Oneida Center for Rehabilitation and Nursing
August 13, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey for 11 of 11 residents (Resident #7, 9, 24, 38, 42, 50, 68, 81, 100, 105 and 410) reviewed for infection control, the facility did not ensure an established and maintained infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not maintain proper hand hygiene/infection control technique during a medication pass for Residents #7, 24, 38, 410; during cream application for Residents #50, 100, 42, and 81; and during treatments for Residents #9, 105, and 68. Findings include: The undated facility policy Standard Precautions stated: - Standard precautions will be used in the care of all residents regardless of their diagnosis, or suspected or confirmed infectious status. - Staff shall be adequately trained in the various aspects of standard precautions to ensure appropriate to ensure appropriate decision making in various clinical situations. - Hand hygiene refers to washing with soap and water or using alcohol based hand rubs. The undated facility policy Transmission Based Precautions stated: - Wearing gloves as outlined under standard precautions, wear gloves (clean, non-sterile) when entering the room. - While caring for a resident, change gloves after having contact with infective materials. - Remove gloves before leaving room and preform hand hygiene. - After removing gloves and washing hands do not touch potentially contaminated environmental surfaces or items in the resident's room. 1) Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 08/01/18 Minimum Data Set (MDS) assessment documented the resident cognitively intact and required supervision for dressing, personal hygiene and toileting. Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 08/15/18 MDS assessment documented the resident was cognitively intact and required extensive assistance with personal hygiene. Resident #38 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 06/20/18 MDS assessment documented the resident was cognitively intact and was totally dependent for activities of daily living (ADLs). Resident #410 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 08/19/18 MDS assessment documented the resident is cognitively intact and requires minimal assistance for personal hygiene. During medication pass on 08/14/18 at 08:00 AM, licensed practical nurse (LPN) #11 did not complete hand hygiene with alcohol based hand sanitizer or soap and water before or after the care of Residents #7, 24, 38, and 410. During an interview on 08/14/18 at 11:44 AM, LPN #11 stated hand washing was supposed to be completed with alcohol-based hand sanitizer before and after contact with each resident. She further stated that she did not complete hand hygiene before and after providing the residents with their morning medications. During an interview on 08/14/18 at 12:00 PM, LPN Unit Manager #7 stated staff were expected to wash their hands before and after each medication pass. 2) Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 07/20/18 Minimum Data Set (MDS) assessment documented resident's cognition status as severely impaired, though able to understand clear, simple commands; and was totally dependent on staff for activities of daily living (ADLs), including for eating. One unstageable ulcer, measuring 2.5 centimeter (cm) x 6.0 cm, with slough in the base of the wound was noted. The physician orders [REDACTED]. the wound), covered with a sacral dressing. A surveyor observed the resident's treatment on 08/13/18 at 10:24 AM. At that time, LPN #7 was at the resident's bedside to do a sacral wound treatment. The LPN did not perform hand hygiene before starting the dressing change, then was noted to have licked fingers to open garbage bag and put gloves on without performing hand hygiene. During an interview on 08/14/18 at 01:36 PM, LPN #7 stated hand hygiene should be done before a dressing change, when moving from contact with dirty items or dressing to clean, and at the end of the dressing change. He explained hand hygiene should be done so residents did not get infections. When asked if he had performed hand hygiene during the dressing change, the LPN stated I don't recall. During an interview on 08/14/18 at 04:34 PM, Director of Nursing (DON), acting as the infection control nurse, stated hand hygiene would be performed before starting a dressing change, and after removing the old dressing before starting the new dressing. She stated hand hygiene prevented the spread of infections. 3) Resident #50 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. The 07/05/18 Minimum Data Set (MDS) assessment documented the resident was totally dependent on staff for activities of daily living (ADLs) and the cognition assessment was missing from the copy. Resident #100 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. The 07/29/18 MDS assessment documented the resident was cognitively intact and required extensive assistance with personal hygiene. Resident #42 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. The 06/25/18 MDS assessment documented the resident was severely cognitively impaired and was totally dependent for most ADLs. Resident #81 was originally admitted on [DATE] with [DIAGNOSES REDACTED]. The 07/25/18 MDS assessment documented the resident was severely cognitively impaired and required extensive assistance for personal hygiene. A surveyor observed on 08/08/18 from 11:40 AM to 11:50 PM, certified nurse aide (CNA) #2 was applying sunscreen to Resident #50, then to Resident #100, then to Resident #42 and on the arms of Resident #81 without changing gloves or performing hand hygiene between residents. The CNA returned the sunscreen to licensed practical nurse (LPN) #4 to place in the medication cart. During an interview on 08/13/18 at 11:59 AM, CNA #3 stated gloves were to be used when applying sunscreen. The expected practice was to take off gloves, use hand sanitizer, and apply new gloves in between residents. During an interview on 08/13/18 at 12:20 PM, LPN #4 stated sunscreen should not be applied to multiple residents without washing hands in between applications. She explained the process to apply sunscreen was to apply with gloves, remove gloves after each resident, wash hands, and put on new gloves to apply to next resident. She stated that hand sanitizer would not be sufficient for hand hygiene in this situation. During an interview with CNA #30 on 08/13/18 at 01:55 PM, she stated when applying sunscreen staff were to wear gloves, change gloves between residents. They did not have to wash hands and should use sanitizer in between each resident. During an interview on 08/14/18 at 02:19 PM, registered nurse (RN) Unit Manager #6 stated the correct process for sunscreen application was to use individual gloves for each resident, discard, wash hands, apply new gloves before application of sunscreen to the next resident. 10NYCRR 415.19(b)(4)


Plan of Correction: ApprovedSeptember 19, 2018

1. Resident #7, 9,24, 38, 42, 50, 68, 81, 100, 105 and 410) were assessed and no adverse effects were identified as a result of these findings 2. All residents have the potential to be affected. Nurse management team conducted a random unit rounding to identify residents that may have the potential to be affected for similar occurrence. Corrective action was taken upon identification. 3. All licensed nurses will have hand hygiene competency with medication administration reviewed and documented proficient to ensure understanding of cross contamination. Nursing assistants will have hand hygiene competency reviewed and documented proficient to ensure the understanding of application of creams and processes to reduce cross contamination between residents. The policy Handwashing/Hand Hygiene was reviewed and adopted. The policy, Pressure Injury and Non-pressure Injury Treatment was reviewed and adopted. Nurses will be educated on the policy which reviews the steps in treatment performance to include hand hygiene and infection control techniques. Treatment competency tool was reviewed and adopted. All nurses will be reviewed on treatment performance competency for hand hygiene and infection control techniques. Nurses will bereviewed for Treatment performance competency for hand hygiene and infection control, on orientation and on ayearly rotation schedule. Licensed nurses and certified nurse?s aides will be educated on Handwashing/Hand Hygiene to ensure the understanding that handwashing as per the policy reduces risk of transmission of communicable diseases and infections. Licensed nurse?s education will additionally focus on Handwashing/Hand hygiene processes with administration of medication. Competency of Handwashing documentation was reviewed and adopted. Nurses and Nursing assistants will be reviewed for Handwashing competency and the understanding of when to wash hands and don gloves on orientation and on a yearly rotation schedule. Medication Administration competency which identifies handwashing process with medication pass will be provided on orientation, periodically as deemed necessary and a rotating yearly schedule. 4.The Nurse Educator or designee will provide random observed handwashing competency audits on 3 licensed nurses and 3 nurses aides, weekly x4, biweekly x2 and monthly x 3. to ensure processes are as per policy/procedure and reduces risk of transmission of communicable diseases and infections. The Nurse Educator /designee will provide random observed treatment competency audits on 3 licensed nurses weekly x4; biweekly x2; and monthly x3 to ensure processes are as per policy/procedure and reduce risks of transmission of communicable diseases and infections during the administration of treatments. All findings will be presented to the QAPI committee for review and comment. All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee. Responsible party Director of Nurses

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review during the abbreviated (NY 725 and NY 270) and recertification surveys the facility did not complete thorough investigations to rule out abuse, neglect, or mistreatment for 5 of 7 residents (Resident #7, 23, 86, 112, and 113) reviewed for abuse. Specifically, Resident #7 had 2 incidents that were not thoroughly investigated to determine root cause and no interventions were added to prevent recurrence; Residents #86 and 113 had an altercation and an investigation was not completed to rule out abuse or neglect; and Residents #23 and 112 had concerns regarding potential abuse and thorough investigations were not completed to rule out abuse, neglect or mistreatment and to protect the resident during the investigative process. Findings include: 1) Resident #23 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 05/07/18 Minimum Data Set (MDS) assessment documented the resident had intact cognition, exhibited multiple mood/depressive symptoms daily, did not exhibit symptoms of [MEDICAL CONDITION] and had no behavioral symptoms. The resident required extensive assistance for hygiene, dressing, and bathing. The physician's progress note dated 06/19/18 documented the resident was stable, had no hallucinations, delusions, or paranoia. A nursing progress note dated 07/10/18 at 09:21 PM documented the resident was displaying behaviors of accusing the staff of not doing things for her, stating she was going to turn them in, redirection was not effective, and she was rude to the nursing staff. A grievance form dated 07/13/18 documented the resident stated two certified nurse aides (CNAs) who gave her a shower treated her rough and they told her what to do. The resident stated she treated them (the CNAs) with respect and dignity and asked them in a nice way to be a little nicer. The grievance form documented the incident occurred on 07/10/18 and was signed by the Administrator. Further investigation was needed to rule out abuse or neglect. A social services progress note dated 07/16/18 at 08:58 AM documented social worker #22 met with the resident on 07/13/18 concerning her grievance. The resident stated they were rough when they washed her hair and rough in general. The social worker noted the resident stated she felt sad when she thought about it and had been referred to the psychologist. The comprehensive care plan (CCP) updated 07/16/18 documented the resident had behavioral symptoms including rejection of care, evaluations, meals, and medications, and lowering herself to the floor. Interventions included calm slow approach, decrease noise in environment, and explain procedures in a simple manner. Social worker #22 added a note on 07/16/18 documenting the resident was exhibiting behaviors which may have been related to loneliness and family did not visit frequently. The 07/2018 certified nurse aide (CNA) care instructions documented the resident required extensive assistance of one person for bathing, and she was to have a shower every Tuesday and Friday on the 06:30 AM-02:30 PM shift. The CNA activities of daily living (ADLs) record documented on 07/10/18, the resident's shower was completed by CNA #2 and no behaviors were documented. When interviewed on 08/14/18 at 10:14 AM, social worker #22 stated if a resident complained about mistreatment by staff, it would be turned over to the Director of Nursing (DON) or the Administrator as it would be possible abuse. A complaint of being treated roughly could be considered possible abuse. The social worker stated she spoke to the resident about her concerns of being treated roughly by two CNAs during her shower and she had not followed up since. She located a copy of the grievance form and stated it was incomplete. During an interview on 08/14/18 at 02:19 PM, registered nurse (RN) Unit Manager #6 stated she was unaware of the accusations the resident made on 07/10/18. She stated if a resident alleged mistreatment by staff an investigation would be initiated immediately and the employee would be kept away from the resident until it was completed or resolved. Statements should be obtained from all staff working on the day of the concern and the resident should be assessed by an RN. When interviewed on 08/15/18 at 10:41 AM, the Administrator stated a resident's allegation of mistreatment by a CNA was possible abuse. She received the complaint from the resident, marked it for a follow-up investigation, and was unsure of the outcome. She stated there should have been statements from the staff who worked on the day of the concern and there was not enough information gathered to rule out abuse or neglect. The Administrator stated if she suspected abuse based on what the resident reported, she would not have allowed the CNAs to care for her until it was resolved, and the resident could not recall the names of the CNAs. She stated staff names could be quickly obtained from assignment sheets and ADL records and she was unaware if there was follow-up. 2) Resident #112 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 10/06/17 Minimum Data Set (MDS) assessment documented the resident had intact cognition and did not exhibit behavioral symptoms. The resident required extensive assistance of two people for most activities of daily living (ADLs) and was frequently incontinent of bladder and bowel. The certified nurse aide (CNA) care instructions updated 03/09/17 documented the resident was totally dependent with two-person physical assistance for bathing, required limited assistance of one person for bed mobility, and extensive assistance for hygiene and dressing. The resident's behaviors and special needs were identified as care resistance and refusal to get out of bed. Instructions included to re-approach and redirect resident in a calm manner when she was refusing care. The resident's statement on the 10/10/17 complaint included documented on 10/07/17 CNA #26 spoke to her disrespectfully and scrubbed her irritated/broken skin under her breast too hard, it was painful, and the CNA was asked to stop. The CNA left her unclothed on the bed. CNA #23 completed the resident's care on 10/07/17 after CNA #26 left the resident's room. On 10/09/17, the resident had no CNA and asked RN #24 multiple times to get someone to care for her. The resident did not receive care on 10/09/17 from 05:00 AM (from previous shift) until CNA #25 provided care at 03:30 PM. Daily assignment sheets for the resident's floor during the day shift (06:30 AM-02:30 PM) documented: - On 10/07/17, 10/08/17 and 10/09/17 CNA #26 was assigned to Resident #112. The CNA activities of daily living (ADLs) record documented: - On 10/07/17 at 02:00 PM, CNA #26 signed for the resident's care during the day shift; - On 10/08/17 at 09:43 AM, CNA #26 signed the resident's care was not performed during the day shift due to resident refusal. - On 10/08/17 the resident's toilet use during the day shift, 10:00 AM, 12:00 PM and 02:00 PM, was signed by CNA #27. The record was entered on 12/01/17 at 03:20 PM. - On 10/09/17, CNA #27 signed for the resident's care during the day shift. The record was entered on 12/01/17 at 02:17 PM. The 10/08/17 time card for CNA #27 documented the CNA clocked in at 02:29 PM and clocked out at 10:32 PM. The 10/09/17 time card for CNA #27 documented the CNA clocked in at 02:38 PM and clocked out at 10:30 PM. The formal compliant form dated 10/10/17, signed by social worker #36 and the Administrator on 10/23/17, contained statements from the resident, registered nurse (RN) #29, CNAs #26 and 32, and social worker #36. The form documented the social worker was responsible for the investigation including interviewing the resident and gathering the appropriate documentation. The complaint form did not include statements from any other staff assigned 10/07-10/09/17, including the staff identified as witnesses by the resident and CNA #26. The facility did not provide any additional investigation regarding the resident's allegations of neglect on 10/09/17. An undated statement from CNA #26 documented she provided care to the resident on 10/07 and 10/08/17 and the resident made multiple complaints about the manner of the CNA's care. CNA #31 was present in the room caring for the resident's roommate, CNA #26 left and returned with CNA #32 to assist due to the resident's multiple complaints. The resident made inappropriate comments/requests during care, CNA #26 refused, and CNA #32 completed the care for the resident. RN #29 approached CNA #26 a few hours later stating the resident requested a different CNA and advised if no one would take her then bring a witness. Later, CNA #23 accompanied CNA #26 to provide care to the resident, the resident complained about CNA #26's care, CNA #26 left, and CNA #23 completed care. On 10/09/17, CNA #26 announced to everyone she was unable to do the resident's care and everyone just said they weren't going to do her, CNA #26 again stated she was unable to care for the resident per the resident's request. Social worker #36's statements attached to the 10/10/17 complaint documented on 10/10/17, the resident had complaints about care she received over the weekend. The resident complained about CNA #26 not cleaning her and not receiving care on multiple occasions over the weekend. The social worker spoke with the interdisciplinary team and an investigation was started. On 10/18/17, the social worker and Assistant Director of Nursing (ADON) spoke with the resident about how she felt things have been going, the resident reported everyone refused to provide her care on the day shift, offered the resident a move to a different floor, and offered the Ombudsman services. On 10/19/17, the resident was offered a room on another floor, was introduced to her new roommate, and was agreeable to the room change. When interviewed on 08/13/18 at 01:35 PM, CNA #33 stated she recalled when the resident refused CNA #26's care and staff would switch their assignments with her. She stated she did not recall any events from 10/07-10/09/17 specifically, and she was never asked to provide any statements regarding the resident. During a telephone interview with RN #29 on 08/13/18 at 02:18 PM, he stated the resident could be difficult to care for as she felt staff were not doing what she wanted. He could not recall any specific accusations or complaints of not being cared for. He stated as a supervisor, any allegation of mistreatment would be cause for an investigation which would include statements from all staff working at the time. When interviewed on 08/14/18 at 10:14 AM, social worker #22 stated social worker #36 was responsible for investigations and complaints and she was out on leave from work. She was aware of the resident's complaint and would expect statements from all the staff on the floor had been obtained. She was unaware of the details of the investigation and stated the resident often complained about staff, refused care from certain staff, and made allegations. She stated the resident complained about the staff on her floor and did not have any further concerns after she moved to another floor. During an interview with CNA #27 on 08/14/18 at 04:18 PM, she stated the resident was known to accuse CNAs of not providing care, when she refused a CNA, others would cover. She did not recall a time from 10/07-10/09/17 when she may have come from another unit to care for the resident. She was unaware of how her initials would be entered for the resident if she had not worked on the unit or during that shift. The CNA had never been asked by anyone to provide a statement regarding the resident's care. During an interview with the Administrator on 08/15/18 at 10:41 AM, she stated a resident complaint about staff mistreatment or neglect would be possible abuse and an investigation should be completed. She stated per the social worker's statement, an investigation was started and she was unaware if there was additional information. She stated the investigation was not completed to rule out abuse or neglect as there were no statements from the other staff working that day or from the witnesses as noted by the resident and CNA #26. She was unaware of how a CNA who worked a later shift on a different floor signed for the resident's care on 10/09/17 on a later date. She would expect an investigation to include looking at the assignment sheets, CNA documentation, and witness statements. 3) Resident #86 was admitted [DATE] with [DIAGNOSES REDACTED]. The 07/12/17 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, had disorganized thinking, had physical and verbal behaviors directed towards others most days, had inappropriate behaviors, required extensive assist of most activities of daily living, ambulated with supervision, transferred with minimal assist, and received an anti-psychotic and anti-depressant daily. The 07/03/17 Resident #86 hospital discharge summary documented the resident had been refusing care, stated he wanted to go home and attempted to elope from the hospital, and became agitated when others were around. The summary documented he remained in his room and ambulated with a walker. The summary documented he was sent to the hospital for a mental health evaluation after he was found in the previous facility using scissors to cut phone wires and call bell wires at the facility. He was cleared by psych to be no threat to himself or others, and that his previous facility would not take him back due to behavioral issues relating to his dementia. The summary documented he had a cane at the previous facility that he used as a weapon, and required 24-hour supervision due to safety and mental status. The 07/05/17 Resident #86 comprehensive care plan (CCP) documented the resident had physical behaviors directed at others (hit, kick, push, scratch, and grab), verbal behaviors, wandering, cutting wires, and taking silverware. Interventions included monitor, 1:1 supervision while awake, 15-minute checks while sleeping, random room checks, psych as needed, redirect, and bed alarm. There were no other interventions for his aggression CCP. Resident #113 was admitted [DATE] with [DIAGNOSES REDACTED]. The 07/08/17 MDS assessment documented the resident had severe cognitive impairment, had verbal and physical behaviors most days, was total care with most activities, and received an anti-psychotic medication daily. The updated 07/08/17 Resident #113 CCP documented the resident had alteration in mobility, and the potential for being a victim. Interventions included a scoot chair, monitor for changes, monitor for psychosocial distress for 72 hours post incident, and meet with the resident immediately after incident. The 08/07/17 at 10:57 PM late entry Resident #113 nurse progress note documented the resident had her shirt pulled down and her chest grabbed by another resident with no obvious injuries. The note documented she did not appear in distress or pain, medical was made aware, refused vital signs to be measured, family was notified and the residents were separated at the time of the incident. The 08/07/17 at 11:22 PM Resident #86 nursing progress note documented the resident pulled down the shirt and grabbed the chest of another resident with no obvious injuries. There were no new orders received from medical, family was notified (guardian), and he was placed on 1:1 observation at that time. The 08/07/17 Resident #86 updated CCP documented the resident had potential for being an aggressor due to known behaviors, aggressiveness, and sexual behaviors towards others (witnessed resident remove a female resident's shirt and grope her breasts). Interventions included divert, 1:1 to help calm, protect others, separate or remove from object of aggression. The CCP documented the social worker met with the resident for follow up to this incident, she was not able to interpret events, did not appear in distress, and family was notified. On 08/08/17 Resident #86 had a room change to be closer to nursing station. The 08/08/17 at 12:41 PM Resident #113 nurse progress note documented the nurse went to perform a skin assessment which was made difficult due to resistance, combativeness, and pulling away. There were no bruises, redness or scratches to visualized areas. When interviewed on 08/10/18 at 12:07 PM, registered nurse (RN) Unit Manager #6 stated Resident #86 had behaviors such as inappropriate touching female residents' breasts and verbal behaviors. He had been on 1:1 until a week before she took over as RN Unit Manager, about 5 weeks ago. Staff were to document 1:1 in the progress notes and on a 1:1 form that was kept at the desk for the CNAs. She stated the resident had no behaviors since she had been here, and was easily redirected. She stated the process for inappropriate touching was staff were to notify the nurse, an investigation was done, employee and resident statements obtained, exam of the person touched, incident report was done, psychiatric referral if ordered, and the physician was made aware. Interventions used were calming techniques, were resident specific, medication management, psych referrals, 1:1 as needed, and evaluate daily during investigation and for as long as needed. These were put in care plans and care instructions by the RN Unit Manager. When interviewed on 08/10/18 at 01:20 PM, the DON stated the 08/07/17 incident report was not available. When interviewed on 08/10/18 at 01:25 PM, certified nurse aide (CNA) #41 stated she was on lunch at the time of the incident, was told to keep them separated and Resident #86 was placed on 1:1 supervision. He had been on 1:1 for a week then was taken off at times due to staffing, and then did something else to put him back on 1:1. She stated she did not complete a witness statement. When interviewed on 08/10/18 at 03:41 PM, the Administrator stated she left the incident report of 08/07/17 regarding the resident to resident abuse for the DON to copy. They were unable to find it. When interviewed on 08/10/18 at 03:43 PM, certified nurse aide (CNA) #42 stated he cared for Resident #86 a few times as 1:1 or on his assignment. He was on 15-minute checks while sleeping during the night and on 1:1 when awake, and performed his own care. He was unaware of the specific incident relating to sexual inappropriateness with a female resident on 08/07/17. When interviewed on 08/10/18 at 04:33 PM, RN Supervisor #29 stated Resident #86 was sexually inappropriate with female residents. He stated Resident #86 did whatever he wanted and told off staff if they told him no to something. He stated he filled out the incident report for Resident #86 and 113 as it was a resident to resident incident. He stated the residents were immediately separated. He did not think Resident #86 was put on 1:1, was put on 15 minutes checks and may have already been on them. When re-interviewed on 08/10/18 at 05:07 PM, the Administrator stated she expected an incident report and a complete and thorough investigation to be done if resident to resident abuse occurred. She expected behaviors to be included in the CCP along with interventions. CCPs were the responsibility of the interdisciplinary team, specifically nursing and social services, for behaviors with input from the other departments. She expected documentation to be done in the progress notes and electronic chart (for CNAs) for any behaviors. The facility did a rapid response with corporate via phone regarding resident to resident incidents so that there was a discussion regarding actions taken by the facility. She expected the CCP to be updated and ongoing post incident, and stated she could not find the incident report. 10NYCRR 415.4(b)

Plan of Correction: ApprovedSeptember 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #23, 86,112,and 113 were assessed. No sign of adverse effects were reported as a result of these findings. Resident 23 (with a [DIAGNOSES REDACTED]. and recanted her complaint of being treated roughly she has since refused to have a different primary aide assigned to her. She currently denies that any staff member treated her roughly. Resident 113 no longer resides at facility Resident 112 is no longer at facility Resident 86 care plan has been reviewed and it has been determined to be clinically appropriate. 2. The facility recognizes that all residents could be affected by this deficient practice. The facility conducted a review of grievances, incident reports during the last 30 days to identify reportable events. No further incidents were identified warranting reporting. 3. The facility is reeducating all employees on resident?s rights, timely reporting of allegations to administrator; reporting guidelines; abuse and neglect protocol and follow-up on grievances. Reeducation of employees will focus on timely reporting of allegations to the administrator,director of nursing and supervisors. Facility policy on reporting allegations of abuse in review with employees. Allegations involving employees will be reported to the administrator immediately. Employee will be suspended pending investigation. The administrator will oversee timely reporting of allegation of abuse to the state licensing authority within required time frame and as defined by the state regulations. The interdisciplinary clinical team will review allegations of abuse in clinical meeting to identify root cause and develop plan of plan and maintain resident?s right and dignity. The director of social services will review grievances log to identify issues relating to allegations of abuse and communicate such reports with the interdisciplinary team to promote resident?s safety. Facility will obtain witness statements from all witnesses, alleged abuser(s), and resident if applicable.Statements will include written statements not only from staff involved in the incident but also from anyone who might have knowledge or participated in the investigative process. The Resident Care Plan will be reviewed by the interdisciplinary team to identify changes in plan of care related to the event as applicable. Events related to altercation in resident care will be reviewed by the interdisciplinary team. Registered nurse assessment will be completed for events related to resident?s injury. Upon conclusion of the investigation, the facility will prepare a report to include details of the investigation, any actions taken by the facility i.e., staff training, appropriate counseling as applicable, interventions to prevent further injury/alleged abuse), a summary of the findings and a conclusion of the investigation (i.e., was the allegation substantiated or unsubstantiated). This final follow-up report will be submitted to the state survey agency as applicable. The center will adopt a monitoring tool designed to track reportable event in order to provide adequate oversight and follow-up. 4.The administrator/designee will provide ongoing monitoring of reportable events for timely reporting of events. The director of social services will complete weekly audits to identify unresolved grievances or issues pending follow- ups, weekly x4, bi-monthly x2 and monthly x3. The administrator will review the reportable tracking tool and report audit findings to the QAPI committee for further recommendations. All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee. Responsible Party: Administrator

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the recertification survey the facility did not maintain drugs and biologicals stored and labeled in accordance with currently accepted professional standards for 1 of 3 nursing units (Unit 3) inspected. Specifically, inspection of Unit 3's medication room and medication cart revealed 4 expired sunscreens and an insulin vial that was not discarded 28 days after being opened. Findings include: The Administering Medications policy updated ,[DATE] documented the expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date will be recorded on container. On [DATE] at 03:03 PM the Unit 3 medication room and medication cart were inspected with licensed practical nurse (LPN) #9 present. Results of inspection were: - One sunscreen with an expiration date of ,[DATE] and 3 sunscreens with expiration dates of ,[DATE]. - One multi-dose vial of Humalog insulin with an opened date of [DATE]. During an interview with LPN #9 on [DATE] at 03:10 PM, he stated he was not aware sunscreen had an expiration date. He stated the stock clerk was there a few days ago restocking the sunscreen and other supplies. The stock clerk checked expiration dates and rotated supplies. He stated insulin should be discarded after 28 days and did not realize the insulin should have been discarded by now. He discarded the 4 sunscreens and insulin vial with the surveyor present. During an interview with stock clerk #19 on [DATE] at 11:07 AM, she stated she went to each unit in the facility and restocked supplies. She remembered being on Unit 3 a few days ago and restocking sunscreen. She stated she usually checked the expiration dates on supplies and removed anything that had expired. She stated she must have missed the expiration dates on the sunscreens. 10NYCRR 415.18(d)

Plan of Correction: ApprovedSeptember 15, 2018

1. The expired sunscreen was discarded and all additional sunscreens were reviewed for current date of use. The expired insulin vial was discarded. All insulin vials in use were reviewed for being dated when opened, within current date of use and were not in use no longer than 28 day. 2.All residents have the potential to be affected. All unit?s medication rooms and medications carts were reviewed for any expired medication/salves to ensure drugs and biologicals are stored and labeled with current accepted professional practices addressed. Any findings were addressed. 3.The policy titled: Storage of Medications was reviewed and revised. The Licensed nurses were educated to check their medication carts daily to assess for expired medication and salves, and additionally check medications prior to administration to ensure all open Insulin is dated and utilized within 28 days of opening, and sunscreen to be used are not expired and that all drugs and biologicals are stored with currently accepted professional standards The unit managers were also instructed to randomly check for expired medications with the licensed nurses to ensure labeling of Insulin and no salves that are to be used are expired and that all drugs and biologicals are stored with currently accepted professional standards. A system has been implemented that on a daily basis the medication room has been reviewed for expired medications/biologicals by the unit manager/designee. The Unit manager/designee will be responsible to oversee and ensure that drugs and biologicals are stored within dates of administration and not expired. 4.An Audit will be conducted by the Unit Manager/Designee of the med room and a med cart for expired medication/salves and that dated insulin in in use during the 28 day period/ sunscreen within date, to ensure medications/biologicals are stored currently within professional standards and not expired. All findings will be reported to QAPI for review and comment. All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee. Responsible Party: Director of Nurses

FF11 483.60(d)(1)(2):NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP

REGULATION: §483.60(d) Food and drink Each resident receives and the facility provides- §483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(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: August 15, 2018
Corrected date: October 14, 2018

Citation Details

Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meals tested . Specifically, food was not served at a palatable temperature and 2 of 3 test trays did not meet the minimum hot temperature. Findings include: The undated Resident Tray Assessment documented acceptable food temperatures for tray items, with entrees, starches, and vegetables to be greater than 130 degrees Fahrenheit (F). The 04/07/18 updated Recording Food Temperatures and Logs Policy Guideline #4 documented food temperatures must be recorded on all food items at the beginning of meal service and repeated midway through at point of service. On 08/08/18 at 10:15 AM, Resident #17 stated the food was usually lukewarm. On 08/08/18 at 12:14 PM, Resident #11 stated the food was usually cold. On 08/09/18 at 12:00 PM, the Food Service Director stated food service staff take temperatures after food is cooked and first placed into the steam tables and again at the end of the meal service. On 08/09/18 at 12:50 PM, a test tray was completed on Unit 1. The country fried chicken had a temperature of 130 degrees F, the broccoli was 118 degrees F, and the mashed potatoes were 122 degrees F. Mashed potatoes were lumpy. On 08/14/18 at 12:24 PM, a test tray was completed on Unit 1. The tray obtained was the last tray of the second cart. The ham had a temperature of 118 degrees F and the sweet potatoes had a temperate of 123 degrees F. The ham had a wrinkled appearance on the edges and was lukewarm when the surveyor tasted it. The sweet potatoes had been boiled and were not uniform in size; the large pieces maintained their shape and the smaller pieces were mushy. The sweet potatoes were lukewarm when the surveyor tasted them. On 08/14/18 at 01:59 PM, the Food Service Director stated temperatures of the served trays were checked by completing tray assessments. The facility could provide documentation of the recent test assessments. She stated temperatures of the vegetables and the entrees had been greater than 140 degrees F when measured during tray assessments. The issue of cold food had not been mentioned to her, and was unaware that resident #11 had issues with food temperatures. When the Food Service Director was made aware of the temperatures from the 08/14/18 test tray, she stated that the food was not hot enough. Record review of the 08/14/18 Food Temperature Log revealed that the end of the lunch line temperature of the ham was 140 degrees F, and the sweet potatoes were 146 degrees F. 10NYCRR 415.14(d)(1)(2)

Plan of Correction: ApprovedSeptember 15, 2018

1. The Director of Food Services is meeting with Residents #17 and #11 to address their identified concerns regarding food temperatures and will meet with them at least weekly to assure resolution until both residents have stated satisfaction for 4 consecutive weeks. 2.The facility recognizes that all residents can be potentially affected by this deficient practice. The Director of Food Service will address Food Temperatures and palatability with residents at their Food Committee Meeting held monthly. In addition, the director of Food Services will distribute a Survey to all residents regarding Food Palatability and Food Temperatures. Results of the Survey will be reviewed by the Director of Food Services and discussed at the Resident Food Committee. All identified issues will be addressed by the Director of Food Services. 3.The process for documenting food temperatures has been revised to reflect monitoring and recording the food temperature of the entrée, starch, and vegetable at the beginning of each meal service and repeated midway through the meal service at the point of service. All thermometers will be calibrated weekly. By the Dietary Supervisor. In addition, it was identified that a significant number of plate warmers were not heating appropriately. New plate warmers and dome lids have been obtained. The defective plate warmers have been sent for repair. All Food Services staff will be in-serviced on the changes to the Temping process and Temp Log documentation. 4.The Director of Food Services/ designee will audit the Temperature Log on a daily basis until compliance with Food temps is 100% for 2 consecutive weeks, then weekly thereafter. Audit results will be reported to the QAPI Committee for review and comment. Need for further reporting will be determined by the QAPI Committee. The Director of Food Services will report outcomes of Food Committee meetings monthly with identified interventions to the QAPI Committee on a monthly basis. The need for continued reporting will be determined by the QAPI Committee. The individual responsible for correction of this deficient practice is the Director of Food Services.

FF11 483.25:QUALITY OF CARE

REGULATION: § 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 5 of 6 residents (Residents #5, 9, 11, 32, 99 and 105) reviewed for timeliness of administration of medication and 2 of 8 residents (Residents #32 and 105) reviewed for skin treatments. Specifically, Residents #5, 9, 11, 32 and 105 did not receive medications at their scheduled times. Resident #32's leg wraps were not administered as ordered. Resident #105 did not receive timely skin treatments. Findings include: The facility policy Administering Medications revised 03/2018 included: All medications/treatments are to be administered within 2 hours (one hour prior and one hour after) of the scheduled time. If for any reason the medication is not administered within the scheduled time, the supervisor, unit manager and the MD must be notified. 1) Resident #9 was originally admitted on [DATE] and had [DIAGNOSES REDACTED]. The 05/12/18 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The 05/2018 Medication Administration Record [REDACTED]. Medication administration documentation was missing between 07:00 and 02:00 on the dates of 05/02-05/04/18. The MAR indicated [REDACTED]. The 06/2018 MAR indicated [REDACTED]. All medication administration documentation was missing for all 01:00 PM and 02:00 PM for 06/10/18 and 06/16/18. The 10:00 PM [MEDICATION NAME] medication administration was missing for 08/28/18. All medication administration documentation was missing for 07:00 PM and 08:00 PM medications on 06/29/18 and 06/30/18. The MAR indicated [REDACTED]. The 07/2018 MAR indicated [REDACTED]. All medication administration documentation was missing from 07:00 PM-10:00 PM on 07/08/18. All medication administration documentation was missing for 02:00 PM on 07/26/18. The MAR indicated [REDACTED]. The 08/2018 MAR indicated [REDACTED]. The [MEDICATION NAME] missed documentation on 08/03/18 at 08:00 AM. The [MEDICATION NAME], and [MEDICATION NAME] missed documentation on 08/07/18 at 07:00 AM and 08:00 AM. The nursing progress notes from 05/03-08/02/18 did not include documentation for missed medications. During an interview on 08/14/18 at 12:32 PM, LPN #60 stated the nurses had an hour before and an hour after the scheduled time; when they were short staffed it was difficult to administer timely. She stated she worked a double shift (16 hours) on Saturday 08/11/18 and had frequently lost connection to the internet and was not able to document, I spent half the time just logging in and out and trying to sign for meds. She stated the medications were not actually administered late, just that she was late signing that they had been given due to connectivity. She stated there was no supervisor on duty to report it to. During an interview on 08/14/18 at 12:44 PM, LPN #61 stated medications were to be given an hour before to an hour after scheduled time. She stated she had difficulty administering due to being short staffed, having to take 2 sets of keys (to 2 different medication carts), which could cause her to pass medications as much as 2-2.5 hours late. She had not been notified or oriented on the need to notify the MD. If she did not complete a treatment, she did not sign that it had been done, and would let the next shift know. During an interview on 08/14/18 at 01:53 PM, physician #13 was asked what his expectations were when medications were administered late; and asked if he was aware that that multiple medications were given hours late for Residents #9 and 105. The physician stated that he should have been notified, and had not been. He stated that the facility did not have enough staff and they were not hiring at that time. During an interview on 08/14/18 at 02:00 PM, LPN #11 stated the policy for medication administration times dictated they had an hour before and hour after scheduled time. She stated she had not had a problem administering on time, but had been having issue signing for them; the internet would go down and she would not be able to sign. When asked, she stated she thought they only notified the doctor if a medication was not given. During an interview on 08/14/18 at 03:07 PM, LPN #40 stated medications were to be give 1 hour before to one hour after scheduled time. The only time she reported late administration of medications was when she had to stay late because she was not familiar with day shift medications and would be extra careful passing so she did not make an error. When asked, she stated a nurse had told her in the past she was somehow passing meds under LPN #40's name. During an interview on 08/14/18 at 04:08 PM, the DON stated LPN #58, who passed medications late on 08/08/18, was no longer employed by the facility. Nurses were expected to administer medications within an hour before or after the scheduled medication time. When there was only one nurse on the medication cart it could be difficult. 2) Resident #32 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 05/12/18 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The 01/28/18 comprehensive care plan (CCP) documented the resident was at risk for altered skin integrity related to diabetic skin ulcers. The physician orders [REDACTED]. The 07/2018 and 08/2018 treatment administration records (TAR) documented the resident's leg wraps were not administered as ordered. - In 07/18 there were 14 (fourteen) times in 25 days since the treatment was initiated that the placement of the ace wraps was not documented. - During the 08/18 there were 13 times in 14 days that there was no documentation of leg wrap administration. There was documentation of 1 refusal by the resident to keep the wraps on during this same period, and documentation that the resident's wraps remained off for 2 days between 08/06-08/08/18 and remained off for 3 days between 08/11-08/14/18. - The TAR did not include a reason for these missed days. The 07/29/18 physician progress notes [REDACTED]. Goals documented to continue skin care treatment. According to the CNA documentation record for 07/2018 and 08/2018 the resident was independent with most activities of daily living (ADLs) except, supervision and up to one assist for toileting and transfers in the evening. The resident was observed by surveyor on 08/13/18 at 09:55 AM in his bed with severe lower extremity [MEDICAL CONDITION]. Bilateral leg wraps were observed to be tightly digging into the resident's lower legs and ankles. On 08/13/18 at 10:05 AM, licensed practical nurse (LPN) #7 removed the wraps from the resident's lower legs. The resident writhed in pain as the wraps were removed. On observation by a surveyor after the wraps were removed, deep indentations were noted on both lower legs especially around the resident's ankles. During an interview with the resident on 08/13/18 at 09:55 AM, he stated that he took the wraps off on Friday 08/10/18 in the evening, and LPN #40 put them on Saturday morning 08/11/18 and nobody took them off on Saturday night, Sunday 08/12/18 morning or Sunday night; and nobody has come in this morning to check my legs. The resident complained that his legs were very painful and heavy. He stated he had complained to LPN #15 on Sunday 08/12/18 overnight, and she told him she would take care of it, but never did. During an interview on 08/14/18 at 10:49 AM, CNA #16 stated she was not involved in any of the daily leg wraps as that was the LPN's duty. During an interview on 8/14/18 at 11:26 AM, LPN #4 stated that she and her coworker LPN #47 were scheduled to work on Unit 1, but were requested by the administrator to work on unit 2 on Saturday 08/11/18 and Sunday 08/12/18. The LPN stated that she had to assist with treatments on side 1 on Unit 2 on Saturday and on side 2 on Sunday. She stated that once the treatments were completed, she and her colleague LPN #47 returned to unit 1. On 08/14/18 at 11:41 AM, LPN #15 was contacted by phone and unavailable and did not return the surveyors call prior to survey exit. During an interview on 08/14/18 at 11:26 AM, the Director of Nursing (DON) stated nobody notified her about the leg wraps being left on and not being signed by staff who placed them on the resident. The DON stated she expected staff to follow physician orders [REDACTED]. 10NYCRR 415.12

Plan of Correction: ApprovedSeptember 20, 2018

1. Residents #5,9,11,32,99 and 105) reviewed for adverse events related to receiving their medications outside the acceptable parameters. the residents did not suffer any adverse reactions.All residents remain at their baseline. Resident 32 continues to be followed by Wound Healing Solutions (WHS) and his wounds showed signs of improvement. No sign of adverse effect identified. Residents 9,11,32,and 105 are at baseline and suffered no ill effects from receiving treatments and medications late. 2. All residents have the potential to be affected. An audit on all resident?s medication administration records and treatment administration documentation, for the past 30 days, looking for medications/treatments given as ordered and timely, if omissions, reasons for medication not given documented and the reporting to the physician were completed. All findings will be addressed. 3. The policy, Administering of Medications,revised 3-2018 was reviewed and no revision was necessary. All licensed nursing staff to include, Unit Managers/ designee and supervisors, will be educated on the above policy and procedures related to medications/treatments given as ordered and timely, if medication not given reasons for medication not given documentation, and the reporting to the physician for additional orders and the checking at the end of the shift, to ensure medications/treatments were given timely and as ordered. Licensed Nursing education will also emphasize reporting medication unable to be provided as ordered or documented to the nursing supervisory staff for follow-up. All medications and treatments not given timely or documented/ not given will be placed on 24 hour report for communication and follow-up. End of shift wrap up will be implemented with review by the unit manager/designee to ensure that all residents medications and treatments are administered as ordered. Unit Managers/Designee will oversee throughout the shifts that medications and treatments are being done timely and documented as ordered by the physician or if not communication to the physician for further orders has been completed. All licensed nursing staff will be re-educated on the proper procedure, outlined in the Medication Administration Procedure, to follow when medications and treatments are not given/ performed on a timely basis. Including notification of the MD and Unit Manager. Licensed Nursing Personnel will be educated that they and only they may perform leg wraps. The facility continues to aggressively recruit nursing staff and has increased the frequency of Job Fairs. Wifi Connectivity was assessed by IT Department in (MONTH) - system rebooted and connectivity issues resolved. Staff currently report no issues with connectivity at this time. IT to be contacted if issues re-occur. 4.Director of Nursing/Designee will audit 10 resident?s Medication Administration Records and 10 Treatment Administration records to identify medication not being given at their scheduled time (timely), not administered as ordered, not documented with reasons not given and physician notification if not timely or administered, weekly x8, Monthly x3. All findings will be brought to the QAPI committee for review and comment. All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee Responsible Party: Director of Nurses

FF11 483.12(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure that all alleged violations involving abuse and neglect were investigated to rule out abuse/neglect for 1 of 6 residents reviewed for abuse (Resident #32). Specifically, Resident #32 reported abuse on 2 occasions, once by another resident and once by a staff member, and the reports were not investigated timely. Findings include: I. Allegation against another resident Resident #32 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The 05/16/18 comprehensive care plan (CCP) documented the resident had potential for being a victim after his roommate used abusive language towards the resident, the resident did not want a room change at that time as he and his roommate were friends. On 08/13/18 at 09:55 AM, the resident stated in an interview his roommate punched him in the left jaw Friday night (08/10/18) around 07:00 PM after he tried to turn off the air conditioner in their room. The resident's left jaw was observed with a small open area surrounded by light bluish/purple bruising. He stated he reported it to licensed practical nurse (LPN #15) who looked at his jaw and stated the injury was a scratch and nobody had hit him. On 08/13/18 at 10:05 AM, Resident #9 stated in an interview, he was in the hall when Resident #32 reported to LPN #15 he was hit. He stated he heard LPN #15 tell Resident #32 the injury was a scratch and nobody hit him. On 08/13/18 at 11:00 AM, the resident's progress notes were reviewed and there was no documentation regarding the resident's allegation against his roommate on 08/10/18 and no documentation of the injury on the resident's left jaw. On 08/13/18 at 02:45 PM, the resident was observed telling LPN #11 his roommate hit him on Friday 08/10/18. The nurse told the resident she would document it. LPN #11's progress note dated 08/13/18 at 03:07 PM, documented the resident reported an incident with his roommate that occurred on 08/10/18 about the temperature on their air conditioner. The resident claimed the roommate hit him in the left jaw, there was slight swelling and bruising, and he requested a room change. There was no documented evidence an investigation was initiated. On 08/14/18 at 10:30 AM, LPN #11 the resident told her his roommate hit him in the jaw last Friday. She stated she reported it to the incoming shift at 03:15 PM on 8/13/18 and completed a progress note. She stated she did not report the incident to a supervisor. On 08/14/18 at 03:00 PM, the Administrator stated in an interview she became aware of the resident's allegation at 06:45 PM on 08/13/18 after the resident saw her on the unit and reported it to her. She stated when the resident told LPN #15 on 08/10/18, it should have been reported immediately to protect the resident from further harm. She stated it was not up to the nurse to judge whether the resident had a scratch or if he was abused. Additionally, she stated when the resident told LPN #11 on 08/13/18, it should have reported immediately and protection of the resident should have been put in place and it was not. On 08/14/18 at 05:40 PM, LPN #15 stated in an interview she should notify the Supervisor, document a progress note and start and accident incident report when a resident reported abuse. II. Allegation against staff On 08/08/18 at 02:24 PM, Resident #32 stated in an interview that LPN #11 hit his hand approximately 3 days ago and nobody asked him for a statement. He stated the Administrator visited him and told him LPN #11's side of the story and never asked for his statement. The resident's progress notes were reviewed from 07/12-08/09/18. There was no documentation of an allegation made by the resident against LPN #11. On 08/10/18 at 09:00 AM, the surveyor observed a statement located at the nursing station documented by LPN #11 noting she accidentally bumped the resident's hand during care on 08/04/18. On 08/10/18 at 12:33 PM there were no incident reports for Resident #32 for 8/2018. On 08/14/18 at 10:30 AM, LPN #11 stated she and the resident were joking around when she accidentally bumped his hand about a week or so ago, he blew things way out of proportion and alleged abuse against her. She stated she was asked to write a statement, did not recall the outcome of the investigation and continued to work on the resident's unit. On 08/14/18 at 03:00 PM, the Administrator stated in an interview the resident never reported to her that LPN #11 hit his hand, she was not aware a statement was written by LPN #11 and an investigation should have been completed. 10NYCRR 415.4(b)(1)(ii)

Plan of Correction: ApprovedSeptember 18, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Reportable event was identified during the survey. Both of Resident #32?s allegations were thoroughly investigated when reported to the Administrator during survey and a report was entered into the HCS System. Resident #32 was assessed by a medical provider who determined the abrasion on his face was due to scratching of a pimple or a self inflicted scratch. A physical altercation did occur between him and his roommate where they were pushing each other in a dispute over the loudness of the tv and the temperature of the room. Both residents refused to speak to the police when they arrived. Resident #32 was moved into a different room and expressed satisfaction with the intervention. Resident #32 has demonstrated no further distress regarding the altercation between himself and his roommate. Stated that he was content with the room change and that resolved the issue. Regarding the allegation against the staff person: After a thorough investigation the allegation was not substantiated. Both nurses who failed to report the resident's allegations were educated regarding their responsibilities to report resident allegations of abuse or mistreatment immediately. In addition, the nurse involved in the allegation against the staff member was educated regarding reporting resident behaviors and documenting on them in the medical record. 2.The facility recognizes that all residents can be affected by this deficient practice. The facility conducted review of grievances, incident reports during the last 30 days to identify reportable events No further incident was identified warranting reportable. 3. The facility reeducated employees on reportable events, including applicable and required documentations. Reeducation of employees focused on timely reporting of allegations to the administrator, director of nursing and supervisors. Facility policy on reporting allegations of abuse were reviewed with employees. Allegations relating to employees will be reported to the administrator immediately. Employee will be suspended pending investigation. 4.The administrator or designee will provide ongoing monitoring of [MEDICATION NAME] for timely reporting of events. The director of nursing or designee will complete weekly audit of residents requiring follow-up relating to assessment and follow-ups, monthly x4, bi-weekly x2 and monthly x3. The administrator will review the reportable tracking tool and report audit findings to the QAPI meeting for further recommendations All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee. Responsible Party: Administrator

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey, the facility did not ensure 2 of 5 residents (Residents #39 and 99) reviewed for advance directives had the right to formulate advance directives. Specifically, Residents #39 and 99 had Medical Orders for Life Sustaining Treatment (MOLST) completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to lack capacity for decision making) and there was no documentation the residents lacked decision-making capacity. Findings include: The facility's Advance Directives policy revised ,[DATE] documented the interdisciplinary team would conduct ongoing review of the resident's decision-making capacity and would communicate significant changes to the resident's legal representative. Such changes would be documented in the care plan and medical record. The MOLST instructions for completion for adult patients without medical decision-making capacity state: A health care agent may make medical decisions on behalf of a patient, after two physicians concur that the patient lacks medical decision-making capacity. 1) Resident #39 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident had intact cognition with no signs or symptoms of [MEDICAL CONDITION] and did not exhibit symptoms of inattention, disorganized thinking, or altered level of consciousness. The resident could understand others, had clear speech, had some difficulty communicating, but could if prompted or given time. The resident participated in the assessment and no family, guardian, or legally authorized representative participated. The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] documented the resident's wishes were to have cardio [MEDICAL CONDITION] resuscitation (CPR), no limitations on medical interventions, do not intubate (DNI, no artificial breathing machine), send to the hospital, no feeding tube, trial intravenous (IV) fluids, and use antibiotics. The resident provided verbal consent and was documented as the decision-maker on [DATE]. The MOLST was witnessed by two nurses and signed by the resident's physician on [DATE]. The MOLST was reviewed and signed by the physician with no changes on [DATE], [DATE], [DATE], [DATE], and [DATE]. The social services initial assessment dated [DATE] documented the resident had no family involvement and did not provide any information regarding her family contacts. The comprehensive care plan (CCP) initiated [DATE] documented the resident's advance directive wishes were to be full code (CPR). Interventions included appropriate disciplines counseling the resident regarding advance directives and to respect the resident's wishes. The social services note dated [DATE] documented the resident's relative contacted the facility as she was unaware of the resident's move to the facility. The relative stated she wanted to be the contact and HCP for the resident, the social worker completed the form, and stated she would let the resident know her relative called. The health care proxy (HCP) form dated [DATE] documented the resident named a relative to act as her health care agent to make any and all health care decisions to take effect only when she became unable to make her own health care decisions. The resident signed the form and no date was provided with the signature. The social worker (no longer at the facility) signed the form as the witness on [DATE]. The physician's progress note dated [DATE] documented the resident had a MOLST form completed, there was a question of capacity, the resident was non-verbal, and HCP involvement was needed. Psychiatry was to be consulted to address determination of capacity. The physician's progress note dated [DATE] documented the resident had a MOLST completed, she did have the capacity to understand the consequences of the MOLST form and elected to be a full code. A psychiatric nurse practitioner (NP) progress note dated [DATE] documented the resident was alert with limited conversation, did not appear to be delusional or hallucinating, and was difficult to evaluate. Her insight, judgment, cognition, and memory appeared to be mildly impaired. The social services progress note dated [DATE] documented social worker #22 and the nurse manager spoke to the resident's HCP concerning her advance directives. The HCP wanted to change the resident's status to DNR/DNI and no feeding tube. A new MOLST was completed with the HCP's verbal signature, care plan changed, and the chart marked DNR. There was no documentation regarding a conversation with the resident about her wishes or if lack of decision-making capacity was determined for the resident. The MOLST dated [DATE] documented the resident's advance directives were DNR, DNI, limited medical interventions, send to the hospital, no feeding tube, trial IV fluids, determine use or limitation of antibiotics when infection occurs. The resident's HCP provided verbal consent and was noted as the decision-maker. Social worker #22 and a nurse signed the document on [DATE] and the physician signed on [DATE]. physician's orders [REDACTED]. The CCP updated on [DATE] documented the resident's advance directives were DNR/DNI and the resident's HCP completed a new MOLST. When interviewed on [DATE] at 10:06 AM, social worker #22 stated she recalled the former nurse manager had called the resident's HCP and notified her the resident was not able to make decisions and they updated the MOLST. She was unable to recall the reason the call was placed. She stated when an HCP made a decision, it should be based on the resident's wishes. The reason the resident was not able to make her own decisions was due to her mental illness including symptoms of delusions, hallucinations, and having unreasonable fears. She stated the resident was known to have confusion and to not make sense. She was unaware of the legal requirements for determination of lack of decision-making capacity when the cause was mental illness or dementia. The social services department and the physician were responsible for legal documentation regarding lack of capacity determination. The social worker was unable to locate any documentation in the resident's record showing the resident was evaluated and determined to lack decision-making capacity. The resident's physician was interviewed on [DATE] at 01:52 PM and stated the facility would sometimes ask him to determine if a resident lacked decision-making capacity and it was not something he did regularly. The facility also had psychologist #21, who could evaluate residents for decision-making capacity. During an interview on [DATE] at 02:19 PM, registered nurse (RN) Unit Manager #6 stated the resident could make her own decisions, it took time to communicate with her, and she had the capacity to understand. Her communication was difficult as she was very soft spoken and difficult to hear or understand at times. She stated the resident should be included in decisions along with her HCP. When interviewed on [DATE] at 04:23 PM, psychologist #21 stated he would assess residents for health care decision-making capacity when he was asked by the facility to do so. He stated he did not seek concurring provider documentation as he was a licensed psychologist and able to determine if a resident had capacity. 2) Resident #99 was admitted on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance with most activities of daily living (ADLs). The resident was difficult to understand at times, could make his needs known and understand others, had some difficulty communicating and was able to if prompted or given time. The resident participated in the assessment and no family, guardian, or legally authorized representative participated. The comprehensive care plan (CCP) entry on [DATE] documented behavioral changes and a psychiatric consult was requested. The CCP was updated on [DATE] and documented the resident's advance directives were full code (CPR). The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] documented the resident's advance directives were do not resuscitate (DNR, allow natural death), do not intubate (DNI), limited medical interventions, send to the hospital, no feeding tube, trial IV fluids, determine use or limitation of antibiotics when infection occurs. A family member signed the MOLST form and was noted as the decision-maker. There was no documentation of determination of capacity. The CCP was updated on [DATE] documented the DNR/DNI remained in place at this time. The active CCP continued to note both full code and DNR. The physician's progress note on [DATE] documented that the resident was depressive, disruptive and agitated, and the resident was able to be redirected. The physician documented the MOLST forms were signed and up to date, and the resident's advanced directives were DNR, DNI. The resident's physician was interviewed on [DATE] at 01:52 PM and stated the facility would ask him on occasion to determine if a resident lacked decision-making capacity and stated that it was not something he did regularly. He said the facility already had a staff psychologist #21, who could evaluate residents for decision-making capacity. When interviewed on [DATE] at 04:23 PM, psychologist #21 stated that he would have assessed the resident for health care decision making capacity had he been asked to do so, but he stated that he was never asked to assess this resident. 10NYCRR 415.3(e)(1)(ii)

Plan of Correction: ApprovedSeptember 19, 2018

1. Residents #39 and #99 have been assessed by their attending physician and found physicians to have healthcare decision-making capacity. Determination of these evaluations was documented in the residents? medical records. Residents? MOLST have be reviewed with them. Resident #39 directed she be a DNR, DNI, do Not send to hospital unless pain or severe symptoms cannot be controlled, no tube feed, trial of IV, use antibiotics. Resident #99 directed he be a DNR,DNI, Do not send to hospital unless pain or severe symptoms cannot be controlled, no feeding tube, don not use antibiotics New MOLSTs generated with residents? signatures as decision makers and care plans updated accordingly. Both residents? care plans have been reviewed for consistency with current MOLST and are consistent with residents? decisions. 2.All residents have the potential to be affected by the alleged deficient practice. A full-house audit will be completed to identify any residents whose MOLST was signed by a HCP or other surrogate, to determine if there is appropriate documentation of their lack of capacity. Any findings will be addressed by initial determination by attending physician of resident capacity to make healthcare related decisions. If residents are determined to lack capacity and have a HCP a second physician will be asked to also make a capacity determination. If resident has a Surrogate, a second licensed professional such as licensed psychologist, LMSW, PA, NP, or MD/DO will be asked to make a capacity determination. All residents found to lack capacity for healthcare decision making will have their lack of capacity determinations documented on the adopted MOLST Incapacity Determination Form. Residents CCPs will be reviewed for consistency with MOLST orders and updated appropriately with any identified discrepancy. 3.Policy titled ?Advance Directives? was reviewed, revised and adopted. Social work department and licensed nurses will be educated on the above policy with emphasis on the legal requirements for determining resident?s lack of capacity in order for a HCP or surrogate to complete a MOLST on behalf of the resident. The ?MOLST Incapacity Documentation Form? was reviewed and adopted to document a resident?s lack of capacity when determined by 2 physicians if the decision maker is to be the HCP and a physician and another licensed professional as listed above if a Surrogate. 4.The Social Work Director/designee will review 3 MOLSTs and corresponding CCPs to ensure the resident had the right to formulate advance directives, and to ensure that there is appropriate documentation on the medical record of 2 physicians? determination of the resident?s lack of capacity if the resident?s HCP or surrogate completed the MOLST on the resident?s behalf, weekly x4 weeks, then bi monthly x2, then monthly x3 months. Findings will be brought to the facility?s QAPI committee for review and recommendations. All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee. The individual responsible for the correction of this deficient practice is the Director of Social Work.

FF11 483.10(c)(7):RESIDENT SELF-ADMIN MEDS-CLINICALLY APPROP

REGULATION: §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey the facility did not ensure that residents were assessed to determine ability to safely self-administer medication, when clinically appropriate, for 1 of 2 residents (Resident #73) reviewed for self-administration of medications Specifically, for Resident #73 there was no physician order for [REDACTED]. Findings include: The Self-Administration of Medications policy and Administration of Medication policy revised in 12/2016 and 03/2018 respectively, documented that residents may self-administer their own medication; only if they have been assessed by the attending physician, in conjunction with the IDCP. The resident will then be instructed on how to complete an accurate record of self-administration. All self-administration medications must be kept in a safe and secure place, not accessible by other residents. Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required supervision for most areas of activities of daily living (ADLs). The comprehensive care plan (CCP) initiated 01/31/18 and updated on 07/11/18 documented the resident was to receive nothing by mouth (NPO) and had a PEG (percutaneous endoscopic gastrostomy, a feeding tube) for nutrition and hydration. The CCP documented the resident had eaten food by mouth and had poured coffee and other fluids down his PEG tube despite the NPO diet. Interventions included providing tube feedings and flushes per physician order. The physician orders dated 07/02/18 and 08/03/18 documented that the resident was NPO. There were no orders documenting the resident could self-administer all of his medications. A physician progress documented on 07/13/18 documented that the resident could feed himself, but he also does not want to use his feeding tube and wants all his food orally. The treatment administration records (TAR) and medication administration records (MAR) for 07/2018 and 08/2018 documented staff were administering medications and treatments to the resident. There was no documentation of self-administration of medications. The CNA care instructions sheet for 07/2018 and 08/20/18 documented that resident was independent to supervision for most of his ADLs and he had PEG tube for eating and toileting with one person assist for tube feeding. On 08/08/18 at 08:50 AM the resident was observed with two medication cups in front of his TV stand. One contained clear liquid and one with pinkish/reddish liquid:and at that time the resident stated he could not remember what the reddish medication was and the clear one was for his throat and he would take them later. The resident had a large plastic syringe that contained two pills, both split in half. He stated they were medications he was going to take later. At 09:20 AM, the resident's roommate came in to the room. At 9:25 AM, resident left the room and his roommate remained in the room with no staff. On 08/10/18 at 11:11 AM two plastic medication cups were observed in the residents room, one contained a red liquid and one contained a clear liquid. During a medication administration observation on 08/13/18 at 11:00 AM, licensed practical nurse (LPN) #11 was observed preparing medications for the resident. She handed the resident a cup of water after she crushed the medication. The LPN then handed the medication over to the resident. The resident mixed the medication with water and flushed the medication down his feeding tube. During the 08/13/18 observation LPN #11 was interviewed. She stated the resident had always self-administered all of his medications. She stated the medications should be in the treatment cart. She thought there was an order for [REDACTED]. During an interview with LPN #40 on 08/14/18 at 03:08 PM, she stated the resident usually gave himself his own medications and feedings. The LPN stated the medications were brought in to him daily by the medication nurse. The LPN stated she thought the resident would flush it down right away when the medication was left with him. During an interview with Director of Nursing (DON) #5 on 08/15/18 at 01:20 PM, she stated the staff should have all of the resident's medications in a locked drawer if kept in the resident's room, otherwise medications were to remain in the medication cart. She stated there should have been a physician's order for the resident's self-administration, and the resident's care plan should include information on medication self-administration. 10NYCRR 415.3(e)(1)(vi)

Plan of Correction: ApprovedSeptember 21, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #73 has been reviewed for self administration of medications using the self-medication administration tool and found to be competent to administer his own medications All residents upon admission and with quarterly MDS assessments will be assessed for medication self administration All licensed nursing staff will be educated on medication administration including not leaving medication at the resident's bedside. 2.All residents that are clinically appropriate to self-administer medications could potentially be affected. Other residents were reviewed, no residents currently identified as self- administering medications All residents upon admission and with quarterly MDS assessments will be assessed for medication self administration MDS will audit self administration of medication assessment quarterly and at admission. A random audit of 15 residents per week to ensure no medications are left at bedside and this audit will be reported to QAPI 3.The policy and procedure entitled Self-Administration of Medication for Residents was reviewed and revised. A nursing assessment tool, and process was created in the EHR which utilizes assessment questions to determine resident's ability to self administer medication and IDT observation/discussion to ensure that resident is clinically appropriate to self-administer medications and can safely administer and physician orders [REDACTED]. A new medication self administration care plan was developed to ensure physician orders [REDACTED]. All licensed nurses and the IDT will be educated on the amended policy and procedure, processes and care plan, utilizing both in bot person and company Webinar format. Unit managers will oversee that the residents self-administering medications are doing so as per the facility new policy and procedure. 4.The ADON/designee will conduct an audit of all residents who are self-administering medications that the EHR nursing assessment tool for Self-Administration of medications was completed as per policy, the resident was determined to safely self- administer medication and physicians orders were obtained, weekly x4, bi-weekly x2 and monthly x3. The DON/ designee will report findings to the QAPI committee monthly for further recommendations All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI Committee. A random audit of 15 residents per week to ensure no medications are left at bedside and this audit will be reported to QAPI MDS will audit self administration of medication assessment quarterly and at admission. Responsible party : Director of Nurses

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during the recertification and abbreviated (NY 900) survey the facility did not maintain a clean environment for 3 of 3 nursing units (Units 1, 2 and 3). Specifically, floors, fall mattresses, table and walls were unclean and strong odors were present for extended periods. Findings include: On 08/08/18, between 10:05 AM and 11:40 AM, the following observations were made on Unit 2: - a strong smell of urine throughout the hallway; - a strong body, urine and stool odor in the hallway; - room [ROOM NUMBER] smelled of urine and feces and smelled musty and damp; and the wall air conditioner was broken. On 08/08/18, between 10:37 AM and 12:10 PM, the following observations were made on Unit: - the area near nursing station smelled of urine; - a crash cart near the nursing station had a blanket with 2 brown spots; - the floor around the entrance to room [ROOM NUMBER] had debris and was sticky; - the floor in room [ROOM NUMBER] was sticky; - a wall in room [ROOM NUMBER] had black marks on it and a fall mat was unclean; - the floor in room [ROOM NUMBER] was unclean with brown spots, there was debris under the bed, a scraped wall between the bed and night stand. On 08/08/18, between 01:34 PM and 02:11 PM, the following observations were made on Unit 3: - the hallways smelled of urine; - the floor in the lounge area was sticky; - a table in the dining room (under the large framed boat picture) was unclean, sticky and had dried debris, - a dining room wall was damaged with scraped paint. On 08/10/18, between 08:42 AM and 11:11 AM, the following observations were made on Unit 2: - room [ROOM NUMBER]'s air conditioner was broken. The room smelled of urine and was musty; -there was a strong urine odor in the hallway; and - room [ROOM NUMBER]'s privacy curtain was unclean with multiple speckled brown spots. On 08/15/18 at 01:39 PM, the Director of Maintenance stated if there was an odor, the Director of Housekeeping would be contacted and the housekeeping staff would take care of it. Odors were usually on Unit 3, although there was constantly some type of odor on all floors. The facility had one wall damaged the day survey started on Unit 1. Each floor had black books and anything a staff person observed within the floor should be documented in the book. On 08/15/18 at 01:48 PM, the Head of Housekeeping stated there was a constant battle to eliminate urine odors, and some rooms needed extra attention twice daily instead of once daily. Every Friday chairs would be wiped down. He had changed out mattresses, including some on the third floor. He stated the Administrator, the Director of Maintenance, and he had done environmental rounds every week and now have they were only done once a month. Terminal cleaning (a process used to ensure complete elimination of pathogens) for walls and baseboards was scheduled/completed every 2 weeks. He was not aware of the worn out chairs on unit 3, and it will be corrected immediately. During an interview with licensed practical nurse (LPN) Unit Manager #7 on 08/15/18 at 02:06 PM, he stated he noticed there were urine odors on every unit. He had not noticed any marks on the walls of Unit 3. 2) The facility did not maintain effective housekeeping and maintenance services necessary to maintain a sanitary, orderly, odor free and comfortable interior. Dried tube feeding was observed on the base of a tube feeding pole and the floor in Resident #68's room: - On 08/08/18 at 04:26 PM. - On 08/09/18 at 08:53 PM. - On 08/10/18 at 08:50 AM. - On 08/13/18 at 11:26 AM. - On 08/14/18 at 10:39 AM. During an interview with licensed practical nurse (LPN) Unit Manager #7 on 08/13/18 at 10:40 AM, he stated housekeeping was responsible for cleaning up any tube feeding spills on the floor and tube feeding pole. During an interview with housekeeper #18 on 08/13/18 at 10:43 AM, he stated he cleaned the floor and tube feeding pole every day. A surveyor observed the resident's room on 08/13/18 at 12:25 PM and the dried tube feeding residue remained on Resident #68's floor and tube feeding pole. During an interview with Housekeeping Supervisor #17 on 08/14/18 at 02:12 PM, he stated housekeeping cleaned the tube feeding poles with a thorough clean every 2 weeks and as needed. Staff were to notify him about tube feeding spills because it dried like cement and he had a specialized cleaner to remove it. He approached the surveyor at 02:51 PM and stated the Director of Nursing (DON) told him the night shift nurses were expected to clean the tube feeding poles weekly. During an interview with the DON on 08/14/18 at 03:20 PM, she stated intravenous (IV) and tube feeding poles should be cleaned every Wednesday by the night nurses and as needed. Nurses should clean a mess when they see it or notify a housekeeper. During a second interview with Housekeeping Supervisor #17 on 08/15/18 at 01:48 PM, he stated the urine odor on unit 3 was a constant battle. Some resident rooms needed cleaning twice daily instead of the usual once per day cleaning. The Administrator, Maintenance Supervisor and he did environmental rounds every week. The housekeepers should bring safety issues to his attention. Terminal cleaning was done every 2 weeks for walls and baseboards. The dining room chairs got wiped down once a week. Anything regarding pest control went to maintenance. 10NYCRR 415.5(h)(2)

Plan of Correction: ApprovedSeptember 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.The air conditioner in room [ROOM NUMBER] was replaced on 8.10.18. The wall on Unit 1 was repaired on 8.17.18 The privacy curtains in room [ROOM NUMBER] have been replaced and laundered. The tube feeding on the floor of the resident?s room and at the base of the pole were cleaned on 8.15.18. The soiled blanket on the Crash cart was removed by 8.9.18 Rooms 205, 310, 311, 321 have all been terminally cleaned including floors and floor mat. The dining area including table, chairs, and floor were cleaned on 8.10.18. All sitting chairs on Unit 3 were inspected by the Housekeeping Coordinator and the Maintenance Coordinator. Those deemed unsafe were removed. The remaining were cleaned and disinfected A schedule for replacement has been established. The Dining Room wall on the 3rd floor has been repaired. Hallway floors on 2nd and 3rd Floor and area near the Nursing Station on Unit 2 were cleaned and disinfected Walls with black marks are being cleaned with Magic Eraser Scrubbers. 2 All residents have the potential to be affected. The facility team to include the Administrator, Director of Housekeeping, Director of Maintenance and the Director of Nurses will carry out an extensive environmental audit to ensure all facility and nursing units environments were safe, clean, comfortable and homelike without odors, disrepair and debris A review of all resident with tube feeding poles will be conducted to ensure they are clean and no dried tube feeding is present. Any findings will be corrected upon identification. 3. The policy and procedure: Cleaning and Disinfecting Residents? Rooms was reviewed and adopted. The housekeeping and nursing staff will be educated on the above policy and procedures to ensure proper sanitation techniques and cleaning techniques to maintain facility environment and nursing floors sanitary and clean. In addition, they will be re-educated on the utilization of the Maintenance Log located on each unit. Upon daily cleaning of resident rooms the fall mattresses, tables, walls, and tube feeding poles will be cleaned and maintained, and the nursing floors will be reviewed for remaining free from odors as stated in policy. Resident privacy curtains will be inspected on a daily basis during routine cleaning and changed if soiled. in addition to the regular rotation for cleaning. The Maintenance Department has restructured their assignment methodology - assigning specific Maintenance Staff to specified areas allowing for consistency and follow-up on the units. The facility initiated a comprehensive cleaning and maintenance plan including but not limited to: a. modifying the environmental rounding form b. weekly comprehensive environmental rounding between maintenance, housekeeping, administration, and nursing c. nursing staff reporting daily any environmental findings to include odors, sticky floors, soiled privacy curtains, soiled floor mats and debris. d. The Unit Manager/ Designee will do weekly environmental walking rounds with results sent to the Director of Nurses and are responsible to ensure a sanitary, orderly, odor free and comfortable interior. e. Administrator will also randomly round the building to ensure effective housekeeping and maintenance services necessary to maintain sanitary, orderly, odor free and comfortable interior. 4.Housekeeping Coordinator/designee; Maintenance Coordinator/designee; Administrator; Director of Nursing/designee will conduct weekly rounds/audits to ensure odor free and clean nursing floors, tables, walls, fall mats, resident rooms/spaces; and feeding pumps / poles. Results will be brought to the QAPI Committee monthly for review and comment. All audits/rounds will continue weekly. The need to report results to QAPI, after 100% compliance attained for 3 consecutive months will be determined by the QAPI Committee. Responsible Party: Administrator

FF11 483.10(f)(10)(vi):SURETY BOND-SECURITY OF PERSONAL FUNDS

REGULATION: §483.10(f)(10)(vi) Assurance of financial security. The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 15, 2018
Corrected date: October 14, 2018

Citation Details

Based on record review and interview conducted during the recertification survey the facility did not assure the security of 88 of 112 residents who deposited personal funds with the facility. Specifically, the facility was unable to provide documentation that a resident trust fund surety bond was established prior to the recertification survey. Findings include: A surveyor requested a copy of the Resident Trust Fund Surety Bond on 08/13/18 from Administration. On 08/14/18 the surveyor was provided a copy of the Resident Trust Fund Surety Bond, dated 08/13/18 and signed by the Administrator on 08/14/18. During an interview with the resident Personal Funds representative on 08/15/18 at 10:50 AM, she stated Administration was responsible for surety bond and she did not know what a surety bond was. During the interview the representative provided the surveyor with a funds balance report that documented there was a total of $63,072.67 in resident funds that was managed and in safekeeping by the facility. During an interview with the Administrator on 08/15/18 at 11:56 AM, she stated she had signed on the surety bond the day prior to the interview and she was not sure if one had been implemented prior to that date. The facility was unable to provide documentation that a surety bond had been implemented to protect the resident funds prior to 08/13/18. 10NYCRR 415.26(h)(5)(v)

Plan of Correction: ApprovedSeptember 15, 2018

1.A Resident Trust Fund Surety Bond, signed by the administrator was provided on 08/14/18. 2.All residents have the potential to be affected. The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. A copy of the Resident Trust Fund Surety Bond, signed by the administrator was provided on 08/14/18. 3 The policy and procedure titled: Surety Bond was reviewed and no revision was necessary. The Administrator, accounting/ finance business office manager were educated on the policy and procedure and that the facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. The finance office manager will review with residents surety bond and obtain proper documentation and signature as appropriate. 4.The business office manager/ designee will audit that the Resident trust fund surety bond is in place, signed timely by the administrator, monthly x 12 months. All findings will be reported to QAPI for review and comment. All audits will continue until 100% compliance is attained. Need for further auditing will be determined by the QAPI committee. Responsible Party : Administrator

Standard Life Safety Code Citations

DEVELOP EP PLAN, REVIEW AND UPDATE ANNUALLY

REGULATION: The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness (EP) survey, the operator did not maintain a current EP Plan. Specifically, the emergency preparedness plan was not updated at least annually. Findings include: During review of the EP plan there was no documented evidence that the plan was being reviewed and updated on an at least annual basis, as required. When interviewed on 8/14/2018 at 3:00 PM, the Administrator stated there was no documentation of an at least annual review. She further stated they just started to use a log and would be continuing that moving forward. 42 CFR 483.73(a)

Plan of Correction: ApprovedSeptember 6, 2018

1. Upon identification that there was no documented evidence that the plan was being reviewed annually and as needed a Signature / Date Page for Review (annual and as needed) was put in the front of the Emergency Preparedness Manual. This was completed on 8.14.18 and reflected known review dates since (YEAR) update. 2. All reviews and updates will be documented in an ongoing manner on the Signature /Date Page whenever the Emergency Preparedness Plan is reviewed annually and/or revised as needed. 3. Compliance with documentation of annual /prn review/revision will be reported monthly x3 months. If 100% compliance maintained then will reduce reporting to Quarterly x1 then d/c if 100% compliance maintained. 4. The individual responsible for completion of this P(NAME) is the Administrator.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on record review, interview and observation during the Life Safety Code survey, the facility did not ensure the testing of the generator was maintained. Specifically, the monthly load test was not conducted at 30% or greater of the generator capacity as required, transfer times were not documented, the total kilowatts (KW) was not documented, and the ampere values were not documented. Findings include: Review on 8/10/2018 of the monthly generator load test reports dated from 8/17/2017 to current, revealed they did not indicate that the load tests were conducted at 30% or greater of the generator capacity, no transfer times of 10 seconds or less, total kilowatts (KW), or ampere values. When interviewed on 8/10/2018 at 10:40 AM, the General Manager of Facilities stated the weekly generator reports lacked specific NFPA 110 requirements including specific monthly load test information. On 8/10/2018 at 11:50 AM, a surveyor witnessed a monthly generator load test and verified that the load was 151 KW, which was over 30% of the generator capacity. 2012 NFPA 99: 6.4.4.1.1.3 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. Generator testing Log has been modified to include all required information for generator Testing and inspection. Log was implemented on 8.10.18. 2. All maintenance employees will be educated and trained on the established procedure for monthly generator testing and documentation. 3. Generator testing log will be reviewed by the Director of Maintenance /designee and compliance results reported to the QAPI Committee 4. The Director of Maintenance is responsible for correction of this deficient practice.

K307 NFPA 101:FIRE ALARM SYSTEM - INSTALLATION

REGULATION: Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code Survey, it was determined that for one of one fire alarm control unit in the fire panel room, the fire alarm system was not properly maintained. Specifically, the location of a fire alarm control unit lacked automatic smoke detection and was not a continuously occupied space. Findings include: When observed on 8/08/18 at 3:18 PM, there was no automatic smoke detection located within the fire panel room. In addition, the room was not continuously occupied. When interviewed on 8/08/2018 at 3:20 PM, the Director of Maintenance stated there had never been a smoke detector installed within the fire panel room. 2012 NFPA 101:19.3.4.1, 9.6.1.3, 9.6.1.4 2010 NFPA 72:10.15 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. Smoke detector to be installed in the Main Electrical Room 2. The facility recognizes that this deficient practice could negatively affect all residents. A comprehensive audit will be conducted for the presence of smoke detectors in accordance with 18.3.4.1; 19.3.4.5; 9.6.1.8 3. An audit will be conducted biannually for the presence of Smoke detectors in all required areas. Any identified smoke detector absence will be rectified. The results of the audit will be reported to the QAPI Committee until determined by the Committee that reporting is no longer needed. 4. The Director of maintenance is responsible for correcting this deficient practice.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on record review and interview conducted during the Life Safety Code survey, the facility's fire alarm system was not inspected/tested in accordance with the requirements of NFPA 72. Specifically, there was no documented evidence that 4 smoke detectors and 8 heat detectors were visually inspected on a semi-annual inspection in (YEAR) and the same 4 smoke detectors were not tested annually during the annual initiating device testing in (YEAR). Findings include: 1) Review on 8/09/2018 of the semi-annual fire alarm inspection report dated 10/25/2017 revealed 4 of 458 smoke detectors were not inspected within elevator shafts and 8 of 14 heat detectors in elevator shafts were not inspected. Further review of the inspection report revealed the not inspected comment box stated elevator devices were not tested due to not having access to elevator shafts and not having an elevator tech onsite or scheduled. When interviewed on 8/09/2018 at 11:00 AM, the Director of Maintenance stated he was unaware of the items not being inspected and tested while the previous Director was in place. He further stated he called the vendor and they stated they needed to have the elevator tech present in order to inspect/test the detectors within the elevator shafts. 2) Review on 8/09/2018 of the annual fire alarm inspection report dated 4/26/2018 revealed 4 of 458 smoke detectors were not inspected within elevator shafts. There was no documented evidence in the inspection paperwork to indicate that the heat detectors were tested . When interviewed on 8/09/2018 at 11:00 AM, the Director of Maintenance stated he was unaware of the items not being inspected and tested while the previous Director was in place. He stated he called the vendor and they stated they needed to have the elevator tech present in order to inspect/test the detectors within the elevator shafts. He also stated he had no other inspection documentation in the binder left from the prior Director. 2012 NFPA 101: 19.3.4.1, 9.6.1.3 2010 NFPA 72: 14.1 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. Director of Maintenance will coordinate a complete fire alarm inspection of all smoke / heat detectors with both the Fire Alarm System testing Company and the Elevator Company to assure a technician is on site. 2. recognizing that this deficient practice has the potential for a negative outcome for residents a comprehensive fire alarm inspection will take place assuring that all required service inspectors are available during the inspection. 3. After each inspection the director of Maintenance will audit the inspection results to assure that all smoke / heat detectors were inspected. Any identified omission will result in the director of Maintenance scheduling a return visit for completion. Audit results will be reported to the QAPI Committee biannually until the Committee determines reporting is no longer required. 4. The Director of Maintenance is responsible for the correction of this deficient practice.

K307 NFPA 101:FIRE DRILLS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on record review and interview conducted during the Life Safety Code survey, the facility did not ensure that fire drills were conducted within the facility on 2 of 3 shifts (evening shift and night shift) during the third quarter of (YEAR) and the first quarter of (YEAR), as required. Specifically, there was no fire drill conducted for the evening shift in the fourth quarter of (YEAR) and no fire drill conducted for the night shift in the first quarter of (YEAR). Findings include: 1. Record review of the facility's annual fire drill reports on 8/10/2018, revealed there was no 11 PM - 7 AM shift drill conducted during the fourth quarter of (YEAR). 2. Record review of the facility's annual fire drill reports on 8/10/2018, revealed there was no 3 PM - 11 PM shift drill conducted during the first quarter of (YEAR). When interviewed on 8/10/2018 at 11:40 AM, Director of Maintenance stated there were no other fire drills he could find and was not aware if those shifts fire drills were conducted. 2012 NFPA 101: 19.7.1, 4.7.4 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. fire drills for the 3-11 and 11-7 shift will be completed on 9.6.18. 2. Frequency of fire drills has been increased to 1 drill per shift per month. 3. All drill reports will be scanned into the computer and logged in to the facility computer drive. Fire drill reports will be shred at the QAPI Committee meeting quarterly until such time the Committee decides reporting is no longer necessary. 4. The Director of maintenance is responsible for the correction of this deficient practice.

INFORMATION ON OCCUPANCY/NEEDS

REGULATION: [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on record review conducted during an Emergency Preparedness (EP) survey, the operator did not comply with Emergency Preparedness requirements. Specifically, the EP plan did not include a policy and procedure on how the facility would share information on their occupancy, needs, and ability to provide assistance. Findings include: Review of the EP plan on 8/09/2018 revealed there was no documented evidence of a policy and procedure that included how the facility would share information on their occupancy, needs, and ability to provide assistance. There was also no policy for what types of services the facility could provide during an emergency. When interviewed on 8/09/2018 at 3:43 PM, the Administrator stated they had no policy; however, the information should be on the Health Commerce System (HCS). 10 NYCRR 42 CFR: 483.73(c)(7)

Plan of Correction: ApprovedSeptember 6, 2018

1. A policy and procedure will be developed that includes how the facility will share information on occupancy, needs, and the ability to provide assistance during an emergency including what types of services the facility could provide during an emergency. This policy / procedure will be integrated with the Oneida County Mutual Aid Program. 2. Recognizing this deficient practice could negatively affect all residents the Staff Development Nurse will educate Employees regarding the policy update as well as incorporate the information into New Hire Orientation and Annual review. Residents and / or families / Responsible Parties will be educated through written notification and at Resident Council. 3. The individual responsible for correcting this deficient practice is the Administrator.

K307 NFPA 101:MULTIPLE OCCUPANCIES - CONSTRUCTION TYPE

REGULATION: Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure a two-hour fire rated occupancy separation was maintained for one isolated area (second floor Adult Day Health Care Program (ADHCP)). Specifically, the door and door frame to the ADHCP were not fire rated. Findings include: When observed on 8/09/2018 at 2:30 PM, the occupancy separation barrier between the nursing home and the ADHCP was not fire rated for two hours, as required. Specifically, the door was labeled with a rating of 45 minutes and the door frame did not have a label that indicated a fire rating. When interviewed on 8/10/2018 at 11:15 AM, the Maintenance Director stated the walls were fire rated, but he did not realize the door and door frame were not. 2012 NFPA 101 19.1.3.5 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. Door and Door frame to ADHCP will be removed and replaced with a 2 hour rating fire door and door frame. 2. All Separation Barrier Doors and Door frames will be audited by Maintenance in accordance with 8.2.1.3. If a door or door frame is found to be non-compliant Corporate facilities will be notified of the need to replace the door / frame and the deficient door/frame will be scheduled for replacement. 3. The Director of Maintenance will assure that all doors/door frames replaced meet established Fire Rating of 2 hours and report replacement of doors / door frame fire ratings to QAPI until QAPI Team determines the reporting can be stopped. 4. The Director of Maintenance is responsible for the correction of this deficient practice.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on record review and interview conducted during the Emergency Preparedness (EP) survey, the operator did not ensure the emergency preparedness requirements were met. Specifically, the EP Plan did not include the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials. Findings include: Review of the EP Plan on 8/09/2018 revealed there was no policy and procedure for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials. When interviewed on 8/09/2018 at 3:30 PM, the Administrator stated there was no policy for the facility's role under a waiver declared by the Secretary. She further stated the facility will be creating one and reference Appendix Z. 10NYCRR: 400.10(d) 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedSeptember 6, 2018

1. The facility has developed a Policy and Procedure for the role of the facility under a waiver declared by the secretary, in accordance with section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management individuals. 2.The facility recognizes that all individuals have the potential to be affected by the deficient practice. All facility staff will be updated and educated by the Staff Development Nurse regarding the update of the Emergency Preparedness Plan and the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act. This component of the education will be added to New Hire Orientation as well as Annual review. 3. The individual responsible for correction of this deficient practice is the Administrator.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 1 isolated area (main kitchen) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2, which states: Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3.; and 3 isolated areas (the bottom level of stairwell #9, the top level and bottom level of stairwell #11, and the bottom level of stairwell #12). Specifically, the main kitchen contained both quick response and standard response sprinkler heads; and there were no sprinklers installed on the bottom level of stairwell #9, on the top level and bottom level of stairwell #11, and on the bottom level of stairwell #12. Findings include: 1) Mixed Sprinkler Heads When observed on 8/08/2018 at 9:50 AM, there were 32 quick response sprinkler heads and 15 standard response sprinkler heads located within the facility's main kitchen. When interviewed on 8/09/2018 at 11:50 AM, the Director of Maintenance stated he was not aware of the requirement that sprinkler heads in a compartment had to be the same type of sprinkler head, and had not had any sprinkler heads replaced recently. 2) Missing Sprinkler Heads When observed on 8/08/2018 between 1:00 PM and 1:20 PM, there was no sprinkler installed on the bottom levels of stairwells #9 and #12. In addition, there was no sprinkler installed on the top level and bottom level of stairwell #11. When interviewed on 8/08/2018 at 1:00 PM, the Director of Maintenance stated the stairwells have been like they were observed to be now, and had not had sprinklers in those locations. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2, 8.15.3.2.1 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. All standard sprinkler heads installed in main kitchen will be converted to quick response sprinkler heads. Bottom Level of stairwell #9; top / bottom level of stairwell #11; and bottom level of stairwell #12 will have sprinkler heads installed. 2. Recognizing this deficient practice could potentially negatively affect all residents a comprehensive audit of the facility will occur to assure that all areas found to be lacking sprinkler system will have appropriate coverage. Any area found without coverage as per code will have sprinkler heads installed. 3. Biannual inspection of the facility's sprinkler system will be conducted to assure 100% compliance with established code by the Director of Maintenance/designee. Results of the inspections will be reported to the QAPI Committee until Committee decides reporting is no longer necessary. 4. The Director of maintenance is responsible for correction of this deficient practice.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on record review and interview conducted during the Life Safety Code Survey, the facility did not ensure the building's automatic sprinkler system was maintained in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Specifically, there was an ice formation on 1 of 2 sprinkler heads within freezer #1 located within the main kitchen. Findings include: When observed on 8/08/2018 at 10:00 AM, there was ice formation approximately 1 x 1 on the deflector plate of 1 of 2 sprinkler heads within freezer #1 located within the main kitchen. When interviewed on 8/09/2018 at 12:10 PM, the Food Service Director stated she did not notice the ice build up and would let maintenance know in the future. When interviewed on 8/09/2018 at 12:10 PM, the Director of Maintenance stated he was not told there was any ice around the sprinkler heads in freezer #1. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. the ice build up on the deflector plate of the sprinkler head located in freezer #1 will be removed. 2. Both Sprinkler heads in the freezer will be replaced with a more suitable sprinkler head to prevent reoccurrence. 3. Sprinkler head observation for ice formation will be completed weekly during Kitchen Rounds . All kitchen staff will be educated on the importance of notifying the maintenance department if ice formation is observed. The Director of Maintenance will report to the QAPI Committee monthly regarding the status of the sprinkler heads in the freezer until the Committee determines reporting is no longer necessary. 4. The Director of maintenance is responsible for the correction of this deficient practice.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 13, 2018
Corrected date: October 12, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 2 isolated areas (3rd floor communication room and 2nd floor communication room). Specifically, there was an unsealed two inch conduit between the 3rd and 2nd floor communication rooms with multiple data wires freely running through it. Findings include: When observed on 8/08/2018 between 11:27 AM and 12:00 PM, there was an unsealed vertical penetration consisting of a 2 inch conduit line with multiple data wire freely running between the 3rd and 2nd floor communication rooms. When interviewed on 8/08/2018 at 12:00 PM, the Director of Maintenance stated he was not aware of the penetration and would fire caulk the conduit. 2012 NFPA 101: 19.3.1, 8.6.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 6, 2018

1. Data wires were securely fastened to one another , all penetration gaps were filled with fire resistant caulk with a 2 hour fire rating. 2. Recognizing this deficient practice could potentially negatively impact all residents the maintenance department will audit all vertical Openings in accordance with 2012 NFPA 101 19.1.3.5. If unsealed penetration is found , the maintenance department will seal any openings with 2 hour fire resistant caulk in accordance with NFPA101 19.1.3.5. The director of Maintenance / designee will inspect all work done by contractors upon completion to ensure no unsealed vertical penetrations exist. 3. the director of Maintenance will conduct weekly ongoing inspections of Vertical Openings at the rate of 2/areas/week. Any unsealed penetrations found will be corrected. Findings of the audits will be reported monthly to the QAPI committee until the Committee determines that reporting is no longer necessary. 4. The Director of Maintenance is responsible for the correction of this deficient practice.