working in this building. Observations on [DATE] at approximately 1:02 PM revealed the door to this room was unlocked and the room was unoccupied. 4. Observations on [DATE] at approximately 10:01 AM revealed a broken black door mounted mailbox. The mailbox was mounted to the office door adjacent to resident room C429 on the Fourth Floor. The mailbox was broken and cracked with a large missing piece. The remaining piece mounted to the door was jagged and sharp. The mailbox was located approximately sixty inches above the floor. 5. Observations on [DATE] at approximately 11:29 AM revealed a broken computer bracket. The computer bracket was mounted to the wall on the Third Floor, closest to resident room B318. The computer bracket was broken and cracked with jagged and sharp edges. The bracket was located approximately twelve inches above the handrail. 6. Observations on [DATE] at approximately 12:55 PM revealed a broken computer bracket. The computer was mounted to the wall on the Third Floor, closest to the television lounge area. The computer bracket was broken and cracked with a large missing piece. The remaining piece mounted to the wall was jagged and sharp. The bracket was located approximately ten inches above the handrail. A resident was observed ambulating in the corridor at this time of observation. 7. Observation on [DATE] at approximately 1:08 PM reveled the door immediately adjacent to the newly renovated Clean Work Room, on the Second Floor Wing C (Rehabilitation Unit), was unlocked. The window to the room was covered with paper. When the door was opened, observations revealed this room was under construction with exposed wall studs, plumbing and the ceiling grid was removed. There was construction equipment inside this room. 415.12(h)(1)(2)

Plan of Correction: ApprovedApril 7, 2017

CNA that transferred resident # 26 to the toilet with one assist received a written disciplinary warning and counseling for failure to follow care plan on 3/16/17.
The loose side rail on resident # 123 bed was tightened by maintenance on 2/23/17.
Broken computer kiosks were removed from units on 3/1/17.
The door to construction zone on the 2nd floor and the door immediately adjacent to the newly renovated Clean Work Room on the 2nd floor C Wing were both locked, and contractors were re-educated on the importance of keeping the door locked always.
The open archway connecting the construction room to the personal care room was sealed.
The broken black door mounted mailbox on the office door adjacent to resident room C429 on the 4th floor was removed, and the door was repaired.
All residents have the potential to be affected.
A full house audit was conducted on transfer status of each active Resident ensuring the Certified Nursing Assistance are transferring according to Plan of Care. No other concerns identified.

A full house Audit was conducted on remaining Kiosks to ensure 100% working properly. No other concerns identified with remaining Kiosks.
Maintenance will conduct a full house audit of all side rails, kiosks, and mailboxes on doors to ensure that all are maintained properly.

Maintenance has installed storage locks and automatic closers on all construction zone doors.
The Policy and Procedure titled Resident Care Plans was reviewed and revised by the DON.
The RN Educator will re-educate all nursing aides regarding adherence to care plan and above policy.
New computer kiosks were ordered to replace the broken kiosks.
The Maintenance Department will in-service all employees regarding work order procedures by utilizing the Maintenance/Housekeeping log books on each Unit.
The RN Unit Managers will conduct 5 audits of resident transfers weekly x 4 and then monthly x 3. Audits will ensure that aides are transferring residents as per care plan.
Maintenance will audit construction zones weekly 100% while construction is underway to ensure that doors are appropriately locked and that computer kiosks are in good repair.
The Maintenance Director will conduct an equipment Audit of 10 Resident rooms/hallways on 1 Unit weekly x4, then monthly x6 to ensure that work orders have been submitted, and items are fixed or replaced.

The results of audits will be forwarded to the QA Committee for review and input.
Responsible party : DON

FF10 483.60(f)(1)-(3):FREQUENCY OF MEALS/SNACKS AT BEDTIME

REGULATION: (f) Frequency of Meals (f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. (f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. (f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on interview and record review conducted during the Standard survey completed 3/1/17, the facility did not ensure that there was no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is provided at bedtime. Issues included a greater than fourteen hour time span between dinner and breakfast with no evidence that substantial bedtime snacks were offered to all residents and the lack of evidence that the meal times were approved by the resident council. The finding is: 1. Review of the undated Meal Times and Dining Locations sheet revealed the last dinner cart leaves the kitchen at approximately 6:20 PM and the last Breakfast cart leaves the kitchen at approximately 9:20 AM. Dinner in the main dining room starts at 5:45 PM and breakfast in the main dining room starts at 8:45 AM. This results in a span of 15 hours between dinner and breakfast meals. Review of the Resident Council Committee minutes dated 2/2016 and 2/2017 revealed a lack of documentation that the meal times were approved by the Resident Council. During an interview on 3/1/17 at 9:10 AM the Resident Council President stated no one has asked the Resident Council Group if they approved of the meal times. During an interview on 2/27/17 at 1:20 AM the Food Service Director revealed they provide bulk food items for the units for HS (hour of sleep) snacks if a resident wants, but they do not provide a substantial snack and they don't offer it to everyone. Additionally, there is no documentation that HS snacks are being offered, accepted, or refused by all residents. 415.14(f)(1)(2)(3)(4)

Plan of Correction: ApprovedMarch 27, 2017

Meal times were adjusted to not exceed 14 hours between the substantial evening meal and the breakfast meal following the day.
All Residents have the potential to be affected
FS cart delivery times were monitored for 5 days, for each meal time.
The FSD adjusted meal delivery times and food service employees work schedules, and educated FS employees on the 14-hour rule for the evening meal and the breakfast meal the next day.
The FSD will audit each meal delivery time for each meal, 3 times per week x4 weeks, and then monthly x6 months.
Any issues noted will be immediately addressed.
Results of the audits will be forwarded to the QA Committee for review and input.
Responsibility:
Administrator

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a complaint investigation (Complaint #NY 782) conducted during the Standard survey completed on 3/1/17, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Three (Units 2, 3, 4) of three units had issues with floors, walls, ceilings in disrepair including areas on walls that were spackled but not sanded or painted; ceilings, walls, and floors with brown spots or splatters; strong smell of urine in residents' rooms; wall heaters with peeling paint exposing bare metal underneath; brown and black debris around shower stall floor; broken tiles in shower room; and a discolored Geri chair seat cushion (Resident #29). The findings include but are not limited to: 1. Intermittent observations on 2/22/17 between 11:00 AM and 1:00 PM of Unit 4 resident rooms and resident areas revealed the following: Room #439 - Teal pebble tiled floor yellow/ brown discoloration on a 12' section under electric wall heater; curtain bracket protruding from wall with no curtains on right hand side and the left hand side has holes; bed headboard in disrepair and taped with duct tape in two sections on top and one section on left side; yellow/ brown stain along perimeter of floor around entire room; yellow/ stain around perimeter of bathroom floors with a strong odor of stale urine; water dripping from the bathroom faucet unable to turn off; above sink approximately eight inches on the wall spackled but not sanded or painted; doorway threshold from hallway has yellow/ brown stained floor the width of the door. Room #424 - Curtain brackets two protruding from wall, no curtains in room; bathroom threshold missing floor tile approximately three oval shaped area; perimeter of toilet stained yellow/ brown; tan molding stained brown and loosened behind toilet; wall next to toilet peeling near molding exposing particle board; door threshold from hallway yellow/ brown stain on teal pebbled tile approximately the length of the door. Room #401 - Room smells like stale urine; teal pebble tile floor on door threshold from hallway discolored approximately the length of the door; bathroom tiled floor discolored around toilet; yellow/ brown stain at the entry into bathroom. Room #435 - Bathroom wall has missing plaster left corner mirror 6 x 12 section; teal pebble tiles floor has yellow/ brown stain around entire perimeter of room; area around toilet base smells like stale urine; two curtain brackets protruding top of windows with no curtains. Room #429 - Molding on wall coming off wall in various areas around perimeter of room; linoleum tiled floor teal pebble design has dark yellow/ brown stains in one corner and under three' section under wall radiator; no curtains in room; window bracket hardware protruding from wall in three areas next to window; Formica windowsill edging under window missing 3' section; opposite floor corner yellow/ brown stain approximately 12' along base of wall; bathroom floor tiles same yellowed/ brown stain all over and the smell of stale urine. Room #425 - Molding not fitted to corners in room and in disrepair; molding loosened with brown and black debris behind toilet and sink/ plumbing; linoleum floor with dark discoloration around perimeter of the toilet; toilet seat dark yellow stain on both sides of opening underside approximately 6 to 12. During an observation on 2/22/17 at approximately 1:57 PM, Resident B stated, They don't always clean the bathroom. 2. Intermittent observations on 2/23/17 between 7:00 AM and 12:00 PM of Units 3 and four resident rooms revealed the following: Room #316 - Multiple brown debris splattered on wall next to bed and on the floor. Room #343 - Resident's belongings in plastic bins; plastic bags scattered on furniture & floor. Room #318 - Paper & plastic food lids on the floor; bed not made until 12:00 PM. Room #338 - Bathroom baseboard had brown debris around perimeter of room; wall behind toilet with holes. Room #325 - Holes in the linoleum on the floor in various areas. Room #339 - Floors are dirty with black debris. Room #434 - Bathroom wall has three missing/ broken tiles at threshold; teal pebble tiles floor has yellow/ brown stain around entire perimeter of room; around toilet base smells like stale urine; two curtain brackets protruding top of windows with no curtains. Room #435 - Floor has yellow/ brown stain around entire perimeter of room; around toilet base smells like stale urine; stained floor underneath wall heater. Interview with a family member on 2/23/16 at approximately 10:15 AM revealed that there are odors of urine and bowel movement in the halls and that the resident's floor is filthy. During an observation on 2/23/17 at approximately 11:26 AM, Resident A stated,The floors and tables are dirty in here. 3. Intermittent observations on 2/28/17 between 9:00 AM and 2:00 PM on Unit 2, 3 and four resident rooms and resident areas revealed the following: Shower room in Hallway A on Unit 2 - wall in shower stall approximately 2' x 1' paint bubbled off wall, one dent approximately 5 in diameter, one dent approximately 2 in diameter cracked, one tile broken, door jamb rusting with flakes of rusty metal on the floor; approximately 4' around the shower stall stained black and brown; bottom of door scraped and missing paint approximately 3' x by 1 1/2', toilet seat cracked stained ceiling tile approximately 1 1/2' x 2' brown stain. Room #343 - Clutter on floor including two bins full with personal effects loaded on top of chairs in room; faint smell of stale urine emanating from bathroom, four holes in wall with wall anchors protruding from holes above a rail in the bathroom; bed pan on arm rail next to toilet. Room #347- Strong urine odor in room; door painted with only primer paint. Room #316 - Multiple brown debris splattered on wall and floor next to bed. Room #318 - Room is cluttered with resident's belongings in multiple areas. Room #324 - Three screws protruding out of wall next to clock, linoleum missing on floor triangle shape 3 x 5 area peeling off of floor; used washcloth in sink. Room #325 - Paint peeling from heater approximately 3 x 1 and 1' x 1 1/2 revealed bare metal underneath. Room #327 - Linoleum missing next to window bed exposing subfloor underneath approximately five 1 square areas; molding missing from wall by window; paint peeling from heater approximately 1' x 1 and approximately 2 x 3, three wall anchors protruding from wall; dry wall not painted sanded approximately 3' x 6' by the window next to the closet; seven finger width gouges in wall exposing drywall underneath; and two, 1' x 2' area spackled but not sanded or painted by the headboard of the door side bed. B Hallway on Unit 3 - 10 areas not painted not sanded. Room #330 - Approximately 3' x 2' area not sanded or painted. Room #334 - Molding removed from wall along with white and brown debris from hinge to end of door including approximately 10 tops to plastic tubes. Hallway C on Unit 3 - Multiple areas spackled but not sanded or painted. Room #339 - Floor is dirty with black debris in various parts of the room. Room #401 - Dirty linen in sink, both doors scrapped up bare metal exposed. Room #407 - Area next to window bed multiple gouges of varying length on wall next to bed approximately in area 4' x 2'; multiple areas not primed or painted on door. Room #411 - Wall spackled not painted, not sanded, used glove on floor, missing molding next to toilet approximately 1' long; molding falling off wall in room; crumpled and dried wash cloth with brown debris on it in tub; multiple brown stains on ceiling small approximately 30 1/2 spots. Room #412 - Multiple brown stains in tub in bathroom. Room #413 - Multiple areas not sanded and not painted seven areas approximately 5diameter. Room #418 - Approximately 4' x 6 spackled but not sanded or painted. Hallway in B corridor on Unit 4 - 27 areas not sanded not painted on walls of varying sizes and shapes. Room #420 - Brown debris approximately 6 x 4 on bathroom door jamb; over the bed table missing approximately 8 x 2 area of veneer. Room #421 - Multiple areas on walls spackled not sanded or painted near bathroom door. Room #424 - heater chipped exposing bare metal three areas approximately 3 x 6. Room #425 - Four areas on wall not painted not sanded next to bed approximately 5 in diameter; molding peeling off wall behind toilet and under sink; drywall gouged and missing not spackled or painted and brown in color in bathroom under sink and next to toilet approximately 6 long. Room #427 - Multiple areas in room spackled but not sanded or painted. Shower Room in B hall on Unit 4 - six tiles pushed in and cracked in shower stall, brown and black stained caulk surrounding shower stalls between floor and wall tiles, approximately 4' long x 1 wide linoleum missing exposing subfloor underneath. Room #429 - Multiple brown stains on floor, missing veneer on window sill approximately 2 1/2' strip. Hallway C on Unit 4 - 25 areas of varying sizes that are spackled but not sanded or painted. Room #431 - Missing top of toilet tank. Room #434 - 2' x 10 area by bathroom door missing linoleum peeling off floor. Room #439 - 2 x 3 brownish rust colored stain on floor near door; approximately 12 x 8 scraped area on wall heat register exposing bare metal underneath; multiple brown stains on floor; two areas on wall approximately 6 x 6 spackled but not sanded or painted; breakfast tray with uneaten food still in room at approximately 11:30 AM. During an interview on 2/28/17 at 12:19 PM, Registered Nurse (RN) #2 stated that she expects her staff to fill out maintenance slips or at least tell her if there are maintenance issues. RN #2 stated that missing linoleum on the floor is a trip hazard and that she will notify maintenance right away. She stated that the paint in the resident rooms and hallways could be better. RN #2 then stated, I didn't realize that a toilet tank top was missing and that it was an issue. I'll have maintenance look at it right away. During an interview on 2/28/17 at approximately 12:30 PM, Resident C stated during an observation, See what they do? They sweep all that stuff behind the door and leave it there. I told the housekeeper about it I don't know how many times. It's filthy. During an interview on 2/28/17 at 12:34 PM, Housekeeping Aide #1 revealed resident rooms should be cleaned every day and that the stains might be under the wax on the floors; they probably need to be stripped. Further interview at approximately 2:30 PM with Housekeeping Aide #1 revealed that she is assigned to help the other housekeeper because of staffing issues and cover two floors. Housekeeping Aide #1 stated she does not always have time to clean the shower rooms on the unit because she needs to finish on one floor to get to the next floor. During an interview on 2/28/17 at 1:09 PM with Housekeeping Aide #2 stated, The rooms aren't getting cleaned on schedule because we are short-handed and I have to cover two floors. During an interview on 2/28/17 at 2:46 PM with Certified Nurse Aide (CNA) #4 revealed that if there is a maintenance issue the person who sees the issue fills out the maintenance slips. CNA #4 also stated that if it's something like a trip hazard we call maintenance right away to fix it. During an interview on 2/28/17 at 2:49 PM, RN #1 stated, It's a potential hazard whether its paint or anything else that's in disrepair. During an interview on 2/28/17 at 3:21 PM, the Director of Housekeeping revealed that they expect their staff to sweep and clean the resident rooms every day. He stated that they think it's the housekeeping aide's responsibility to clean the resident's fall mats. They think that the housekeeping staff should use the bathroom cleaner to remove any black or brown debris in the shower rooms. During an interview on 2/28/17 at 3:27 PM, the Director of Maintenance revealed that he would expect staff to put in a work orders for repairs stating, If we know it's broken we can fix it but we need to know. Requested copies of facility policy and procedures regarding room cleaning schedules and maintenance schedules were not provided by end of survey on 3/1/17. 4. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/10/16 revealed the resident is rarely/ never understood and is frequently incontinent of bowel and bladder. During an observation on 2/28/17 at 8:40 AM a Geri chair was noted in the hallway outside of Resident #29's room. The chair was blue however there was a large brown stain surrounded by white discoloration and stained circular area on the seat measuring approximately 8 long x 12 wide. The seat also had an indentation in the area that was discolored. During an interview on 2/28/17 at 8:40 AM, CNA #3 stated, Isn't it terrible? I've told them about it, but she hasn't gotten a different chair. During an interview on 2/28/17 at 9:17 AM, Licensed Practical Nurse (LPN) #7 stated, We've told therapy about her chair, I think she got a new one in (YEAR) but she's a heavy wetter and it's stained. Observation on 2/28/17 at approximately 10:30 AM revealed the resident was sitting up in her Geri chair near the Nurse's Station, with a pad beneath her, eating her breakfast. 415.5(h)(3)

Plan of Correction: ApprovedApril 7, 2017

Resident rooms and bathrooms #427, #425, #424, #429, #434, #439, #327, #334, #338, #324, and #325 will be deep cleaned by Housekeeping then totally renovated by the Construction crew. Renovation of rooms # 439, 424,425,434, 429,and 324 will include curtain brackets and holes, new window treatment(blinds), new faucets for bathrooms,toilets/seats, wall paint and repair and replacement of window sills. Replaced bed for # 439.
Resident Rooms 316, 318, 339, 347, 401, 420, and 435 floors will be stripped and waxed.
Resident rooms 316, 318, 333, 339, 343, 347, 401, 412, and 435 were deep cleaned.
All nourishment rooms, all shower rooms, rooms # 343, # 318 and each dining room on floors 1-3, have been thoroughly cleaned, and all clothing items/plastic containers have been removed from floor.

The shower room 4B will have floor tiles repaired.
Resident rooms/bathrooms 411 floor Molding will be repaired and/or replaced.
Resident Rooms 435 window brackets were removed and holes patched, window treatments will be added.

2A Shower room, 3B and 3C hallways, and Resident rooms 330, 343, and 347. 4B and 4C hallways, Resident rooms 401, 407, 411, 413, 418, 421, and 435 walls and doors repaired and painted.
Toilet tank cover in room 431 was replaced. Toilet seat in shower room 2A and resident room # 429 were replaced. Sink Faucet in room 439 was repaired. Toilet seat replaced in room 425.
Bathtub in room # 412 bathroom will be deep cleaned to remove all brown stairs.
Resident #29 Geri chair and seat cushion replaced.

Ceiling tile in shower room 2A was replaced.
The Over bed table in room 420 was replaced.
All Residents have the potential to be affected.
Maintenance and Housekeeping will conduct a full house audit to determine if additional areas require any cleaning or repairs of any kind.
All concerns noted will be addressed by Maintenance and Housekeeping Directors, including deep cleaning of rooms, repairs of any walls, molding, doors, spot painting, and any equipment needing repairs or replacement.
The Administrator Reviewed the Preventative maintenance program for Buffalo Center.
A meeting was held at Buffalo Center on 4/23/2017 with the Consultant, Construction crew, corporate, and facility Maintenance and Housekeeping Directors to review the projected schedule of renovation plans.
Housekeeping Director completed a monthly equipment schedule for cleaning of all Resident chairs and Cushions, then housekeeping director will send the clean chairs to Maintenance for repair checks.
Maintenance Director/Housekeeping Director implemented a Maintenance/Housekeeping Unit logging system for environmental concerns or issues needing attention on all 3 Units.

All facility staff will be educated on the above system by the Maintenance Director and the appointed Centers consultant.
Maintenance and Housekeeping Directors will conduct an Audit of 10 Resident rooms throughout the building and 1 Unit weekly x4; then 10 random rooms throughout the building monthly x12.
Results of audits will be forwarded to the QA committee Monthly for review and input.

Responsible Party:
Administrator



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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/1/17, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Three (Residents # 30, 57, 244) of 10 residents observed for infection control practices during blood glucose monitoring had issues. The facility did not have an effective system in place for the proper disinfection of shared glucose meters between resident use. Specifically, nursing staff were observed testing finger stick (sample of blood to determine glucose level) blood glucose levels for multiple residents using a shared glucose meter and did not disinfect the blood glucose meter with a germicidal (a substance that destroys germs) cleaning agent. In addition, three of three nursing units observed for infection control had issues involving a soiled towel left on a toilet seat; a mat next to a resident bed covered with a fitted sheet with foot print marks; and soiled washcloths and towels left in sinks in resident rooms, in bath tubs, shower room and on furniture in resident rooms. 1. (a) Resident #148 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set-assessment tool) dated 12/17/16 revealed the resident has moderately impaired cognition and is usually understood and usually understands. During an interview on 2/23/17 at approximately 8:30 AM the RN (Registered Nurse) Unit Manager stated the resident is a newly diagnosed diabetic. Review of the Medication Administration Record dated 2/1/17- 2/28/17 revealed the resident receives Humalog (fast acting) insulin injections per sliding scale (dose of insulin based on blood glucose level) for blood glucose levels checked at 7:30 AM, 11:30 AM, 5:00 PM, and 8:00 PM. (b) Resident #244 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident receives insulin injections and is cognitively intact. Review of the Medication Administration Record dated 2/1/17-2/28/17 revealed the resident receives Humalog (fast acting) insulin (a natural hormone made by the pancreas that controls the level of the sugar glucose in the blood) injections per sliding scale for blood sugars checked at 7:30 AM, 11:30 AM, 5:00 PM, and 8:00 PM. A continuous observation on the 3rd Floor D-Wing on 2/22/17 at 11:46 AM -12:08 PM revealed the following: - At 11:46 AM LPN #2 was observed to exit a resident room with a glucose meter in her hands. The LPN walked toward her medication cart, dropped the glucose meter on the floor, picked it up off of the floor and placed it on top of her medication cart. The LPN did not clean the glucose meter and left her cart to help a CNA. - At 11:57 AM LPN #2 took the glucose meter from the top of her cart, did not clean or disinfect it, and placed a test strip into it. The LPN was observed to go into a resident's room, wash her hands, apply gloves, cleanse Resident #148's finger with an alcohol pad, puncture the fingertip, and obtain a sample of blood. The LPN then touched the tip of the test strip to a droplet of blood on the resident's fingertip. At 11:59 AM the LPN exited the room and placed the glucose meter on top of her medication cart. The LPN sanitized her hands, but did not clean or disinfect the glucose meter. - At 12:02 PM LPN #2 went in to give resident #148 an insulin injection. - At 12:04 PM LPN #2 performed hand hygiene and moved the medication cart down to Resident #244's room. - At 12:05 PM, without cleaning or disinfecting the glucose meter, LPN #2 was observed to go into resident #244's room and perform a blood glucose test on the resident's left finger using the same glucose meter used for Resident #148. - At 12:07 PM LPN #2 went to her cart, used a MICRO-KILL germicidal alcohol wipe and cleansed the glucose meter for approximately 10 seconds then placed the meter on top of her medication cart. At 12:08 PM the glucose meter was not visibly wet for one minute. A continuous observation on the 3rd Floor D-Wing on 2/23/17 from 4:26 PM- 4:47 PM revealed the following: - At 4:26 PM LPN #5 was observed to perform a blood glucose test for resident #148. - At 4:29 PM LPN #5 was observed to place the glucose meter on top of the medication cart, unlock the cart and place the glucose meter into the top drawer without cleaning or disinfecting it. -At 4:41 PM LPN #5 gave resident #148 an insulin injection. - At 4:43 PM LPN #5 performed hand hygiene, and moved the medication cart down to resident #244's room. - At 4:44 PM LPN #5 removed the glucose meter from the top drawer, put gloves on, placed test strip into the glucose meter and gathered alcohol pad and lancet (needle used to puncture skin for blood sample), the glucose meter was not cleaned or disinfected. - At 4:45 PM LPN #5 entered Resident #244's room and asked resident his name and permission to perform the glucose test, the LPN removed the gloves she was wearing and washed her hands. - At 4:47 PM LPN #5 put gloves on and went to clean the resident's finger with an alcohol pad, surveyor intervened and stopped the LPN from performing the blood glucose test. During an interview on 2/23/17 at 4:47 PM when asked if she cleans the glucose meter between residents, LPN #5 stated I usually do, I use the alcohol pads, is that ok? I was nervous. I usually use the small alcohol pads and I clean it when I come out of the room. I heard that those (pointing to MicroKill wipes) cause cancer. Review of the manufacturer's instructions for cleaning the Even Care Proview (blood glucose monitoring system) revealed the meter should be disinfected after use on each patient. Disinfection instructions include wiping the glucose meter thoroughly and allow the surface of the meter to remain visibly wet for the contact time listed on the disinfecting wipes instructions for use. Review of the Micro Kill One Germicidal Alcohol Wipes container revealed the following disinfecting instructions: - use one or more wipes to thoroughly wet the surface to be treated. - treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on the label. During an interview on 2/24/17 at 10:10 AM the DON stated they had a vendor come in and do in servicing on their newer glucose meters approximately two-three weeks ago. The DON stated I assume they went over how to clean them and the specific cleaning guidelines. On the wipes we use it says 60 seconds, after you wipe down the glucometer it should be given 60 seconds to dry before you use it. Review of the facility policy entitled Obtaining a Fingerstick Glucose Level revised 12/2011 revealed the following: - To always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. - Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 2. During an observation on 2/23/17 at 4:12 PM of the 3rd Floor B-Wing, the Licensed Practical Nurse (LPN #3) completed a finger stick blood glucose test on a resident and returned to the medication cart and wiped the outside of the blood glucose meter with an alcohol swab and returned the blood glucose meter to the top drawer of the medication cart. LPN #3 left the locked medication cart for approximately five minutes and returned to the medication cart that was continually observed by the surveyor in the LPN's absence. At 4:24 PM on the same day, LPN #3 returned to the cart and retrieved the blood glucose monitor from the top drawer of the medication cart, obtained alcohol wipes, single use lancet disposable device, glucose meter test strips and put on gloves after sanitizer his hands. LPN #3 entered Resident #57's room and begin to prepare the blood glucose meter for testing the resident finger stick blood glucose. The LPN was stopped by the surveyor and asked to exit the resident's room prior to completing the resident's finger stick. LPN #3 stated that he will clean the multiple resident use blood glucose meter with an alcohol swab between resident use. LPN #3 further stated that he could use the Micro Kill One Germicidal Alcohol Wipes on the medication cart also. LPN #3 stated he was not aware of the facility policy for cleaning blood glucose meters and would have to check with the Unit Manager. 3. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 10/20/16 reveals that the resident is cognitively intact, understands and is understood. During an interview with the Registered Nurse (RN #1) Unit Manager (UM) at approximately 4:30 PM on the same day, the UM stated that she thought it was okay to use an alcohol swab to clean the blood glucose meter between residents but was not certain of the facility policy and would have to check with the Director of Nursing (DON) During an interview with the DON at 4:31 PM on the same day, the DON stated that nursing staff should clean blood glucose meter between resident use. The DON stated it was the facility policy to use germicidal wipes on the medication carts but thought it was acceptable to also use an alcohol swab to clean multiple resident use blood glucose meters. 4. During an observation of LPN #4 on 2/24/17 from 8:55 AM to 9:26 AM on the 3rd floor C-wing, LPN #4 completed blood glucose meter testing on four residents using a multiple resident use blood glucose meter, between each resident the LPN wiped off the outside casing of the meter using Micro Kill One Germicidal Alcohol Wipes for approximately 10 seconds and placed the meter on the top of the medication cart. The meter was visibly dry within 10-15 seconds. LPN #4 then left the nursing unit to obtain a new blood glucose meter because the blood glucose meter would not turn on. LPN #2 obtained the same type of meter, Evencare ProView Blood Glucose Monitoring System, from the medication storage room. LPN #4 set up the new blood glucose meter for testing. At 9:41 AM on the same day, LPN #4 wiped off the meter using a germicidal wipe, gathered supply on a tissue, put on gloves and entered Resident #197's room to complete blood glucose testing. 5. Resident #197 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 11/18/16 revealed the resident is cognitively intact, usually understands and is usually understood. LPN #4 completed blood glucose meter testing on Resident #197 and needed to repeat the test due to the meter reading low. After completing a second blood glucose testing on Resident #197 and exited the room with the blood glucose meter wrapped in the tissue used as a clean work surface while in the resident's room. LPN #4 placed the soiled wrapped blood glucose meter on the top of the medication cart and disposed of the contaminated supplies in the biohazard container attached to the medication cart, removed her glove and cleaned her hands with sanitizer. Resident #197 came to medication cart located at the door of his room to obtain his oral medications as he was on leaving the facility for the day. LPN #4 then moved the medication cart down the hall to Resident #30's and prepared to obtain supply for blood glucose testing. 6. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, usually understands and is usually understood. At 9:59 AM on 2/24/17, LPN #4 picked up the multiple resident use the blood glucose meter, wrapped in a tissue, that sitting on the top of the medication cart and began to enter the resident's room with the glucose meter and necessary items for blood glucose testing. The surveyor then stopped LPN #4 to ask if the blood glucose meter had been cleaned since testing Resident #197 blood glucose level. The LPN #4 stated no, she had forgot to clean the blood glucose meter between resident use. Review of facility in-service record for the Evencare ProView Blood Glucose Monitoring System and a list of nurse actively working in the facility revealed that 14 of 43 nurses were in- serviced on the use of the Evencare Proview Blood Glucose Monitoring System During an interview with LPN #4 on 2/24/17 at 9:26 AM, LPN #4 stated that there is only one blood glucose meter on the medication cart. LPN stated that no residents have their own blood glucose meter and stated that is why she wipes the meter with a germicidal wipe between resident. During an interview with the DON on 02/24/17 10:10 AM the DON stated that there was an in-service last month on how to use the Evencare ProView Blood Glucose Monitoring System. The facility began using this blood glucose meter last month. The DON stated that the in-service included instruction to clean the blood glucose meter for 60 seconds after resident use. During an interview with LPN #4 on 02/24/17 at 12:59 PM, LPN #4 stated that blood glucose meter should be wiped for one minute and she thought she did cleanse glucose meter for that length of time each time she cleansed the blood glucose meter and then stated she thought that the glucose meter was moist from the germicidal cleanser for one minute after cleaning. 7. During intermittent observations on 2/28/17 between 9:00 AM and 2:00 PM in the following resident rooms revealed: room [ROOM NUMBER] - a fitted sheet that had brown/ black debris and footprints on it was on a fall mat; a towel with moderate amount of brown debris on it was left on the back of the toilet. room [ROOM NUMBER] - a used washcloth with a scant amount of brown debris was left on a chair sitting next to the bed; urine measuring hat and urinal were on toilet rail was not labeled in shared bathroom. room [ROOM NUMBER] - used washcloth with yellowish debris was left in sink. room [ROOM NUMBER] - a water irrigation kit used to flush the resident's feed tube (a device that's inserted into your stomach through your abdomen used to supply nutrition when you have trouble eating) was left on top of the toilet tank. room [ROOM NUMBER] - two dirty towels/ linens were on the back of the toilet; one soiled hospital gown and one soiled brief were on the floor next to the bed by the door. room [ROOM NUMBER] - a fracture bed pan and denture cup were both not labeled in a shared resident bathroom. Resident states during observation It's gross. It's not mine (denture cup), but I would hope they wouldn't mix it up. They probably would. room [ROOM NUMBER] - an unlabeled fracture bed pan and three wash basins were in a shared resident bathroom. Interview on 2/28/17 at approximately 1:16 PM with Certified Nurse Aide (CNA #5) revealed that a soiled towel should not be left on the toilet. She stated that she will remove it and put it in the soiled linen room. Interview on 2/28/17 at approximately 1:26 PM with Registered Nurse (RN #5) revealed that she expects her staff to label resident's equipment with a name or room number. She also stated that she expects her staff to remove soiled linen from the resident's room and put it in the soiled linen room. Interview on 2/28/17 at approximately 2:49 PM with RN #1 revealed that she expects all resident equipment to be labeled with the resident's name. She also stated that the items that aren't labeled need to be thrown out and replaced with new ones. 415.19(a)(1-3) 415.19(2) 415.19(c)

Plan of Correction: ApprovedApril 13, 2017

The licensed nurses #1, #2, #3, #4, #5, were educated on the cleansing of Glucometers by the DON/ADON on 2/24/17 involving Resident #30, #57, #148, #197, and #244.This education included review of facility policy and demonstration of proper Glucometer cleansing. Residents # 30,#57,#148,#197 and # 244 were monitored and no ill effects were noted from use of potentially contaminated equipment.
Resident room?s #222, #240, #324, #316, #408, #338, and #207 were completely cleaned by Housekeeping including all soiled equipment and dirty linens removed.
Resident specific equipment for residents # 240, 338 and 207 were labeled.
All residents have the potential to be affected.
A full house Audit was conducted to check Resident rooms and Resident areas for dirty linens, cleanliness of floor mats where utilized.Any dirty linen was immediately removed and any floor mats in place were cleaned by housekeeping.
An audit of all resident personal care equipment will be conducted to ensure that all equipment is labeled . Any issues noted will be immediately corrected.
The Medical Director was consulted on 2/28/17 regarding the issue with Glucometer cleansing and the ramifications of potential contamination was discussed.
All in house and discharged residents ( for the last 30 days) who have had blood glucose testing will be notified of possible exposure and will be offered follow up labwork.
All residents who have had blood Glucose testing will be monitored for any adverse effects from potential contamination of Glucometers.
The policy and procedure titled Glucometer Cleansing was reviewed and revised by the DON.
The RN Educator will educate all nursing staff regarding facility cleanliness with Glucometer cleaning as relates to infection control practices and above policy.
Additional education for all nursing and all housekeeping staff will include the importance of immediately disposing of soiled linen in the appropriate areas and the importance of double checking that resident equipment is clean and properly labeled.
The ADON/Designee will conduct environmental Infection control audits on each unit weekly x 4 and then monthly x 3. These audits will ensure that Infection control practices as relates to soiled linen and resident equipment are followed.
The RN Educator/Designee will conduct Glucometer cleansing audits for all nurses across all shifts weekly x 4 and then monthly x 2 months.
Results of the audits will be forwarded to the QA Committee Monthly for review and input.

Responsible Party:
DON

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY 831) conducted during the Standard survey completed on 3/1/17, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Two (Residents #57, 243) of five residents reviewed for nutrition had issues including weight loss with no nutritional interventions; no re-weights for a resident with significant weight loss; and a diet not provided per physician's orders [REDACTED].#57). The findings are: 1. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS- a resident assessment tool) dated 1/17/17 revealed the resident had intact cognition. Review of the weights were as follows: 1/13/17 = 380.5 pounds (lbs.) 12/1/16 = 405 lbs. There were no weights available in (MONTH) or (MONTH) (YEAR). 9/26/16 = 404 lbs. Review of a Nutrition Note dated 11/11/16 revealed the resident had recently been readmitted from the hospital secondary [MEDICAL CONDITION] (blood infection). She had a pressure ulcer to her left heel, vascular ulcers to her lower left leg, and right ankle. Review of the Nutrition Notes throughout the year (YEAR) revealed the resident has a history of low pre-[MEDICATION NAME] (a blood test that can indicate severe nutritional deficiency). Review of a Nutrition Note dated 1/13/17 revealed the resident had a 24.5 lbs. weight loss and weights and intake would be monitored. However, there is no documented evidence of a quarterly nutrition assessment in January, (YEAR) nor a re-weight due to the weight loss. Interview with the Registered Dietitian (RD) on 3/1/17 at 9:00 AM revealed the resident should have had a quarterly assessment completed in January, (YEAR) with the completion of the MDS. The RD stated there were no weights available for (MONTH) and November, (YEAR) and there was no re-weight in January, (YEAR). In summary, there were no weights obtained for two months and no re- weights when the resident had a 24 lbs. weight loss. There was no quarterly assessment completed in January, (YEAR) when the MDS was completed for the resident with a history of multiple open areas and low pre- [MEDICATION NAME] levels. 2. Resident #243 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's weights revealed the following: 9/9/16 =165 lbs. October and November, (YEAR) no recorded weights. December, (YEAR) resident refused to be weighed. January, (YEAR) no recorded weight. 2/24/17 = 157 lbs. 2/27/17 = 145 lbs. Review of a Nutrition assessment dated [DATE] revealed the resident is 65 inches tall. (Ideal body weight = 122-155 lbs.). There were no supplements added with or between meals and no re- weight obtained. The note documented the resident was on a No Added Salt (NAS) diet. and recommended liberalizing the diet to increase intake. Review of a physician's orders [REDACTED]. Review of the resident's current meal plan on 2/28/17 revealed the resident continued to receive a NAS diet. Review of the resident's Comprehensive Care Plan revealed no revisions were made to address the resident's weight loss or diet order change. 415.12(i)(1)

Plan of Correction: ApprovedApril 7, 2017

A nutritional assessment was completed for residents #57 and #243.
All Residents have the potential to be affected.
A full house audit was conducted, with a look-back of 90 days, to ensure: weights were taken, weight changes were noted and acted upon, abnormal labs and altered skin integrity were identified,resident diet was correct as MD/NP order and nutritional assessments/interventions were completed. Any interventions needed were immediately documented and implemented.
The policy and procedure titled Weight assessment was reviewed by the DON/Dietician.
Resident diets will be reviewed at the weekly weight/wound meeting to ensure that diets are provided as per MD/NP order.
All RN Unit managers, dieticians and IDCP team members were educated on the need to double check that resident diets are provided as per MD/NP order.

The Registered Dieticians/ Nursing staff were educated by the Regional Director of Nutrition Services as to the importance of weights consistently taken, weight changes documented and acted upon, abnormal labs and altered skin integrity reviewed and nutritional interventions implemented as necessary, and that resident diets are provided as per MD/NP order.
The RD supervisor will conduct monthly audits x6 on 10 residents per floor, to ensure that weights are consistently taken, weight changes documented and acted upon, abnormal labs and altered skin integrity are reviewed, quarterly nutrition assessments/interventions are completed and that proper diet is provided as per MD/NP order.
The results of audits will be forwarded to the QA Committee Monthly for review and input.
Responsibility: Administrator

FF10 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: (i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: May 12, 2017

Citation Details

Based on interview, observation and record review conducted during the Standard Survey completed 3/1/17, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. One of one dish washing machine rooms, located on the Ground Floor had fruit/ sewer flies prevalent in the room. The finding is: 1. Observations of the the dish washing machine room located on the Ground Floor, with the Director of Maintenance, on 2/24/17 at approximately 11:55 AM revealed fruit flies were present in the room. When one of the two 55-gallon trash receptacles were moved, a large swarm of flies flew out and gathered in flight above the cans. Interview with the Director of Maintenance at the time of the observation revealed that both of the trash cans were recently purchased to replace the old cans that were discarded. Further observations revealed the floor was recently mopped, as the floor was wet and appeared clean. Continued observation of the area under the dish washing machine shelves revealed pooling of water, approximately ½ inch deep. Continued interview with the Director of Maintenance revealed the pooling water is coming from an old grease trap that is located under the floor. Review of Pest Control Management Logs on 2/24/17 revealed 9 of 10 Technician Reports from the outside contractor identified Fruit Fly as a Target Pest. The following comments were written on the Technician's reports: - 2/16/17 Thank you for cleaning back wall of the dish room. Now clean floor drains, physically, hot water flush and closing. - 12/28/16 Garbage, grease still on floor & water leak in dish room. - 11/28/16 Dish room still not fixed, water leaking from sprayer down wall. Fruit flies better but still has them. - 6/30/16 Dish machine room needs cleaning around grease trap & under garbage disposal. Tiles need repairing. - 4/11/16 Dishwashing room needs scrubbing & drying out along baseboards, walls & floors under equipment still. Review of Maintenance Logs section of the pest control binders, as written by the pest control technician, under Recommendations stated: - 11/28/16 Need to fix dish room leaks. - 10/31/16 Need treatment when room is cleaned. 415.29(j)(5)

Plan of Correction: ApprovedApril 6, 2017

The dish/wash room was fully cleaned and sanitized.
The 55-gallon trash receptacles were removed.
The pooling of water in the dish/ wash room was suctioned away.
The FSD in-serviced all food service employees regarding sanitation standards and practices.
The Maintenance Director educated the FS employees on the 32-Gallon receptacle requirement.
The Maintenance Director implemented a new protocol for the daily removal of water on the dish room floor.
The grease trap in the floor was permanently disabled and floor was leveled so there is no further pooling water; in addition a new grease trap was installed.
The FSD will audit the dish room on a weekly basis x4, and then monthly x6 to ensure that all sanitation standards and practices are being met.
Any issues noted will be immediately addressed.

Results of the audits will be forwarded to the QA Committee for review and input.
Responsibility:
Administrator

FF10 483.25(g)(4)(5):NG TREATMENT/SERVICES - RESTORE EATING SKILLS

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- (4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident?s clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and (5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Standard survey completed on 3/1/17, the facility did not provide the appropriate treatment and services to ensure nutritional needs were met for a resident with a tube feeding (nutrition provided through a tube placed in the stomach). Specifically, one (Resident #140) of two residents reviewed for tube feeding had issues involving a significant weight change that was not monitored, weights were not completed as ordered, a lack of follow up on abnormal labs, and the lack of monitoring the actual volume of feeding provided. The finding is: 1. Resident #140 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) revealed the resident's cognition is severely impaired. Review of an Admission Nutritional assessment dated [DATE] revealed the resident had an enteral feed (nutrition provided through a tube placed in the stomach) and was NPO (receives nothing by mouth). The resident received Glucerna 1.2 (liquid formula) via the tube feeding at 85 milliliters (ml) per hour continuously. The most recent weight on 8/18/16 was 156.8 pounds and documents the resident has had no significant weight change. The resident had a Stage IV sacral pressure sore on the sacrum (area on the buttocks). The resident had a pre- [MEDICATION NAME] (a blood protein) dated 8/19 of 4.0 (normal levels 17-34) and an [MEDICATION NAME] (protein level in the blood) of 2.3 (3.3 to 4.8). The resident's estimated needs were 1780-2140 calories and 85-114 grams of protein. The tube feeding provided 2448 calories and 122 grams of protein which was adequate to meet the resident's needs. The resident also received Proform Advanced (protein supplement) 30 ml twice a day (BID) providing an additional 200 calories and 34 grams of protein. The goal for the resident was to maintain weight. Review of the current comprehensive care plan with a revision date of 2/28/17 revealed interventions to include monitor weights per policy, and report significant weight losses to MD (medical doctor) and IDC (interdisciplinary team) for input. Review of the Weight Summary sheet revealed there was no (MONTH) weight available. On 10/14/16 the resident's weight was documented as 131.6 pounds. Review of a Dietary Progress Note dated 11/25/16 revealed they received a request for a fluid restriction. The plan was to decrease the free water flushes. The fluid restriction was related to a [DIAGNOSES REDACTED]. Review of the Weight Summary sheet revealed there were no documented weights available for (MONTH) or December. Review of a Dietary Progress Note dated 12/1/16 revealed the resident received tube feeding of Glucerna 1.2 at 60 ml per hour. The resident also received Proform Advanced BID providing for an additional 200 calories and 34 grams of protein. Review of the Physicians Progress Notes dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed that there was no documentation addressing the resident's weight loss. Additional review of the Weight Summary sheet revealed the resident's (MONTH) weight was documented as 129 pounds. Review of a Dietary: Nutritional Quarterly assessment dated [DATE] revealed the resident is still NPO and received an enteral feed which was changed to Glucerna 1.5 at 50 ml/hr. times 24 hours. This provided 1800 calories and 99 grams of protein. The most recent weight on 1/6/17 was documented at 129 pounds. The assessment documented the resident had a Stage IV pressure sore on the sacrum and a Stage III on the right heel. The [MEDICATION NAME] level is 2.4. The Assessment Summary documents weight loss and estimated nutritional needs are based on actual weight. The estimated nutritional needs are 1770-2065 calories, and 89 to 106 grams of protein. Additionally, providing Proform Advance liquid protein supplement. The resident is receiving 2000 calories and 133 grams of protein. Review of the Weight Summary sheet revealed the resident's weight on 2/10/17 was documented as 127.4 pounds. Review of a Dietary Progress Note dated 2/13/17 documents the resident has seen weight loss of 29.4 pounds since 8/18/16 for a -18.8% (percent) decrease in body weight. Enteral feeds and supplements should meet estimated needs. Resident has been receiving feeds per the Medication Administration Record [REDACTED]. Continue to monitor weights and need to adjust feed. Review of the Clinical Physician order [REDACTED]. Review of the MARs from 8/16/16 through 2/16/16 revealed there was no documentation of the total daily volume to be infused. Observation of the resident on 2/28/17 revealed the tube feeding pump was off at 12:45 PM. It was observed on at 1:00 PM. Review of the Weight Summary sheet printed on 2/28/17 revealed the last weight documented was 2/10/17. Interview with the Registered Dietitian (RD#1) on 2/28/17 at 9:00 AM revealed those are the only weights there are for the resident and there should have been weekly weights completed as ordered on [DATE]. Interview with RD #2 on 2/28/17 at approximately 10:30 AM revealed the nurses are just checking off the formula as administered on the treatment record. We really should have them accounting for how much formula is infused per shift. During a further interview with RD#2 on 3/1/17 at 10:05 AM revealed they should have followed up on the resident's weight loss. The nurses really should be accounting for the total formula infused and there should have been a re-evaluation of the pre-[MEDICATION NAME]. During a phone interview on 3/1/17 at 10:45 AM, Physician #1 stated that she was unaware of the resident's weight loss. The weight loss may be related to [MEDICAL CONDITION] (swelling) or use of a diuretic (medication that promotes urine excretion). The resident's formula was adjusted because she was hyponatremic. Review of the current Clinical Physician order [REDACTED]. Review of a facility policy entitled Weight Assessment and Intervention dated 2/27/17 the nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter. If no weight concerns are noted at this point weights will be measured monthly. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing staff will immediately notify the Dietitian in writing. The Dietitian will respond in 24 hours. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends. Negative trends will be evaluated by the team whether or not the criteria for significant weight change has been met. Review of a facility policy entitled Enteral Nutrition Dietary-Nursing dated (MONTH) (YEAR) revealed that the enteral feeding orders will be written to ensure consistent volume infusion. The following will be included to ensure that the full volume will be infused regardless of any interruption of the feeding, total daily volume to be infused (number of ml per day). 415.12(g)(2)

Plan of Correction: ApprovedApril 13, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Nursing staff were counseled and educated by the RN Educator on 2/27/17 and 3/1/17 regarding obtaining resident weights in a timely manner.
Lab work was obtained for resident # 140 on 3/1/17, reviewed with MD and obtained any new orders if needed.
Resident # 140 was admitted to the hospital on [DATE]. Upon resident?s return to facility, MD order will include total daily volume of feeding to be infused (number of ml per day) as per facility policy.
An up dated nutritional assessment was completed on resident #140.
All residents have the potential to be affected.
All residents were weighed by nursing staff on 2/27/17.
All residents noted to have weight loss were re-evaluated by the Dietician to ensure that nutritional interventions were initiated as needed. There were no issues noted.
All residents receiving alternative feeding were reassessed and interventions were implemented as needed.
The policy and procedure titled Enteral Feeding was reviewed and revised by the DON/Dietician.
Interdisciplinary weekly weight meeting was initiated on 3/17/17.All residents with noted weight loss were reviewed and interventions implemented as necessary. This meeting will continue on a weekly basis.
All nursing and dietary staff will be re-educated on facility weight and Enteral feeding policy by the ADON/designee. This will include: the importance of documenting on the MARS and quantity of feeding that was infused, obtaining weights in a timely manner, initiating interventions for those residents noted with weight loss, timely follow up on labs and enteral feeding orders written to specify consistent volume infusion.
The need to notify physicians of resident significant weight loss will be stressed. When resident significant weight loss is identified the physician will be contacted via phone by the Dietician and or nurse for any further directives/ orders, this will be documented in the medical record.
All residents receiving enteral feedings will be audited by the Registered Dietician weekly x 4 and then monthly x 3. Audits will ensure that weights are obtained in a timely manner and that interventions are initiated,needed lab work obtained and that physicians are notified for any residents experiencing weight loss.
The MD order will also be checked to verify that actual volume of feeding administered is documented. Any issues noted will be immediately addressed.
Results of audits will be forwarded to the QA Committee for review and input.
Responsibility : DON

FF10 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: (d) Food and drink Each resident receives and the facility provides- (d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation, interview and record review conducted during a Standard Survey completed on 3/1/17, the facility did not provide food for resident consumption that was palatable, attractive and at the proper temperature. One of one test trays conducted during a lunch meal revealed the hot and cold food was not served at acceptable temperatures. This involved Residents # 1, 104, 139, 161 and 308. The finding is: 1. During an interview on 2/22/16 at approximately 8:40 AM, Resident #161 stated the food is terrible and cold. During an interview om 2/23/17 at approximately 8:37 AM, Resident #139 stated the food is lousy, we don't get what we ask for and the food is scarce. In addition, resident stated it has been less of a problem since survey staff is here; however I know it will go back to being bad when the survey team leaves. During an interview on 2/23/17 at 9:45 AM, Resident #308 revealed the food is always cold. The resident stated You'd think they could keep it hot, were just on the second floor. One floor away. During an interview on 2/23/17 at at approximately 11:00 AM, Resident #1 stated the food is awful. They serve hot food cold. I have lost weight because I won't eat because the food is so bad. During an interview on 3/1/17 at 9:10 AM, Resident #104 stated the food is frequently served cold. There are many complaints from all the floors and the main dining room. Many times the trays are late because they say they are short of staff. Sometimes they have to go down stairs to get the carts and bring them up to us. By that time the food is cold. Review of the Fall/ Winter (YEAR) Week three menu revealed the lunch meal on Monday 2/27/17 was chicken alfredo with noodles and broccoli. A test tray was conducted on the third floor with the Food Service Supervisor using the facilities thermometer. The food cart arrived on the 3rd floor unit at 1:00 PM and temperatures were taken at 1:45 PM after all trays in the cart had been passed to residents. The chicken alfredo with noodles was tempted at 120 degrees Fahrenheit (F) and luke warm to taste; broccoli was tempted at 106 degrees F and cold to taste; coffee was tempted at 125 degrees F and cool to taste; milk was tempted at 50 degrees F warm and not palatable. Review of a facility policy and procedure entitled Food Safety Requirements dated 1/27/17 revealed general holding temperatures is 135 degrees F or above for hot food and 41 degrees F or below for cold food. 415.14(d)(1)(2)

Plan of Correction: ApprovedApril 7, 2017

Residents: #1, #104, #139, #161, and #308, were interviewed regarding food preferences, cultural/religious dietary practices, and menu options. Meal plans were adjusted as needed.
All residents were interviewed (as appropriate) regarding food preferences cultural/religious dietary practices, and menu options. Meal plans were adjusted as needed.
Food temperatures were taken for one week, for each meal, when carts arrived at the nursing floors, to ensure hot/cold temperatures were maintained.
The FSD audited each food preparation, and tray assembly practices for each meal time for one day, to assess the level of level of palatability on meal presentation.
The FSD in-serviced all food service employees and RDs on the importance of honoring resident preferences, cultural/religious dietary practices,consistent temperatures and providing menu options .
The FSD also in-serviced all food service employees regarding food palatability, consistent temperatures and meal presentation. Meal preparation and presentation modifications were identified and implemented.
Diet Histories will be completed on all new admissions to review and obtain food preferences, cultural/religious dietary practices, and ensure menu options are known.
The RDs/FSD will audit 10 diet histories and preferences per floor, per week x4, then monthly x6; to ensure that preferences/practices are noted and being honored.
The FSD will audit each food/preparation and tray assembly practice for each meal ensuring correct temperature and palpability, 3 times per week x4 weeks, and then monthly x6 months.
Any issues noted will be immediately addressed.

Results of the audits will be forwarded to the QA Committee for review and input.
Responsibility:
Administrator

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/1/17, the facility did not ensure that residents received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Three (Residents #72,157 and 197) of thirty-two residents reviewed for quality of care had issues. Specifically, Resident #72 was receiving [MEDICATION NAME] (medication used for [MEDICAL CONDITION]) and laboratory (lab) work was not completed as ordered. Resident #157 was sent to the hospital and had a completed MOLST (medical orders for life sustaining treatment) form revealing no hospitalization . In addition, Hospice Care was not notified prior to the hospital transfer. Resident #197 did not receive monitoring of a [MEDICAL TREATMENT] shunt for approximately three months by nursing. The findings are: 1. Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a significant change MDS (minimum data set- an assessment tool) dated 2/13/17 revealed the resident is cognitively intact and is understood and understands. Review of Comprehensive Care Plan (CCP) with date initiated 1/4/17 revealed the resident has a MOLST in place which indicates DNR (do not resuscitate) with a goal that resident's advance directives will be regarded and respected. The CCP lacked coordination of care between the facility, hospice agency, resident and family. Review of the Medical Orders for Life-Sustaining Treatment (MOLST) form signed by NP and dated 1/27/17 revealed comfort measures only. Do not send to the hospital unless pain or severe symptoms cannot be otherwise controlled. Review of a Order Listing Report dated 2/27/17 revealed physician order- Do not hospitalize unless pain or severe symptoms cannot be otherwise controlled. Review of the Hospice Buffalo Information Form for Facilities revealed the resident was started on Hospice 1/7/16 and then when readmitted was started back again on Hospice on 2/7/17. It directed facility staff to call Hospice Buffalo 24 Hours per Day, Seven Days per Week for: - All changes in physician orders (medications and treatments). - Changes in condition. - Symptom management needs. - Anticipated transfer to ER. - Resident/family concerns. Review of Nurses Progress Notes dated 2/2/17 at 2:21 PM revealed the resident demonstrates or verbalizes controlled pain levels with current interventions. Review of Nurses Progress Notes dated 2/2/17 at 4:34 PM and 9:35 PM revealed the resident was medicated with [MEDICATION NAME] (a narcotic pain reliever) 5 mg (milligrams) for pain with effect. Review of Nurses Progress Notes dated 2/2/17 at 11:56 PM reveals resident's Hgb levels critically low 6.5. The NP ordered a blood transfusion and the resident was sent out to the hospital. Review of the Hospital Discharge Summary dated 2/6/17 revealed the resident was sent to the ED (emergency department) for [MEDICAL CONDITION] noted on lab. Hgb (hemoglobin) 6.5 noted on outpatient lab and patient was sent to the ED. Of note, patient's MOLST form indicates Do not send to hospital unless severe uncontrollable symptoms. Pt. denies any symptoms from his [MEDICAL CONDITION]. It was further noted that Hospice liaison saw the patient yesterday and apparently the facility sent the patient to the hospital without informing hospice service. Please avoid doing any further change Hgb & Hct (hemoglobin and hematocrit) or CBC (complete blood count) in the facility and contact hospice before any decision was made to send the resident to the hospital. Patient is on hospice care measures and comfort care and does not need his labs to be checked. MOLST form is in the chart and signed by the patient. During an interview with the Director of Social Work on 2/27/17 at 12:15 PM revealed Hospice should have been notified prior to the resident's transfer to the hospital. During an interview on 2/27/17 at 12:49 PM the Registered Nurse (RN #4) stated that she was unable to locate a physician's order to transfer the resident to the hospital on [DATE]. During an interview with the Physician on 2/27/17 at 2:44 PM revealed performing labs for chronic [MEDICAL CONDITION] is not necessary. He would expect the nurse would call Hospice before calling the NP. He further stated that communication is a problem and everyone should be on the same page. During an interview on 2/27/17 at 3:00 PM the NP stated that she was not aware of the MOLST direction. She reviewed the lab and recommended the transfusion. Usually hospice residents are on the 3rd floor. She would expect the nurse to inform her that the resident was receiving Hospice services. During an interview on 2/27/17 at 3:05 PM the RN #6 revealed she saw the lab results and called the NP. She didn't recall seeing the directive to call Hospice first. She further stated she did not write the order to transfer the resident to the hospital because she usually just sends residents without writing an order. During an interview with RN #4 on 2/27/17 at 3:10 PM she stated that if the Physician or NP recommend sending a resident to the hospital the nurse is supposed to write the order. During an interview with RN #5, RCC (Resident Care Coordinator) on 2/28/17 at 10:11 AM revealed she did not know why the resident was sent to the hospital because he was on Hospice. Review of the facility policy titled Hospice Program Buffalo Center revised 2/2014 reveals under #4- When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/ family will be developed. 2. Resident #72 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact and is understood and understands. Review of the undated Comprehensive Care Plan revealed the resident is at risk for falls due to a [MEDICAL CONDITION] disorder. Review of a Order Summary Report dated 12/10/16 revealed physician orders for [MEDICATION NAME] (also known as [MEDICATION NAME]- is an anti-epileptic drug or anticonvulsant) Sodium Extended Capsule 100 mg- give four capsules PO (by mouth) at HS (bedtime) for anticonvulsant. Review of the Order Summary Report dated 3/7/16 revealed an order for [REDACTED]. Review of the lab section of the medical chart and the Electronic Medical Record (EMR) lab section on 2/27/17 at approximately 11:00 AM revealed a lack of documentation that the [MEDICATION NAME] level was drawn. Interview with the MDS Coordinator on 2/28/17 at approximately 10:30 AM revealed this order was written around the time we had many staffing changes. Review of the lab draw book with the MDS Coordinator on 2/28/17 at 10:35 AM revealed a lack of documented evidence that the [MEDICATION NAME] level was drawn. Interview with the MDS Coordinator at that time stated the lab results may be with the Medical Records Person who scans the lab results into the computer and she would see if the lab results were with her and had just not been scanned into the EMR. On 3/1/17 at approximately 2:15 PM the RN #7, Assistant Director of Nursing (ADON) provided the Surveyor with [MEDICATION NAME] level results dated 3/1/17 timed at 2:00 PM. During an interview with the RN#7 ADON at that time it was stated those are the only [MEDICATION NAME] results we have available. Review of the results revealed a [MEDICATION NAME] level of 20.3 slightly high with normal levels at 10.0-20.0. 3. Resident #197 was re- admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, usually understands and is usually understood. Further review of the MDS revealed the resident is taking anticoagulant medication and received [MEDICAL TREATMENT] services. Review of the Order Summary Report for the period 11/12/16 to 3/1/17 revealed physician orders for [MEDICAL TREATMENT] Monday, Wednesday and Friday at an outpatient [MEDICAL TREATMENT] unit as well as the following active orders, dated as follow: - 2/8/17 Check left upper arm fistula for bleeding and infection every shift - 2/8/17 Check left upper fistula for bruit (a whooshing sound of blood flow heard with a stethoscope) and thrill (a buzzing palpation felt by palpitating the site) every shift. Further review of the Order Summary Report revealed the following discontinued physician orders: - 11/18/16 Check Bruit and thrill to fistula ULE ( upper left extremity-arm). - 2/8/17 Check left arm fistula site for bruit and thrill every shift for [MEDICAL CONDITION]. Review of the Comprehensive Care Plan dated 11/17/16 revealed the resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. Interventions include to not draw blood or take blood pressure in left upper arm fistula, the resident receives [MEDICAL TREATMENT] Monday, Wednesday and Friday; and to monitor/ document/ report to MD (medical doctor) as needed for signs/ symptoms of bleeding, hemorrhage, bacteremia (bacteria in the blood) and septic shock (life threatening illness). Review of Progress Notes from 12/1/16 to 1/30/17 revealed a total of twelve nursing observations of the status of the resident's left arm fistula. Review of the Medication and Treatment Administration Records (MAR, TAR) for (MONTH) and (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documented evidence that the resident's left arm fistula was observe for proper functioning and for possible complication on days between [MEDICAL TREATMENT] treatments and before or after returning from [MEDICAL TREATMENT] treatment. Review of the (MONTH) (YEAR) MAR and TAR revealed nursing staff began documenting the assessment of the left upper arm fistula for bleeding, infection, and bruit and thrill every shift beginning on 2/9/17 at 3:00 PM except on the 3:00 PM to 11:00 PM shifts on 2/18/17 and 2/19/17 where there is no documentation. During an interview with the Registered Nurse Director of Nursing (DON) on 03/1/17 at 8:32 AM the DON stated that nursing staff should observe the [MEDICAL TREATMENT] shunt every shift. The DON stated that this would be a physician's orders that would carry over to the MAR. The DON stated that a second check of Physician Orders is completed for medication reconciliation after the Admission Nurse completes the Physician Orders and the lack of an order to observe the [MEDICAL TREATMENT] shunt this should be have identified at that time. 415.12

Plan of Correction: ApprovedApril 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** RN UM was counseled by the DON on 2/28/17 regarding lab work not obtained for resident #72 and the MD was notified that labs were not obtained in a timely manner. Labs were obtained for resident #72 on 3/1/17 with no new orders per MD.
Advanced directives were reviewed for resident # 157 with no changes noted.
The [MEDICAL TREATMENT] shunt site for resident # 197 was assessed by the RN with no complications or issues noted.
RN Nursing supervisor and the NP were counseled by the DON on 3/22/17 regarding sending resident #157 to the hospital despite him being on Hospice care and MOLST directives clear in regards to no hospitalization . The need to notify Hospice of resident being transferred to hospital was also discussed during this counseling, along with the need to obtain/ write MD order.
The RN UM responsible to ensure that resident #197 [MEDICAL TREATMENT] shunt was monitored was counseled by the DON on 3/20/17.
All Residents have the potential to be affected.
A full house audit of all residents receiving [MEDICATION NAME] or Hospice care services and that have [MEDICAL TREATMENT] shunts will be conducted.
The audit will ensure that all appropriate labs are drawn per MD order for residents receiving anti-[MEDICAL CONDITION] medication, that residents with [MEDICAL TREATMENT] shunts have daily clinical monitoring including MD orders for shunts, and Residents on Hospice services the plan of care is followed and appropriate.
The Policies and Procedures titled [MEDICAL TREATMENT] Care, [MEDICAL TREATMENT] Access Care, and Lab Diagnostic test results FU were reviewed by the DON.
All licensed nurses and Nurse practitioners will be educated by the RN educator on above policies regarding Hospice services, importance of obtaining ordered lab draws and daily monitoring of [MEDICAL TREATMENT] shunts.
The ADON/Designee will conduct an Audit on all [MEDICAL TREATMENT] Residents and all Hospice Residents weekly x4 then monthly x3 to ensure [MEDICAL TREATMENT] Shunts are monitored and Hospice Resident care plan is adhered to.

The ADON/Designee will conduct an Audit of 20% of Resident Lab draws x4 weeks then monthly x 3 to ensure labs are obtained and addressed by Nursing and MD.
Results of the audits will be forwarded to the QA Committee Monthly for review and input.
Responsible Party: DON



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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation ( Complaint # NY 907) during the Standard survey completed on 3/1/17, the facility did not maintain clinical records on each resident in accordance with acceptable professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Seven (Residents #26, 48, 134, 161, 169, 209, 222) of 32 residents' medical records had issues involving incomplete and inaccurate documentation of the administration of the residents' medications. The findings include but are not limited to: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/21/16 revealed the resident has moderate cognitive impairment, understands and is understood. Review of the Order Summary Report for the period 12/21/16 to 1/21/17 included physician orders [REDACTED]. - [MEDICATION NAME] 5-325 mg one tablet by mouth every 12 hours for pain. - [MEDICATION NAME] Ointment 5% (percent) apply to posterior neck topically every morning and at bedtime for pain. - [MEDICATION NAME] 5 mg (milligram) one tablet by mouth one time a day for [MEDICAL CONDITION] ([MEDICAL CONDITION]- enlarged prostate gland.) - Mirabegron ER (extend release) 25 mg one tablet by mouth one time a day for overactive bladder. - [MEDICATION NAME] 137 mcg (microgram) one tablet by mouth in morning for [MEDICAL CONDITION] maintenance. - Aspirin Chewable 81 mg one tablet by mouth one time a day for heart health. - [MEDICATION NAME] powder 17 grams by mouth one time a day for constipation - [MEDICATION NAME] 150 mg one tablet by mouth one time a day [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease.) - Senna-[MEDICATION NAME] Sodium 8.6-50 mg one tablet by mouth two times a day for constipation Review of the Medication Administration Record [REDACTED] - 1/8/17, 6:00 AM [MEDICATION NAME] - 1/10/17, 6:00 AM to 10:00 AM - [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] - 1/11/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Mirabegron - 1/12/17, 7:00 AM to 10:00 AM - Mirabegron - 1/13/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Mirabegron - 1/16/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Mirabegron - 1/17/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Mirabegron - 1/22/17, 6:00 AM - [MEDICATION NAME] - 1/24/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] - 1/27/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] - 1/31/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] - 2/1/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, Mirabegron, [MEDICATION NAME] - 2/2/17, 7:00 AM to 10:00 PM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, and [MEDICATION NAME] - 2/7/17, 6:00 AM and 8:00 AM - [MEDICATION NAME] - 2/8/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] - 2/9/17, 8:00 AM - [MEDICATION NAME] - 2/10/17, 8:00 AM - [MEDICATION NAME] - 2/14/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] - 2/15/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Aspirin, [MEDICATION NAME], Senna-[MEDICATION NAME] Sodium, [MEDICATION NAME], Mirabegron, [MEDICATION NAME] Further review of the medical record revealed no documentation regarding the lack of administration of the identified medications. 2. Resident # 209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired cognitive skills and sometimes understands. Review of the Order Summary Report for the period 1/1/17 to 2/28/17 included physician orders [REDACTED]. - [MEDICATION NAME] 100 mg one capsule by mouth two times a day for stool softener. - [MEDICATION NAME] Sprinkles 125 mg one capsule by mouth every 12 hours for episodic dyscontrol - Klonopin 0.5 mg one tablet by mouth in the morning and two tablets by mouth at bedtime for anxiety. - Senna-S 8.6-50 mg two tablets by mouth two times a day for constipation. - [MEDICATION NAME] 100 mg one tablet by mouth one time a day. - [MEDICATION NAME] Shampoo 2% to scalp and nasolabial folds (area of skin that separates the cheeks from the upper lip) topically every Wednesday day shift for dandruff. - [MEDICATION NAME] Cream 0.1% to nose, cheeks, forehead topically every day and evening shift for skin redness. Review of the MAR for (MONTH) and (MONTH) (YEAR) revealed no documented evidence that the resident received, refused or was unable to take the following medications as ordered on these dates: 1/3/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Cream 1/4/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Shampoo, [MEDICATION NAME] Cream 1/8/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Cream 1/9/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Cream 1/10/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] Cream 1/11/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Shampoo, [MEDICATION NAME] Cream 1/12/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Cream 1/13/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] Cream 1/16/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] Cream 1/17/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] Cream 1/24/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] 1/25/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Shampoo, [MEDICATION NAME] Cream 1/26/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Cream 1/27/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] Cream 1/30/17, 7:00 AM to 3:00 PM - [MEDICATION NAME] Cream 1/31/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] 2/1/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S, [MEDICATION NAME] 2/2/17, 7:00 AM to 10:00 AM - [MEDICATION NAME] 2/7/17, 7:00 AM to 10:00 AM - [MEDICATION NAME] 2/8/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S 2/10/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S 2/10/17, 7:00 PM to 10:00 PM - [MEDICATION NAME] Sprinkles, Klonopin 2/14/17, 7:00 AM to 10:00 AM - Klonopin, [MEDICATION NAME] Sprinkles, [MEDICATION NAME], Senna-S Further review of the medical record revealed no documentation regarding the lack of administration of the identified medications. 3. Resident #161 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. Review of the Order Summary Report for the period 1/1/17 to 2/28/17 included physician orders [REDACTED]. - [MEDICATION NAME] 10 mg one tablet by mouth two times a day for muscle relaxant - [MEDICATION NAME] 75 mg one capsule by mouth every 12 hours for pain. - [MEDICATION NAME] 1000 mg one tablet by mouth two times a day for [MEDICAL CONDITION] (from 2/9/17 to 2/16/17). - [MEDICATION NAME] 500 mg one tablet by mouth in the morning for convulsion (as of 2/16/17). - [MEDICATION NAME] 1000 mg one tablet by mouth in the evening for convulsions (as of 2/16/17). - Neurotin 100 mg two capsules by mouth every 8 hours for nerve pain (discontinued 2/16/17). - Neurotin 300 mg one capsule by mouth three times a day for pain (as of 2/16/17). - [MEDICATION NAME] 10 mg one tablet by mouth two times a day for anxiety. - [MEDICATION NAME] 10 mg one tablet by mouth at bedtime for depression. - [MEDICATION NAME] coated Aspirin 81 mg one tablet by mouth one time a day for heart health. - [MEDICATION NAME] Tablet 20 mg one tablet by mouth at bedtime for acid indigestion. - Sennosides-[MEDICATION NAME] 8.6-50 mg one tablet by mouth a day for constipation - [MEDICATION NAME] 1000 mcg (micrograms) one tablet by mouth one time a day for vitamin deficiency. - Multiple Vitamin-Minerals two capsules by mouth every 8 hours for nerve pain. - Vitamin C 500 mg one tablet by mouth two times a day for supplement. Review of the Medication Administration Record [REDACTED] 2/14/17, 7:00 AM to 10:00 AM - [MEDICATION NAME], Neurotin, [MEDICATION NAME] coated Aspirin, Multiple Vitamins-Minerals, Sennosides-[MEDICATION NAME], Vitamin C, [MEDICATION NAME] 2/17/17, 8:00 AM to 2:00 PM - [MEDICATION NAME], 2 doses of Neurotin 2/17/17, 4:00 PM to 10:00 PM - [MEDICATION NAME], Neurotin 2/18/17, 9:00 PM - [MEDICATION NAME] 2/24/17, 4:00 PM to 10:00 PM - [MEDICATION NAME], Neurotin, [MEDICATION NAME], Vitamin C, [MEDICATION NAME] 2/28/17, 4:00 PM to 10:00 PM - [MEDICATION NAME], Neurotin, [MEDICATION NAME], Vitamin C, [MEDICATION NAME] Further review of the medical record revealed no documentation regarding the lack of administration of the identified medications. During interview with the Director of Nursing (DON) on 3/1/17 at 8:32 AM, the DON stated that the electronic medical record has a report that should identify any medications that were not signed off. The DON stated that she just became aware of the lack of nursing sign off for medication administration. The DON also stated that the UM should have been able to identify blanks on MAR indicated [REDACTED] During an interview with the Registered Nurse (RN #1) Unit Manager (UM) on 3/1/17 at 9:12:59 AM, the UM stated she has been working at the facility for approximately three weeks and has identified there are many things she needs to address. The UM stated that she was not aware that the MAR indicated [REDACTED]. During an interview with the RN UM (RN #2) on 3/1/17 at 9:43 AM, the UM stated that she cannot see medications not signed off on the MAR indicated [REDACTED]. The UM was not aware that the administration of all medication were not documented for residents on the nursing unit. 415.22 (a)(1,2)

Plan of Correction: ApprovedApril 10, 2017

Licensed nurses responsible for medication administration for residents # 26, 48, 134, 161, 169, 209, and 222 were counseled by the ADON on 3/20/17 regarding the need to ensure that all medications given are accurately signed for on the MAR and in the narcotics log.
All residents have the potential to be affected.

A full house audit will be conducted on previous 30 days of MAR?s for accuracy of documentation. Any issues noted will be immediately addressed by the DON/ADON; nurses will be counseled and or receive medication error memos where indicated.
The policy and procedure titled Medication Administration was reviewed and revised by the DON/Administrator.
The RN Educator will educate all licensed nurses regarding facility medication administration policy. Timely signing of medications administered, accuracy of medical records and Nurses giving shift report by reviewing the EMAR together for any un-signed items for the shift. The on-coming Nurse will not accept the assignment until EMAR is clear.
Medication Administration Audits for each unit will be run via Point Click Care (EMAR exceptions report) daily by the ADON/ designee and brought to daily Morning meeting for team review. This Audit will be on-going at this time to ensure all medications are given per MD order.
The results of audits will be forwarded to the QA Committee for review and input.
Responsibility : DON

FF10 483.90(i)(5):SAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRON

REGULATION: (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: May 12, 2017

Citation Details

Based on observation and interview during the Standard Survey completed on 3/1/17, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents' staff and the public. Four (Ground, Second, Third, Fourth) of four resident use floors had issues involving resident showers that were out of service; plumbing fixtures that could not be turned off; an HVAC (Heating, Ventilation and Air Conditioning) duct that had a missing vent cover; light fixtures with missing shield covers: a dryer vent that was disconnected and venting into laundry room, and water pooling on the floor in the dish machine room due to a faulty grease trap. The findings are: 1. Observation on 2/22/17 at approximately 9:47 AM revealed a ventilation duct, located in the Fourth Floor corridor across from resident room #C436, was missing its vent cover. Observation on 2/22/17 at approximately 9:49 AM revealed the ceiling mounted light fixture in the Fourth Floor corridor across from resident room #C434, was missing its light shield cover, exposing two U shaped fluorescent light bulbs. Observation on 2/22/17 at approximately 10:12 AM revealed two of two showers in the Central Shower room on the Fourth Floor, B wing were not operable. The handles for both showers were disconnected. Interview with the Director of Maintenance on 2/27/17 at approximately 11:25 AM revealed the shower valves are going to be replaced. 2. Observation on 2/22/17 at approximately 11:45 AM revealed the water in the handwashing sink in the Central Shower room on the Third Floor, A wing, could not be turned off. 3. Observation on 2/23/17 at approximately 11:45 AM revealed one of four dryer vents was disconnected and venting into the Ground Floor Laundry room. The dryer was on at the time of the observation. 6. Observation of the Dish Washing Machine Room, located on the Ground Floor, in the presence of the Director of Maintenance on 2/24/17 at approximately 11:55 AM revealed there was water pooling , approximately ½ inch deep, under the dish washing machine and attached shelving. Interview with the Director of Maintenance at the time of the observation revealed the pooling water was coming from an old grease trap located under the floor, that was not removed when a new grease trap was installed. 415.29

Plan of Correction: ApprovedApril 6, 2017

The vent cover located in the 4th floor corridor across from room C436 was replaced.
The light fixtures were replaced in the 4th floor corridor across resident room C434.
The two shower rooms on the 4th floor were renovated, and made fully operable.
The handwashing sink in the 3rd floor shower room on A wing was replaced.
The dryer vent in the laundry room was repaired.
The pooling of water in the dish room was suctioned away.
The grease trap in the floor was permanently disabled and floor was leveled so there is no further pooling water; in addition a new grease trap was installed.
A full house audit was conducted to ensure that all equipment and fixtures are intact and fully operable. Issues were addressed immediately.
The Maintenance Director will in-service all employees on revised work-order protocols.
The Maintenance and Housekeeping Directors will conduct an Audit of 10 Resident rooms on 1 Unit weekly x4 then monthly x12.
Any issues noted will be immediately addressed.
Results of the audits will be forwarded to the QA Committee for review and input.
Responsibility:
Administrator

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint #NY 907) conducted during the Standard Survey completed on 3/1/17, the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. One (Residents #161) of 32 residents reviewed for care plan implementation had issues involving staff not providing showers according to the plan of care. The finding is: 1. Resident #161 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 11/18/16 revealed the resident is cognitively intact, understands and is understood. The resident requires the extensive assistance of one person for personal hygiene and requires the physical help of one person for bathing. Review of the Comprehensive Care Plan revealed the resident requires assist with ADLs (Activities of Daily Living). The interventions included limited assist with bathing and shower days were listed as Wednesday and Saturday, 3:00 PM to 11:00 PM, effective 1/27/17. Review of the Certified Nurse Aide (CNA) Kardex (used by the CNA to provide care), dated 2/28/17 revealed the resident required limited assist with bathing; and shower days were Wednesday and Saturday, 3:00 PM to 11:00 PM. Review of the Documentation Survey Report for (MONTH) (YEAR) and (MONTH) (YEAR) revealed showers were scheduled Sunday, 7:00 AM to 3:00 PM and Wednesday, 3:00 PM to 11:00 PM. Further review of the Documentation Survey Report revealed the resident did not receive showers twice weekly during the weeks of: - Sunday, (MONTH) 4, (YEAR) - Sunday, (MONTH) 18, (YEAR) - Sunday, (MONTH) 25, (YEAR) - Sunday, (MONTH) 22, (YEAR) Review of the P(NAME) (Plan of Care) Response History for (MONTH) (YEAR) revealed the resident did not receive showers twice weekly during the weeks ending on: - Saturday, (MONTH) 4, (YEAR) - Saturday, (MONTH) 18, (YEAR) During an interview with Resident #161 on 2/23/17 at 8:14 AM, the resident stated that she is supposed to receive two showers a week and wanted to receive at least one shower a week. The resident further stated that she can go for two to three weeks without receiving a shower. Interview with the Registered Nurse (RN) #1 Unit Manager (UM) on 3/1/17 at 9:12 AM revealed that resident's showers are listed on the CNA daily assignment sheet. The CNA should make the Nurse Team Leader aware if a shower is not completed and why it was not completed. The Nurse Team Leader is responsible to follow up and determine what further action is needed in regards to the resident's shower. RN #1 UM further stated that there are reports that can be generated from the CNA electronic documentation to identify the lack of completion of all assignment aide tasks and she has not yet generated these reports as she has been working in the facility for only three weeks. Review of a facility policy entitled Quality of Life/ Dignity, dated 1/2017 revealed individualized bathing per Resident Care Plan will be initiated per resident choice. 415.11(c)(3)(ii)

Plan of Correction: ApprovedApril 7, 2017

The unit staff responsible for providing showers to resident # 161 were counseled by the RN Unit Manager on 3/20/17. The counseling stressed the need to provide showers as per care plan.Resident # 161 received a shower on 2/29/17. The IDCP team will meet with resident # 161 to review bathing preferences and care plan interventions .
All Residents have the potential to be affected.
A full house audit will be completed of all Resident showers/bathing schedules as per care plans versus CNA assignment sheets to ensure accuracy.Any concerns noted will be corrected immediately.
The UMs will review resident bathing/ showers on a daily basis; issues noted will be immediately corrected.
The policy and procedure titled Quality of life/dignity (Dignity and respect) was reviewed and revised by DON/Administrator.
The RN educator will educate all Nursing staff regarding above policy to include adherence to care plan with specific emphasis on bathing/ showers.
The RN Educator will conduct weekly Audit x4 then monthly x3 for 12 Residents (4 per each Nursing Unit) to ensure that residents are receiving showers/ baths as per care plan.
Results of the audits will be forwarded to the QA Committee Monthly for review and input.
Responsible Party: DON

FF10 483.60(a)(3)(b):SUFFICIENT DIETARY SUPPORT PERSONNEL

REGULATION: (a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observations, interview and record review conducted during the Standard survey completed on 3/1/17, the facility did not employ sufficient support personnel competent to carry out the functions of the dietary service. One (Kitchen) of one Kitchen had an issue did not have adequate dietary staff to prepare and deliver meals as scheduled or to maintain kitchen cleanliness. The finding is: 1. (a) Review of the Facility Survey Report (FSR), signed by the Administrator on 2/23/17, revealed the Registered Dietitian (RD) was full time and acted as the Food Service Director (FSD) and the Clinical Dietitian. Review of the facility staffing hours dated 3/30/16 revealed the RD full time hours listed as 84 and the part time hours at 40. Review of the facility staffing hours dated 3/7/17 revealed the RD hours were listed as 84 hours and no part time hours. Review of Food Service Worker hours in (YEAR) were listed as full time 808 hours and part time 790 hours. Review of Food Service Worker hours in (YEAR) were listed as full time 756 hours and part time 500 hours (b) Review of the meal delivery times revealed the last cart leaves the kitchen for breakfast at 9:30 AM to be delivered to the fourth floor Dementia Unit. Observation on 2/28/17 at 10:00 AM revealed the cart was being delivered to the fourth floor Dementia Unit. Interview with Certified Nurse Aide (CNA) #1 at that time revealed this was the normal delivery time for breakfast recently. CNA #1 stated at times, nursing staff had to go to the dietary department and bring the carts up as dietary is short-staffed. (c) Review of the Resident Council Minutes dated 10/26/16 revealed issues with the evening trays being late with missing food items. Alternate meal choices were limited. When the aides call down to the kitchen, there is no response. Also the food is cold when received. Resident Council Meeting 12/28/16 revealed alternate food meals were not available and residents were receiving items on their tray even though they were allergic to it. Interview with the Food Service Supervisor (FSS) on 2/27/17 at 2:00 PM revealed her staff routinely works short-staffed especially if there are many call-ins. On some days, three or four people may call-in causing shortages that affects meal deliveries and kitchen operations. Interview with the Administrator on 2/28/17 at 10:45 AM revealed they were actively interviewing to fill the FSD position and that the RD job was to be separate from the FSD position going forward. 415.14(b)(1)(2)

Plan of Correction: ApprovedMarch 27, 2017

The RD/FSD role was separated immediately and an interim FSD was transferred to Buffalo Center.
A new Food Service Director (FSD) was hired, and will begin working full time at Buffalo Center on 4/3/17.
All Food Service employee vacancies are actively being filled, cross-training roles are being developed, and per diem positions have been posted, and interviews are underway.
All Residents have the potential to be affected
FS employee start times and cart delivery times were adjusted and monitored for compliance.
Food temperatures were taken for one week, for each meal, when carts arrived at the nursing floors, to ensure hot/cold temperatures were maintained.
A one day audit of all trays to assess the level of accuracy with choices and dietary needs was conducted, and corrections were made.
The FSD educated all food service employees on the importance of timeliness, consistent temperatures and accuracy of meal tickets.
The FSD will audit one cart per floor: 2 times per week, x8 weeks, then monthly x6; to ensure proper hot/cold temperatures, accuracy of meal tickets, and timeliness of cart delivery.
Any issues noted will be immediately addressed.

Results of the audits will be forwarded to the QA Committee for review and input.
Responsibility:
Administrator


Standard Life Safety Code Citations

K307 NFPA 101:ALCOHOL BASED HAND RUB DISPENSER (ABHR)

REGULATION: Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation during the Life Safety Code survey completed on 3/1/17, ABHR (Alcohol Based Hand Rub) was not properly stored. The issue is, quantities of ABHR, greater than five gallons (640 oz) in a single smoke compartment did not meet the requirements of NFPA 30, Flammable and Combustible Liquids Code. This affected one (Ground) of four resident use floors. The finding is: 1. Observation on 2/23/17 at approximately 12:00 PM revealed 18 cases of 65 % (percent) Ethyl Alcohol ABHR refill boxes were stored on a shelf in the Ground Floor Storage Room that contained disposable briefs and nursing supplies. Further observation revealed each case contained 12 individual refill boxes, each listed as 27 ounces. Each case was equivalent to 324 ounces (12 refills x 27 ounces) of ABHR. All 18 cases were equivalent to 5832 ounces (18 cases x 324 ounces) of ABHR. Per the 2012 edition of NFPA 101 Life Safety Code, storage of quantities greater than five gallons in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code. NFPA 30 requires storage in a Flammable Liquids Storage Cabinet. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.6 2012 NFPA 30: 9.5

Plan of Correction: ApprovedApril 4, 2017

17 cases of Ethyl Alcohol ABHR refill boxes were removed from the ground floor storage room.
The storage room, and other storage areas were inspected to ensure no additional cases of Ethyl Alcohol ABHR refill boxes were being stored there in quantities that exceeded compliance.
The administrator educated the supply/storage room purchaser on the 5-gallon smoke compartment requirements.
The administrator will conduct a monthly audit x 6 months, of the supply/storage room to ensure that no more than 5 gallons of Ethyl Alcohol ABHR refill boxes are being stored.
Any issues noted will be immediately addressed.
Results of audits will be forwarded to QA Committee for Monthly review.
Responsible Party:
Administrator

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, a door protecting a hazardous area was held open and was obstructed from closing by a device that was not arranged to automatically close the door upon activation of the required fire alarm system, local smoke detectors, automatic sprinkler system, or loss of power. Issues included a door whose hold open device was disabled and the door was tied in an open position. This affected one (Ground) of four resident use floors. The finding is: 1. Observation on the Ground floor on 2/24/17 at approximately 11:50 AM revealed two of two corridor doors to the Dish Machine room were equipped with self-closing mechanisms. The corridor door that opened into the A-corridor, was also equipped with an electro-magnetic hold open device that was designed to release during loss of power or activation of the fire alarm or sprinkler system. This door was obstructed from closing by a drying rack. The electro-magnetic hold open device that was installed on the corridor door that opened closest to the Dining Room, was broken off of the door. This door was tied open by the door handle. In the event of an emergency, this door would not be able to self-close and latch. The Dish machine room contained two, approximately 55-gallon trash cans, both of which contained trash. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.2.2.2.7

Plan of Correction: ApprovedMarch 27, 2017

The drying rack blocking A corridor door in the dish room was removed and stored in its designated area so that it is not obstructing the doors. The electro-magnetic hold open device on the corridor door (in the dish room) closest to the dining room was replaced and the string holding the door open was removed and discarded.
The maintenance department inspected every door equipped with an electro-magnetic hold open devices, or otherwise required to close when the fire alarm is engaged, to ensure proper function and that they are not held open or blocked by devices that would prevent them from automatically closing when the fire alarm is engaged.
The Maintenance Director educated all staff regarding the proper use of doors with electro-magnetic hold open devices, and the importance of not obstructing them.
The Maintenance Department will conduct weekly audits of all doors equipped with electro-magnetic hold open devices, x 8 weeks; then monthly x6 months.
Any issues noted will be immediately addressed.

Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator

K307 NFPA 101:EGRESS DOORS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, exit doors identified by signage to have delayed egress locking release features, did not have the features installed. This affected one (Ground) of four resident use floors. The findings are: 1) Observation on 2/23/17 at approximately 12:15 PM revealed that the Ground Floor, B-stairway corridor door, was labeled with a sign with instructions on how to operate a delayed egress locking mechanism. Further observation at this time revealed a delayed egress locking mechanism was not installed on this door. Interview with the Director of Maintenance at the time of the observation revealed that the delayed egress feature was removed and replaced with an elopement prevention system. 2) Observation on 2/23/17 at approximately 3:04 PM revealed that the Ground Floor, A-stairway corridor door, was labeled with a sign with instructions on how to operate a delayed egress locking mechanism. Further observation at this time revealed a delayed egress locking mechanism was not installed on this door. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.2.2.4, 7.2.1.6.1

Plan of Correction: ApprovedMarch 27, 2017

All signage for affected doors, without delayed egress locking release features, were replaced with signs identifying ?emergency exit only?.
The maintenance department inspected every exit door sign, to ensure that all doors with delayed egress locking release devices had proper signage and that only those doors with a delayed egress function has delayed egress signage.
The Maintenance Director educated maintenance staff regarding proper signage.
The Maintenance Director will conduct 4 quarterly audits, beginning (MONTH) (YEAR).
Any issues noted will be immediately addressed.
Results of audits will be forwarded to QA Committee Monthly for review.

Responsible Party:
Administrator

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observations made during the Life Safety Code survey completed on 3/1/17, electric components were not maintained. Issues include unapproved power strips and extension cords that were used to supply a permanent supply of power to electrical appliances and medical appliances, and a duplex electric outlet that was missing a cover plate. This affected three (Ground, Third, Fourth) of four resident use floors. The findings are: 1. Observation on 2/22/17 at approximately 10:09 AM revealed a duplex electrical outlet in resident room B427 on the Fourth Floor, was missing a cover plate. Further observation revealed this outlet was located at the bed's headboard. 2. Observation of the A-corridor on the Ground Floor on 2/23/17 at approximately 2:59 PM revealed an extension cord was plugged into an electrical outlet in the corridor closest to the rear entrance, by the Oxygen storage cage. Further observation revealed the extension cord was strung up the wall and into the lay in ceiling tile assembly. Interview with the Director of Maintenance at the time of the observation revealed the extension cord went to a heater unit. 3. Observation of the Ground floor on 2/23/17 at approximately 3:01 PM revealed an approximate 20-foot long orange extension cord was supplying power to a fan located in the clean side of the Laundry room. 4. Observation of the Third Floor on 2/27/17 at approximately 12:40 PM revealed a power strip, that was not rated to be used in a resident room, was supplying power to a television in resident room B323. Continued observation at this time revealed there was no UL (Underwriter's Laboratory) information printed on or attached to the power strip. 5. Observation of the Third Floor on 2/27/17 at approximately 12:42 PM revealed a power strip, that was not rated to be used in a resident room, was supplying power to a television in resident room B317. Continued observation at this time revealed there was no UL (Underwriter's Laboratory) information printed on or attached to the power strip. 6. Observation of the Third Floor on 2/27/17 at approximately 12:50 PM revealed a power strip, that was not rated to be used in a resident room and with medical equipment, was supplying power to an oxygen concentrator in resident room C334. Continued observation at this time revealed there was no UL (Underwriter's Laboratory) information printed on or attached to the power strip. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.2.3.6 2011 NFPA 70: 400.8(1)

Plan of Correction: ApprovedMarch 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Unrated power strips located in rooms [ROOM NUMBER] were removed and replaced with rated power strips.
The cover plate in room [ROOM NUMBER] was replaced.
The extension cords in ground floor A-corridor, and laundry were removed.
Each resident room was inspected to ensure that all unrated power strips were removed and replaced with rated power strips.
All resident rooms were inspected for broken or missing cover plates.
All areas were inspected for extension cords.
All staff were educated on the use of approved power strips and discontinued use of extension cords.
All Housekeeping and maintenance employees were educated on the need to ensure that cover plates are on all electrical outlets, and if broken or missing, to be reported.
The Director of Maintenance will conduct random audits of resident rooms, laundry, and Ground floor A corridor areas to ensure compliance with regards to the the use of power strips, electrical cords, and outlet covers monthly x6 months.
Any issues noted will be immediately addressed.
Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, hazardous areas were not protected. Issues included corridor doors to hazardous areas that did not self-close and latch into their door frames. This affected four (Ground, Second, Third, Fourth) of four resident use floors. The findings include but are not limited to: 1. Observation on 2/23/17 at approximately 10:40 AM revealed the corridor door to the Fourth Floor A-corridor Clean Work Room would not self-close and latch into its door frame. The latch bolt would not engage the door frame unless the doorknob was turned and the door was pulled closed. 2. Observation on 2/23/17 at approximately 11:07 AM revealed the corridor door to the Third Floor D-corridor Soiled Work Room would not self-close and latch into its door frame. 3. Observation on 2/23/17 at approximately 11:19 AM revealed the corridor door to the Third Floor C-corridor Soiled Work Room would not self-close and latch into its door frame. 4. Observation on 2/23/17 at approximately 11:45 AM revealed the corridor door to the Ground Floor Laundry room (Clean Side) was obstructed from closing by a clean linen cart. Further observation revealed this door was equipped with a self-closing mechanism, tied into a supervised hold open device. 5. Observation on 2/23/17 at approximately 11:51 AM revealed the corridor door to the Ground Floor Elevator Machine room would not self-close and lath into its doorframe. Interview with the Director of Maintenance at the time of the observation revealed the door needed to be tightened up. 6. Observation on 2/24/17 at approximately 10:43 AM revealed the corridor door to the Third Floor B-corridor Clean Work Room would not self-close and latch into its door frame. Interview with the Director of Maintenance at the time of the observation revealed the newly installed no-wander system was preventing this door from properly closing. 7. Observation on 2/24/17 at approximately 11:00 AM revealed the corridor door to the Second Floor A-corridor Clean Work Room would not self-close and latch into its door frame. Continued observation at this time revealed the self-closing mechanism was removed from this door. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.3.2, 19.3.2.1, 19.3.2.1.3

Plan of Correction: ApprovedApril 4, 2017

The following doors were repaired so that they self-close and latch: 2nd floor A corridor clean work room; 4th Floor A corridor clean work room; 3rd Floor B, C and D corridor soiled work rooms; and ground floor elevator machine room
The cart that was obstructing the ground floor laundry room door was removed and laundry staff were educated.
All corridor doors to hazardous areas in the facility were inspected to ensure they properly self-closed and fully latched into the door frames, and there was nothing obstructing their path.
The Maintenance Director educated all employees on the importance of ensuring all corridor doors to hazardous areas are free from obstruction.
The Maintenance Director educated all maintenance employees on the importance of ensuring all corridor doors to hazardous areas self-close and fully latch.
The Maintenance Department will conduct weekly audits of every corridor door to hazardous areas x8 weeks, then monthly x6 months.
Any issues noted will be immediately addressed.
Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observations during the Life Safety Code survey completed on 3/1/17, means of egress were not continuously maintained free of all obstructions to full instant use in case of emergency. This affected three (Ground, Second, Third) of four resident use floors. The findings include but are not limited to: 1) Observation of the D-corridor on the Third Floor on 2/22/17 at approximately 11:09 AM revealed a black recliner was stored approximately 24 inches away from the D-Stairway door. Further observation on 2/22/17 at approximately 11:50 AM revealed a sign on this recliner stated Please do not remove this chair, the family will be back to get it. This sign was dated 4/20/16. 2) Observations on the Second Floor, in the Physical Therapy corridor, on 2/22/17 at approximately 11:54 AM revealed the following items were stored in the egress corridor: - a wooden pallet, approximately five feet high, full of paper towel dispensers - a wooden pallet, approximately five feet high, full of lighting fixtures - three bags of concrete mix - a folding table 3) Observation of the A-corridor on the Second Floor on 2/22/17 at approximately 12:12 PM revealed the following items were stored in the egress corridor: - two over bed tables - one toileting chair - three unoccupied wheelchairs - five walkers 4) Observation of the B-corridor on the Ground Floor on 2/23/17 at approximately 12:12 PM revealed the following items were stored in the egress corridor: - a wooden pallet containing dish machine supplies including six, five gallon buckets of soap and sanitizing solution - a portable air conditioning unit - a trash can - a pallet with five case of ceiling tiles - a pallet with a desk/cabinet - a four wheeled cart - two mobile trash receptacles - a pallet with desk parts 5) Observation of the A-corridor on the Ground Floor on 2/23/17 at approximately 2:55 PM revealed the following items were stored in the egress corridor immediately adjacent to the Dish machine room: - two drying racks full of dish lids - one six foot high by three foot long by two foot deep meal delivery cart - an overbed table 6) Observation of the A-corridor on the Ground Floor on 2/23/17 at approximately 2:58 PM revealed the following items were stored in the egress corridor immediately adjacent to the A-stairway: - a ladder - a two wheel dolly - three broken windows - an overbed table with a suction machine on it - a 50-gallon trash can - three overbed tables - four oxygen concentrators - one mechanical lift. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2.1, 19.3.2.4, 7.1.10

Plan of Correction: ApprovedMarch 27, 2017

All items obstructing means of egress on: ground floor on A and B corridors, 2nd floor physical therapy egress corridor,
2nd floor A corridor, and 3rd Floor D corridor stairway door, were removed and were placed in proper storage area/containers.
Maintenance inspected every egress area to ensure each area was free of obstruction.
Maintenance Director re-educated all employees, on the need to keep egress areas free of obstruction.
The Maintenance Department will conduct 4 random weekly audits of all facility means of egress, x8 weeks; then monthly x6 months.
Any issues noted will be immediately addressed.

Results of audits will be forwarded to QA Committee Monthly for review.
Responsible Party:
Administrator

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

REGULATION: Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, portable fire extinguishers were not properly maintained or installed. Issues include portable fire extinguishers that were obstructed from immediate use and fire extinguishers that were stored on the floor and not on a wall bracket or in a cabinet. This affected two (Ground Floor, Second Floor) of four resident use floors. The findings are: 1. Observation on 2/23/17 at approximately 11:51 AM revealed the ABC style fire extinguisher was stored on the floor inside the Ground Floor Elevator machine room. Further observation revealed there was a wall mounting bracket immediately above the fire extinguisher. 2. Observation on 2/23/17 at approximately 12:57 PM revealed the ABC style fire extinguisher was stored on the floor, on the Ground Floor, at the rear exit door in the Reception Lobby. Further observation revealed there was not a wall mounting bracket installed at this location. Interview with the Director of Maintenance on 2/24/17 at approximately 2:30 PM revealed the Lobby has been renovated. 3. Observation on 2/23/17 at approximately 3:17 PM revealed the ABC style fire extinguisher mounted on the wall on the Second Floor, in the Physical Therapy corridor closest to the Personal Care room, was obstructed from immediate use by a table, two bags of concrete mix and wooden pieces of wall moldings. 4. Observation on 2/23/17 at approximately 10:55 AM revealed the ABC style fire extinguisher on the Second Floor 2A corridor was obstructed from immediate use by an over bed table, that was stored directly in front of it. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.3.5.12, 9.7.4, 9.7.4.1 2010 NFPA 10: 6.1.3.1, 6.1.3.3, 6.1.3.3.1, 6.1.3.8.3, 6.1.3.4

Plan of Correction: ApprovedMarch 27, 2017

The ABC fire extinguishers in ground floor elevator room and reception lobby, were remounted correctly.
All obstructions near the ABC fire extinguishers on 2nd floor A and D wings, were removed.
All ABC fire extinguishers were inspected for proper mounting and to ensure that they are free of obstructions.
All staff were educated on the importance of keeping ABC fire extinguishers free of obstruction.
All maintenance employees were educated on proper mounting of fire extinguishers.
The director of maintenance will audit weekly x4 and then monthly x6 months, all fire extinguishers for proper mounting and being free of obstruction.
Any issues noted will be immediately addressed.
Results of audits will be forwarded to QA Committee for Monthly review.
Responsible Party:
Administrator

K307 NFPA 101:SOILED LINEN AND TRASH CONTAINERS

REGULATION: Soiled Linen and Trash Containers Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended. Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent. 18.7.5.7, 19.7.5.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observations during the Life Safety Code survey completed on 3/1/17, trash receptacles exceeding 32 gallons in capacity, were not stored in rooms protected as hazardous areas. This affected one (Ground) of four resident use floors. The findings are: 1) Observation of the service corridor on the Ground floor on 2/24/17 at approximately 11:50 AM revealed two approximate 55-gallon trash cans, both of which contained trash, were stored in the Dish Machine room. One of two doors to this room was obstructed from closing by a drying rack. The second door was tied open by the door handle. 2) Observations of the A-corridor on the Ground floor on 2/23/17 at approximately 2:58 PM revealed an approximate 50-gallon trash can was stored in the corridor. Further observation revealed this can was full of trash. 3) Observation of the Ground Floor B-corridor, closest to the Main Kitchen, on 2/23/17 at approximately 2:30 PM revealed a white mobile trash receptacle, measuring four feet long by three feet wide by three feet deep and exceeding 32 gallons, was stored in the corridor. Further observation revealed this mobile trash receptacle was full of cardboard. Continued observations at this same location revealed a gray colored mobile trash receptacle measuring four feet long by three feet wide by three feet deep and exceeding 32 gallons was also stored in the corridor. This gray receptacle contained trash. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.7.5.7

Plan of Correction: ApprovedMarch 27, 2017

Trash receptacles exceeding 32 gallons, located in the dish room, and ground floor A and B corridors were removed.
Maintenance inspected all non-hazardous areas, for trash receptacles exceeding 32 gallons, and removed them as needed.
The maintenance director will educate the Directors of Food Service and Housekeeper regarding the 32-gallon receptacle limit in hazardous areas.
The maintenance director will a conduct quarterly audits x4, to ensure receptacle compliance in hazardous areas.
Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, it was determined that the stairway was not maintained. Issues included items that were stored inside stairways; stairway exit doors that did not self-close and latch; and unsealed penetrations that were observed through a stairway door. This affected three (First, Second, Third floors) of three resident use floors. The findings are: 1) Observation in the C Wing Stairwell on 2/22/17 at approximately 9:42 AM revealed a trash can was stored on the Third floor stairway landing. Further observation revealed the trash can did have trash inside of it. 2) Observation in the B Wing Stairwell on 2/22/17 at approximately 10:06 AM revealed a folded/ bunched up white blanket was stored on the Fourth floor stairway landing. 3) Observation of the Ground Floor service corridor on 2/23/17 at approximately 11:36 AM revealed the A Stairway door did not self-close and latch into its door frame. Interview with the Director of Maintenance at the time of the observation revealed that the crash bar assembly was loose and needed to be tightened. 4) Observation of the Ground Floor service corridor on 2/23/17 at approximately 12:15 PM revealed the B Stairway door had approximately eight screw sized penetrations through the door. Interview with the Director of Maintenance at the time of the observation revealed that the screw holes were from a magnetic locking device which had been removed from this door. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.2.2.4, 7.2, 7.2.1.1, 7.2.3.3, 7.2.2.3.1, 7.1, 7.1.3, 7.1.3.2, 7.1.3.2.1, 7.7.2(3)

Plan of Correction: ApprovedMarch 27, 2017

Items were removed from C and B wing stairwells; the crash-bar assembly on ground floor stairwell A wing door was repaired; and the ground floor stairwell B wing door penetration was repaired.
The maintenance department inspected every stairwell and exit door to ensure items were not being stored, doors latched appropriately, and were free of penetrations.
The Maintenance Director educated all maintenance employees on the need to ensure that stairways and smoke proof enclosures used as exits are free of any storage, the exit doors latch properly and are free of penetrations.All staff were educated on the need to ensure that stairways and smoke proof enclosures used as exits are not used for any storage.
The Maintenance Department will conduct weekly audits of every stairwell and exit door to ensure items are not being stored, doors latched appropriately, and are free of penetrations, x8 weeks; and then monthly x6 months.
Any issues noted will be immediately addressed.
Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, smoke barrier walls were not properly maintained. Issues included smoke barrier walls that were not complete from floor to ceiling/ roof deck; were not designed to have at least a 30-minute fire resistance rating; and were not designed to resist the passage of smoke, due to unsealed and improperly sealed penetrations. This affected three (Second, Third, Fourth) of four resident use floors. The findings include but are not limited to: 1. Observations made above the ceiling tile assemblies on 2/24/17 from approximately 10:00 AM through 11:20 AM revealed the following: a) A two inch by two-inch penetration through the smoke barrier wall, above the elevator lobby doors, on the Fourth Floor. Interview with the Director of Maintenance at the time of the observation revealed the electrician likely made this penetration when running the components of the new air conditioning system. b) A one inch by three-inch penetration through the Fourth Floor B-corridor smoke barrier wall, above the smoke barrier doors. c) A one-inch diameter penetration through the smoke barrier wall, above the elevator lobby doors, on the Third Floor. Interview with the Director of Maintenance at the time of the observation revealed the electrician likely made this penetration when running the components of the new no wander system. Continued observation of this smoke barrier wall revealed a three inch by three-inch penetration through the adjacent Clean Work room wall. d) An eight inch by four inch and a two inch by two-inch penetration through the smoke barrier wall on the Second Floor A-Corridor. The eight inch by four inch penetration had air conditioner condenser lines going through it. The two inch by two inch penetration was filled with mineral wool that was not sealed with a fire rated material. e) A four inch by two-inch penetration through the smoke barrier wall on the Second Floor B-Corridor. Interview with the Maintenance Director at the time of the observation revealed this penetration was made as the result of the new air conditioning installation. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101:19.3.7, 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedApril 3, 2017

The following smoke barrier walls were sealed with a fire-rated caulk: 3rd and 4th floor lobby elevator door walls; 3rd floor clean work room wall; 2nd floor A and B corridor smoke barrier walls; and 4th Floor B corridor wall above smoke barrier doors.
All smoke barrier walls were inspected for penetrations, and sealed as needed.
The Maintenance Director will deploy a new process for work done by external contractors, which ensures they are educated and compliant with penetration protocol.
The Maintenance Director will keep a log of all contractor and external vendors doing work in or around a fire/smoke barrier wall, door, or vertical opening, note the penetrations, and inspect the area after the work is completed to ensure compliance
The Administrator will review all vendor education/penetration agreements monthly x6 months.
The Administrator will review the penetration log monthly for 6 months and inspect, or arrange to inspect, the filled penetrations quarterly x2.

Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator

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: March 1, 2017
Corrected date: April 26, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 3/1/17, vertical openings were not protected. Issues included stairways and an elevator shaft that were not enclosed with construction having a fire resistance rating of at least one hour, due to the presence of unsealed penetrations. This affected three (Second, Third, Fourth floors) of three resident use floors and one of one Basement. The findings include but are not limited to: 1. Observation of the C Wing Clean Utility Room located on the Fourth Floor on 2/22/17 at approximately 9:55 AM revealed approximately eight air conditioner condenser lines and associated electrical conduits, were installed through the roof assembly, traveled the height of the Clean Utility Room, and went through the floor into the Third Floor. The penetrations created through the roof assembly and floor assembly to accommodate the air conditioning lines, were sealed only with an expandable red/orange colored foam product, that was not trimmed flush with the floor/roof and sealed with a fire rated sealant. Interview with the Director of Maintenance on 2/24/17 at approximately 2:35 PM revealed the installation of the new air conditioning system was being completed by contractors. The contractors were responsible for properly sealing any penetrations created as a result of the project. 2. Observation of the B Wing Clean Utility Room located on the Fourth Floor on 2/22/17 at approximately 10:17 AM revealed approximately eight air conditioner condenser lines and associated electrical conduits, were installed through the roof assembly, traveled the height of the Clean Utility Room, and went through the floor into the Third Floor. The penetrations created through the roof assembly and floor assembly to accommodate the air conditioning lines were sealed only with an expandable red/orange colored foam product, that was not trimmed flush with the floor/ roof and sealed with a fire rated sealant. 3. Observation of the A Wing Clean Utility Room located on the Fourth Floor on 2/22/17 at approximately 10:27 AM revealed approximately eight air conditioner condenser lines and associated electrical conduits, were installed through the roof assembly, traveled the height of the Clean Utility Room and went through the floor into the Third Floor. The penetrations created through the roof assembly and floor assembly to accommodate the air conditioning lines were sealed only with an expandable red/ orange colored foam product, that was not trimmed flush with the floor/ roof and sealed with a fire rated sealant. 4. Observation of the C Wing Clean Utility Room located on the Third Floor on 2/22/17 at approximately 11:25 AM revealed approximately eight air conditioner condenser lines and associated electrical conduits, were installed through the ceiling assembly from the Fourth Floor, traveled the height of the Clean Utility Room and went through the floor into the Second Floor. The penetrations created through the roof assembly and floor assembly to accommodate the air conditioning lines were sealed only with an expandable red/ orange colored foam product, that was not trimmed flush with the floor/ roof and sealed with a fire rated sealant. 5. Observation of the B Wing Clean Utility Room located on the Third Floor on 2/22/17 at approximately 11:35 AM revealed approximately eight air conditioner condenser lines and associated electrical conduits, were installed through the ceiling assembly from the Fourth Floor, traveled the height of the Clean Utility Room and went through the floor into the Second Floor. The penetrations created through the roof assembly and floor assembly to accommodate the air conditioning lines were sealed only with an expandable red/ orange colored foam product, that was not trimmed flush with the floor/ roof and sealed with a fire rated sealant. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3, 19.3.1, 8.6, 8.6.1, 8.6.5

Plan of Correction: ApprovedMarch 27, 2017

Penetrations in clean utility rooms on 4th floor A, B and C wings, and 3rd floor B and C wings, were trimmed and sealed with a fire-rated sealant.
All clean utility rooms were inspected for penetrations, then trimmed and sealed as needed.
The Maintenance Director will deploy a new process for work done by external contractors, which ensures they are educated and compliant with penetration protocol.
Furthermore, the Maintenance Director will keep a log of all contractor and external vendors doing work in or around a fire/smoke barrier wall, door, or vertical opening, note the penetrations, and inspect the area after the work is completed to ensure compliance.
The Administrator will review all vendor education/penetration agreements monthly x6 months.
The Administrator will review the penetration log monthly for 6 months and inspect, or arrange to inspect, the filled penetrations quarterly x2.
Results of audits will be forwarded to QA Committee for Monthly review.

Responsible Party:
Administrator