NYS Veterans Home in NYC
January 29, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(b)(2)(ii):COMPREHENSIVE ASSESSMENT AFTER SIGNIFCANT CHG

REGULATION: §483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2018
Corrected date: March 22, 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 a Significant Change (MDS) Minimum Data Set assessment was completed for a resident who experienced a major improvement in multiple care areas. Specifically, Resident #182 experienced major improvement in their functional status, and improved bowel and bladder continence and the facility staff did not conduct a significant change assessment to reflect the resident's status. This was evident for 1 out 35 sampled residents. Findings are Resident #182 is [AGE] years old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical records also documented that the resident had a history of [REDACTED]. The initial Physical therapy assessment dated [DATE] documented the that the resident had a poor balance, ambulates up to 15 feet distance, static is fair, resident like to lean forward with his head, severe [MEDICATION NAME] Kyphosis. The admission MDS (Minimum Data Set 3.0 assessment) dated 5/02/17 documented that resident was not able to perform in room, or floor ambulation. The admission MDS further documented that the resident is total dependent on staff for bathing, and frequently incontinent in bowel and bladder. A comparative review of the resident's status as documented on the comprehensive assessment with the most recent (Quarterly MDS assessment) was conducted. It revealed that the resident consistently improved in ambulation, bathing, bowel and bladder status. The last two quarterly MDS assessments dated 10/01/17 and 12/18/17 both documented that the resident requires limited assistance for mobility status, bowel and bladder is always continent. The PT (physical therapy) discharge summary dated 6/27/17 documented that the resident was seen in restorative PT 5 times per week for at least 175 minutes for therapeutic exercise, transfer training, neuromuscular facilitation and safety education. Resident is gradually making progress in bed mobility, balance, transfer, and ambulation. The resident ambulates without using any assistive device. The comprehensive care plan dated 4/20/17 was revised on 10/18/17 and documented that the resident is highly involved in activity; staff provide guided assistance with one person in mobility/transfer, bowel and bladder is always continent There was no evidence that a significant change assessment was done to accurately reflect the improvement in the resident's condition. On 01/29/18 at 10:28 AM the resident was observed in the room alert and awake. The resident was lying in bed, appeared to be confused, the resident did not speak. On 01/29/18 at 11:00 AM, the resident was also observed walking in the hallway independently without an assistive device, gait and balance were steady. The resident was not standing straight while walking. On 01/29/18 at 11:20 AM, an interview was conducted with the assigned Certified Nursing Assistant (CNA#1) who stated that he has been providing care for the resident for over 6 months. He stated that the resident had improved in ADSL, compared to when the resident was just admitted . CNA #1 further stated that the resident requires assistance with toileting but sometimes the resident goes to the bathroom, able to clean himself up and pull up his pant at times. CNA #1 also stated that the resident uses a wheel chair when going long distances, because he gets tired. On 01/29/17 at 11:35 AM, an interview was conducted with CNA #2. CNA #2 alternates a schedule with CNA #1. CNA #2 stated the she has been working on Unit 1 for the past 2 years. CNA #2 stated that the resident has been walking independently for a few months with little assistance. She also stated that the resident needs assistance sometimes for toileting, and sometimes goes to the toilet without calling staff. The resident is confused the CNA #2 stated. The CNA records dated from 01/2017 to 1/28/18 documented that the resident requires limited assistance with ADLs, and the resident is always continent of bowel and bladder. On 01/29/18 at 11:45 AM an interview was conducted with the charge nurse, a License Practical Nurse (LPN). She stated that she has been working in Unit 1 for about 3 years. She also stated that the resident had been walking with no assistive device, has a wheel chair if he gets tired while walking out the door. The LPN further stated that the resident sometimes bends down as if he's reaching to pick something from the floor, and this was believed to be the cause of his most recent accident. On 01/29/18 11:58 AM, an interview was conducted with MDS coordinator, who stated that she and the MDS nurses are responsible for the accuracy of the MDS assessment. She also stated that she makes sure that each discipline completed the assessment accurately. She further stated that they have interdisciplinary communication form that should be completed if there is any change in resident status, for example if there were improvement or decline. The staff who noticed a change will notified the MDS staff also . In addition to that, we also have verbal morning report and if there is any issues , it will be discussed. At the 7 days look back periods, we have the notes that document the ADLs, we also collect the ADLS status of the CNA records. The MDS assessors don't routinely do a physical assessment of resident unless there is an issues that will warrant the MDS nurse to look at the resident . This particular one was missed. The MDS coordinator could not explained why a significant change assessment was not done. She stated that a significant change was supposed to have done. It was an oversight. The MDS continues to explain that the resident was admitted in (MONTH) (YEAR), the resident improved significantly from the admission MDS which the walking in the room and corridor were (Activity not occur) meaning that the resident is non ambulatory at that time. The resident consistently improved. There were no documented evidence that a significant change MDS assessment was completed within 14 days after a determination was made that the resident improved in ADLS status. The improvement was permanent. 01/29/18 12:25 PM, the resident was also observed walking to the dining room, no assistive device, gait was observed steady. 01/29/18 02:18 PM an interview was conducted with the Director of Rehab, who stated that the rehab department sends a notice of discharge to the MDS and all the discharged orders were signed by the physician. The nursing is also notified. The resident in question improve greatly and we discharged him. 415.11(a)(3)(ii)

Plan of Correction: ApprovedFebruary 16, 2018

I. Corrective Actions for Affected Residents
1. The resident identified by the Surveyors with the deficient practice of staff oversight on conducting a Significant Change Assessment for improvement, did not experience any adverse harm or injury.
2. A Significant Change in status MDS was immediately conducted for resident?s improvement.
3. The Facility respectfully submits that staff caring for this resident was knowledgeable about the care resident needed and was providing the appropriate care based on his needs.

II. Identification of Other Residents Potentially Affected
The Inter Disciplinary Team will review all current residents in the Facility from the last Comprehensive Assessment to ensure compliance and that no Significant Change Assessments were missed. Where deficient practice is observed, an immediate correction will be done.

III. System Changes and Measures to Prevent Reoccurence
1. The Policy and Procedure on ?MDS and CAA Process? was reviewed and was found to be compliant.
2. The MDS Coordinator re-inserviced the IDT members (Nurse Supervisors, Unit Nurses, Social Workers, Dietitians, Recreation Staff, Rehab Therapists, Medical Doctors, CNAs) on how to identify and report Significant Changes in resident?s status.
3. A revision of the Notification Form for reporting Significant Changes was also completed.
Lesson Plan:
a. Definition of Significant Change
b. Guidelines to follow to determine if a resident has a Significant Change. (Please refer to Notification Form).
c. Documentation of the Significant Change in the Medical Record and on the 24-Hour Report
d. Completion of the Notification Form
e. Submission of the Notification Form to the MDS Department
f. Review of the Notification Form by the MDS Coordinator/Designee
g. MDS Department will consult with the IDT members to determine if resident meets the criteria for Significant change in status. If the resident meets the criteria, a Significant Change MDS Assessment will be conducted.
h. Completed Notification Forms will be kept on file in the MDS Department
The Lesson Plan and Sign-In sheets will be filed for reference and validation.

IV. Monitoring of Corrective Action
1. The MDS Coordinator developed an Audit Tool to monitor compliance of all MDS Assessments. The tool will be used by Supervisors and Managers to track all completed MDS prior to the Care Plan Meetings.
2. The MDS Coordinator/Designee will review all residents thoroughly during the Care Plan Meeting to ensure correct documentation.
3. The Director of Nursing/Designee will ensure that all Supervisors and Unit Managers document all Significant Change in Condition (up or down) in Progress Notes and on the 24-Hour Report for discussion and follow-up.
4. The MDS Coordinator will report on the # of Significant Changes that were identified correctly by the MDS Assessment Team.
5. The MDS Coordinator/MDS Nurses will double check all MDS Assessments prior to submission on an ongoing basis to prevent reoccurrence of the deficient practice and to ensure the correct Assessment (MDS) was completed.

V. QA Monitoring
Findings will be presented to the CQAI/QAPI Committee by the MDS Coordinator monthly for six (6) months and then quarterly thereafter for twelve (12) months.

FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2018
Corrected date: March 22, 2018

Citation Details

Based on observations and staff interviews during the recertification and abbreviated survey, the facility did not ensure the garbage compactor area was kept clean and free of debris, specifically the surrounding area of the garbage compactor including the loading dock had empty soda can and milk carton, used disposable gloves, used plastic cups, loose slices of bread and sheet of plastic. This was evident during the Kitchen Task - Garbage and refuse was disposed of properly. The findings are: On 01/26/18 10:31 AM, the area surrounding the garbage compactor was observed to be littered with debris and not kept clean, specifically, the ground on both sides of the compactor (the front side of the compactor close to the loading dock and back side of the garbage compactor), and the extension ramp or the metal flapper (the metal plate attached to the loading dock that opens and serves as the bridge from the loading dock to the compactor), and . The ground on the front sides of the compactor have puddles of brown water on both sides. On the left of the front side of the compactor (viewing the compactor from the loading dock), an empty 8 oz milk carton and sheet of plastic were on the brown water. The ground on the right side of the garbage compactor (the right side when standing on the loading dock) has a puddle of brown water. There is a drainage situated on the ground next to the back of the compactor (left side). The drainage was covered with dried leaves. Pieces of compressed black cardboard were strewn next to the drainage. The metal flapper is broken on top, leaving about 2 feet gap between the loading dock and the garbage compactor. The broken metal flapper is on top of its base, leaving the metal base that holds the metal flapper, open. The base of the flapper is filled with empty can of soda, used disposable gloves, used plastic cups, loose slices of bread. There was an empty 8 oz carton of milk and a sheet of plastic on the brown water (a puddle of brown water (accumulated dust and water mixed together) There is a drain by the front which is fully covered with dried leaves and there are pieces of compressed black cardboard. On 01/26/18 03:40 PM, the garbage compactor area was being cleaned by Housekeeper #1. Housekeeper #1 was sweeping the front left side of the area where the brown water with litter was. On 01/26/18 10:33 AM, Housekeeper #1 was interviewed: Housekeeper #1 said that the metal flapper is broken about 2-3 months ago. The driver took the dumpster and when he was backing off to put the compactor back, he backed up all the way to the extension metal flap and it broke open. The compactor is washed when they take it on Monday or Tuesday. On 01/26/18 10:59 AM, Food Service Worker 1(FSW 1) #1 was interviewed. FSW1 #1 was interviewed and said when he throws out the garbage he tries to tie the bag well avoiding the gap between the garbage compactor and the loading dock. And every time the compactor is full, a Staff from Housekeeping, Dietary and the Big Storeroom can compress the items thrown in. The metal plate between the compactor has been noticed to be broken about 3 weeks ago. On 01/26/18 11:22 AM, Food Service Director (not a RD or CDN) was interviewed. Cleaning of the garbage compactor area is Housekeeping's responsibility. Maintenance/Engineering does the repair of the garbage compactor extension(metal flapper), or any repairs needed in the kitchen like a leaking faucet, a paint job, etc., including the kitchens on the floors. Dietary did not put in any repair to Engineering regarding the broken compactor extension or metal flapper. On 01/26/18 11:32 AM Assistant to the Acting Housekeeping Director was interviewed. Housekeeping is responsible for cleaning the compactor. The top of the loading dock and the area around the compactor is cleaned daily every morning and afternoon, around AM and PM. The Director of Engineering was informed about the broken metal plate. On 01/26/18 11:38 AM Acting Director of Housekeeping was interviewed. Cleaning the compactor area is supposedly a shared cleaning responsibility between Housekeeping and Dietary. Nobody cleaned the inside of the gap (the base of the metal flapper) because they don't want the cover to fall. The ground around the compactor is cleaned daily as needed. There is a ditch closer to the dock that holds water. There was no work order given to Engineering for the broken metal flapper. The flapper was broken since (MONTH) (YEAR). The Director of Engineering was notified when it happened in (MONTH) (YEAR). The piece that covered the metal flapper was on the ground at one point. On 01/26/18 11:51 AM Food Service Worker 1(FSW1) #2 was interviewed. FSW1 #2 said that the Porter cleans the kitchen, empties the garbage, sweeps the floors, wipes down the counters and mops the spills in the kitchen, throws the garbage at least 3 times daily between meals. About 3 months ago, he noticed the plate was broken. Porters from dietary never cleans the area. They clean what spills and falls out of the garbage. On 01/26/18 03:40 PM, the Director of Engineering was interviewed and said that Environmental rounds are done weekly. Director said he did not know that the metal flapper is broken not until today. 415.14(h)

Plan of Correction: ApprovedFebruary 16, 2018

I. Corrective Actions for Affected Areas
A. The Dock area identified by the Surveyor as having litter and debris, was immediately cleaned and sanitized by Housekeeping staff. Engineering staff also cleaned the debris under the scissors lift by the Loading Dock and all dried leaves near the drain were removed.
B. The standing water near the compactor was immediately vacuumed up by Housekeeping staff.
C. The broken flapper was immediately removed by Engineering staff and a temporary and stable platform was installed. A Sheet Metal Vendor was contacted by the Director of Engineering to permanently complete the repair on the Loading Dock area.

II. Identification of Other Areas Potentially Affected
The Dock area is fully restricted and not assessible to residents. Therefore, no other areas or residents were affected by this deficient practice.

III. System Changes and Measures to Prevent Reoccurrence
The Director of Engineering and the Director of Housekeeping developed a policy on ?Maintenance of the Loading Dock and External Perimeters.? In-services with competencies will be completed for all Housekeeping, Engineering, Dietary and Store Room staff on the policy.
Lesson Plan will include but is not limited to:
-Cleaning up spilled garbage on the Dock
-Clearing accumulated water on the Dock
-Completing ?Work Orders? to report any damages on Loading Dock
-Cleaning of covered drains
-Storage and clutter on Dock
-Compactor waste removal
Lesson Plan and Sign-In sheets will be filed for reference and validation.
A. The Director of Housekeeping developed a schedule for checking, cleaning and sanitizing the Loading Dock. This will be done four times daily by assigned Housekeeping staff. Any non-compliance identified will be corrected immediately.
B. The areas identified around the compactor with water puddles will be repaired/raised with heavy duty concrete mixture by a contracted vendor. This will prevent the pooling of excess water in the area of the trash compactor and drains.
C. The company that delivers the compactor was notified of the damaged flapper by the driver. Emphasis will be placed on monitoring the driver when he picks up and drops off the compactor. This will be done by both the Director of Engineering and the Director of Housekeeping.

IV. Monitoring of Corrective Action
A.
1. An Audit Tool was developed by the Housekeeping Director to monitor the Loading Dock daily for cleanliness.
2. The Tool will be used by Housekeeping Supervisors during Environmental Rounds to document findings. Any identified concerns will be corrected on the spot and documented on the Tool for follow-up by the Director of Housekeeping.
3. The Audit Tool will be filed in the Housekeeping Department for QA purposes.
B.
1. The Director of Engineering developed an Audit Tool to monitor the newly repaired area around the compactor.
2. The tool will be used by assigned Engineering staff to document findings. Any noncompliance will be corrected on the spot or reported to the Director of Engineering for repairs via a Work Order.
3. The Audit Tool will be filed in the Engineering Department for QA purposes.
C.
1. Staff that uses the Loading Dock will be required to report immediately to the Director of Engineering, any condition that may exist and pose any harm or danger to any personnel.
2. Blank Work Orders will be distributed to the Director of Housekeeping, Director of Dining Services and Store Room Manager for staff to document any damages observed on the Loading Dock.
3. Upon weekly drop off and pick up of the compacter, the Director of Engineering/Director of Housekeeping/Designee, will be present on the Dock to ensure there are no damages to the flapper and Dock.

V. QA Monitoring
All Findings will be presented to the CQAI/QAPI Committee by the Director of Engineering/Designee and the Director of Housekeeping/Designee monthly for six months and then quarterly thereafter for twelve months.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 29, 2018
Corrected date: March 22, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification survey, the facility did not ensure proper hand hygiene practices were performed during [MEDICAL CONDITION] care. Specifically, a Licensed Practical Nurse (LPN) was observed handling sterile supplies with soiled gloves. This was evident for 1 resident reviewed for [MEDICAL CONDITION] care out of 35 sampled (Resident #183). The finding is. The facility policy and procedure titled Hand Hygiene (Dated 9/16) documented the following. .the following is a list of some situations that require hand hygiene .after contact with a resident's mucous membranes and body fluids or excretions, after handling soiled or used catheters, after removing gloves .change gloves during resident care if moving from a contaminated body site to a clean body site. Resident #183 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated 12/19/17 documented resident needing total dependence for activities of daily living. Resident was also receiving daily suctioning and [MEDICAL CONDITION] care. The Comprehensive Care Plan (CCP) titled Suction last updated 1/26/18 documented the following. .[MEDICAL CONDITION] as ordered using sterile technique . The CCP titled Infection last updated 1/7/18 documented the following. .Use good hand washing technique . On 1/26/18 at 9:49 AM, the resident was observed sitting up in bed with white secretions collected inside [MEDICAL CONDITION]. On 1/26/18 at 10:37 AM, the LPN was observed performing [MEDICAL CONDITION] care. Next to resident's bed was a cart that had a suction machine and supply boxes of gauze,[MEDICAL CONDITION], inner cannula, gloves, foley, normal saline, and ambu bag. The LPN had on gloves and placed a sterile drape over the resident's chest and underneath [MEDICAL CONDITION]. The LPN than proceeded to move the resident's room garbage can, holding it with her gloved hands from the left side of bed, to the right side for it to be closer to her. She then took off gloves and put on new gloves without washing her hands or using an Alcohol Based Hand Rub (ABHR). The LPN retrieved a [MEDICAL CONDITION] from the cart, opened it, held it with her gloved hands, disconnected the old collar and connected the new one wearing the same gloves. She then removed her gloves and put on new ones without washing her hands or using as ABHR. The LPN proceeded to unwrap a soft red rubber foley and held it with one hand, opened a bottle of Normal Saline (NS), than dipped the red rubber foley inside bottle of NS, and proceeded to insert the red rubber foley in the resident's [MEDICAL CONDITION] suctioning it three to four times. The secretions were observed to be clear to white in color. The LPN held the soiled red rubber foley with her left gloved hand contaminating her glove and proceeded to retrieve a packaged gauze pad with her right hand from the cart, opened it, and held the gauze with her soiled left gloved hand. She poured NS over the gauze pad and used it to wipe down the red rubber foley and then disposed it in the garbage. The LPN then retrieved a packaged inner cannula, opened it, disconnected the old one and connected the new one while wearing the same soiled gloves. The LPN removed the sterile drape that was over the residents chest and disposed it in the garbage with the same soiled gloves. She then proceeded to move the garbage can back to the original location with the same soiled gloves. The LPN was observed washing hands with soap and water upon completion. On 1/26/18 at 11:20 AM, the LPN was interviewed. She stated she was supposed to set up supplies over the table but she grabbed, used, and discarded supplies along the way instead. The LPN stated she only washes her hands before and after completing treatment. She puts on new gloves before suctioning and changes gloves after suctioning and wiping off tube. She stated she would've changed gloves if there was mucous on it because you don't want to do dirty and clean. The LPN stated she was supposed to change gloves but didn't and stated her hands did not get soiled so she didn't wash her hands. The LPN stated she has not been in-serviced on how often she should wash or use ABHR when performing [MEDICAL CONDITION] care. However, she stated she was in-serviced on infection control and hand washing every six months and as needed. On 1/29/18 at 2:21 PM, the Assistant Director of Nursing (ADON) who is also the Infection Control Nurse was interviewed. She stated the nurses are expected to remove gloves and wash hands with soap and water if gloves get soiled during suctioning. The ADON further stated the nurses are not to touch any part of [MEDICAL CONDITION] retrieve sterile supplies when gloves are soiled. All Registered Nurses (RN) and LPN are in-serviced twice yearly regarding infection control and [MEDICAL CONDITION] care and competency on hand hygiene are performed biannually and as needed. 415.19(b)(4)

Plan of Correction: ApprovedFebruary 16, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective Actions for Affected Residents
1. Resident #183 was assessed by MD and no adverse effects were noted.
2. Monitoring will be ongoing by Licensed Nurses to observe for adverse effects which includes but is not limited to vital signs, respiratory function, secretions (amount and characteristic) and condition of the stoma.
3. The Licensed Practical Nurse was immediately re-educated to ensure that:
-Proper hand hygiene practices are carried out during [MEDICAL CONDITION] care and tracheal suctioning
-Hand hygiene is performed before and after contact with blood or body fluid and when handling a contaminated item.

II. Identification of Other Residents Potentially Affected
There were no other residents affected by the same deficient practice.

III. System Changes and Measures to Prevent Reoccurrence
1. The Policy on Hand Hygiene was reviewed and found to be compliant.
2. The Policy on [MEDICAL CONDITION] Care and Tracheal Suctioning was also reviewed and revised as appropriate.
3. All Licensed Nurses will be re-inserviced on the proper hand hygiene processes during [MEDICAL CONDITION] Care and Tracheal Suctioning.
4. The Lesson Plan will consist of the following but is not limited to:
-General guidelines on hand hygiene
-Procedure on hand hygiene
-When to perform hand hygiene
-Guidelines on tracheal suctioning
-Procedure on performing proper [MEDICAL CONDITION] care and tracheal suctioning with emphasis on when to perform hand hygiene during the process.
-Guidelines on [MEDICAL CONDITION] care
Lesson Plan, competencies and Sign-In sheets will be filed for reference and validation.
5. Inservice/competency was initially given by Staff Educator and Infection Control Preventionist on [MEDICAL CONDITION] care and tracheal suctioning to all Licensed Nurses. Follow up will be done every six (6) months for the next twelve (12) months, and annually thereafter by the Staff Educator and Infection Control Preventionist.

IV. Monitoring of Corrective Action
1. An Audit tool was developed by the Director of Nursing and Staff Educator for the purpose of monitoring competency on hand hygiene during [MEDICAL CONDITION] care and tracheal suctioning.
2. Competencies and Inservices was initially done by the Staff Educator and Infection Control Preventionist on tracheal suctioning and [MEDICAL CONDITION] care with emphasis on when to perform hand hygiene during the process.
3. Staff who regularly care for residents with tracheostomies will be randomly observed by the Supervisors/Staff Educator/Infection Control Preventionist for hand hygiene during [MEDICAL CONDITION] care and tracheal suctioning, once weekly for three (3) months and then monthly thereafter for twelve (12) months.

V. QA Monitoring
The Director of Nursing/Designee will report to the CQAI/QAPI Committee monthly for the next six (6) months and then quarterly thereafter for two years.

Standard Life Safety Code Citations

ARRANGEMENT WITH OTHER FACILITIES

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:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 6, 2018
Corrected date: April 18, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the development of arrangements with other Long Term Care facilities was met. Specifically, review of the facility's transfer agreements with other Long Term Care facilities revealed dated contracts from 2013. This was noted during review of the facility's Emergency Preparedness plan. The findings are: On 2/6/2018 between the hours of 8:30am and 3pm during the Emergency Preparedness survey, the following was noted: Upon review of the facility's Emergency Preparedness documentation, it was revealed that the transfer agreements with other facilities were dated 2013. In an interview with the Assistant Administrator at approximately 10:45am, she stated the contracts are with other state veteran facilities and despite the contract being outdated, they are still upheld. She further stated she will contact the facilities and update the contract agreements. The facility submitted updated transfer agreement contracts with 2 other Long Term Care facilities on 2/6/2018. The agreements were dated 2/6/2018.

Plan of Correction: ApprovedMarch 2, 2018

E025
I. Corrective Action for Affected Areas
1. The Facility immediately requested and received the updated Transfer Agreement Contracts from the facilities with whom we have an arrangement to receive residents in the event of limitations or cessation of operations to maintain continuity of services to the facility residents. Copies were presented to the Surveyor at the time of the Survey and were filed in the Disaster Preparedness Manual for validation.
2. The Facility will continue to develop other arrangements with additional facilities and other providers to receive residents in the event of limitations or cessation of operations to maintain continuity of services to the Facility residents.

II. Identification of Other Areas and Residents Potentially Affected
The corrective steps above will cover all affected residents in the Facility.

III. Systemic Changes and Measures to Prevent Reoccurrence
1. All current Contracts/Agreements with receiving Long Term Care Facilities will be updated on at least an annual basis for signatures and to ensure that they are still capable of providing the level of care required for our residents as written in the Contract/Agreement.
2. Updated copies of the Agreements/Contracts will be filed in the Disaster Preparedness Manual.

IV. Monitoring of Corrective Action
1. A Check List was developed by the Assistant Administrator to monitor compliance.

2. The Check List will be used to ensure that Transfer Agreements and Contracts with receiving facilities are current and signed by the receiving party. The Facility will review the contracts at least annually.
3. The Check List will be filed in the Facility?s Disaster Preparedness Manual for reference and validation.

V. QA Monitoring
The Assistant Administrator will conduct QA Monitoring quarterly for 6 months then at least annually thereafter to ensure compliance and report to the Administrator.

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2018
Corrected date: April 2, 2018

Citation Details

2009 NFPA 17A: 7.2 Owner's Inspection. 7.2.1 On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. 7.2.2 At a minimum, this quick check or inspection shall include verification of the following: (1) The extinguishing system is in its proper location. (2) The manual actuators are unobstructed. (3) Tamper indicators and seals are intact. (4) The maintenance tag of certificate is in place. (5) No obvious physical damage or condition exists that might prevent operation. (6) The pressure gauge (s), if provided, shall be inspected physically or electronically to ensure it is in the operable range. (7) The nozzle blowoff caps, where provided, are intact and undamaged. (8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated. Based on observation and staff interview, the facility failed to ensure that at a minimum, quick checks were being performed on the extinguishing equipment in the kitchen and the cafe within the facility. The findings are: On 2/2/2018 and 2/5/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was observed: The pull station for the Ansul system in the cafe was noted to contain an inspection tag. The tag contained the semi-annual inspection dated Nov (YEAR). In an interview on 2/5/2017 at approximately 10:25am with the Director of Security, he stated he was unaware that monthly inspections needed to be performed. He also stated he would start inspecting the system monthly. 2011 NFPA 96 2009 NFPA 17A 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 2, 2018

K324

I. Corrective Actions for Affected Areas
The Director of Engineering immediately conducted a ?Quick Check? on the pull station for the Ansul System in the Main Kitchen and the Cafeteria. These areas are fully restricted and not accessible to Residents. No Residents are affected by this.

II. Identification of Other Areas Potentially affected
No other areas are affected as there is no other Ansul System in the Facility.

III. System Changes and Measures to Prevent Reoccurrences
1. The Director of Engineering assigned an Engineering staff to perform weekly Quick Checks on the Ansul System, Checks will include but not be limited to:

-Checking Spray heads
-Checking Trip System to ensure proper functioning
-Checking to ensure safety devices are in place
-Checking for timely bi-annual inspection
The Director of Engineering will inspect both Ansul Systems in the Main Kitchen and the Cafeteria monthly to confirm that the ?Quick Check? inspection is done in a timely manner. This will be added to his Monthly Audit Tool. Any inspection found out of compliance will have immediate corrective action.

IV. Monitoring of Corrective Action
The Engineering staff assigned to perform the monthly Quick Check Inspections will be monitored by the Director of Engineering to ensure Quick Checks are conducted accordingly. The results of these checks will be maintained in a log Book in the Engineering Department.

V. QA Monitoring
The Director of Engineering will report all findings to the Administrator monthly for twelve months and quarterly thereafter for 18 months.

DEVELOPMENT OF EP POLICIES AND PROCEDURES

REGULATION: (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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 These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 6, 2018
Corrected date: April 18, 2018

Citation Details

Based on document review and staff interview, the facility failed to ensure that the facility developed and implemented policies and procedures based upon the risk assessment. This occurred while reviewing the facility's emergency preparedness documentation. The finding is: On 2/6/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was observed: Documentation review of the facility's emergency preparedness manual revealed that policy and procedures had not been developed and implemented based upon the risk assessment. In an interview on 2/6/2018 at approximately 10:45am with the Assistant Administrator, she stated the risk assessment was conducted in house and they have a few policies such as loss of the generator. She further stated that she is currently working on creating policies for the other areas.

Plan of Correction: ApprovedMarch 2, 2018

E013
I. Corrective Action for Affected Areas
The Facility will continue the process of developing and finalizing the policies and procedures based on the emergency events that were identified in the Facility-based and Community-based Risk Assessment.

II. Identification of Other Areas and Residents Potentially Affected
The corrective steps above will cover all affected residents in the Facility.

III. Systemic Changes and Measures to Prevent Reoccurrence
1. The Risk Assessment will be updated to include Policies and Procedures to address all the emergency events identified in the Assessment. Policies on events identified will include but not be limited to:
-Procedure in the event of a fire
-Procedure in the event of equipment or power failure
-Procedure in the event of care-related emergencies
-Procedure in the event of water supply disruption
-Procedure in the event of a Bomb Threat
-Procedures in the event of loss of gas service
-Procedures in the event of a severe snowstorm
-Procedures in the event of an earthquake
-Procedures in the event of Telephone Outage
2. Any other community-based or facility-based risks identified, will warrant development of a Policy and Procedure.

IV. Monitoring of Corrective Action
1. A Check List was developed by the Assistant Administrator to monitor compliance for emergency events identified on the Risk Assessment. The risk assessment will be reviewed bi-annually for 1 year then at least annually thereafter
2. The Check List will be used to ensure that Polices, and Procedures are in place for these events.
3. The Check List will be filed in the Facility?s Disaster Preparedness Manual for reference and validation.

V. QA Monitoring
The Assistant Administrator will conduct QA Monitoring quarterly for 6 months then at least annually thereafter to ensure compliance and report to the CQAI/QAPI Committee.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2018
Corrected date: April 2, 2018

Citation Details

2012 NFPA 99: 11.3.4 Signs 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING Based on observation and staff interview, the facility failed to ensure that oxygen storage areas were correctly labeled and electrical outlets were not installed below 5 feet. This occurred on 4 of 4 floors of the facility. The findings are: On 2/2/2018 between the hours of 8:30m and 3:30pm during the recertification survey, the following was observed: The Oxygen Storage Rooms on the 4th, 3rd, 2nd and 1st floors all lacked the appropriate signage. In addition, the 4th floor Oxygen Storage Room contained an electrical light switch that was installed below 5 feet. In an interview on 2/2/2018 at approximately 9:15am with the Director of Engineering, he stated he could add a sign with the correct wording and was unaware that the light switch needed to be above 5 feet. He further stated he could relocate the switch. 2012 NFPA 99 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 2, 2018

K923
I. Corrective Action for Affected Area
A. The Director of Engineering immediately purchased the appropriate sign which include the wordings ?Caution Oxidizing Gases Stored Within No Smoking? and installed them on the oxygen storage rooms on the 1st, 2nd, 3rd and 4th Floors, as well as the Storage Room in the basement.

B. The light switch was removed immediately from the 4th Floor oxygen storage room. This area is fully restricted and not accessible to residents. No Residents are affected by this.


II. Identification of Other Areas Potentially Affected
A. There are no other areas in the Facility where oxygen is stored.
B. The Director of Engineering checked all other oxygen storage rooms in the Facility for compliance. All were found to be compliant.

III. System Changes and Measures to prevent Reoccurrence
A. The Engineering staff will check all Oxygen Storage Rooms during Environmental Rounds to ensure that the signs posted are not removed/missing or defaced. This will be added to their Weekly Audit Tool. Any sign found missing or damaged will be replaced immediately. The Director of Engineering will also add this to his Monthly Audit Tool.
B.The Director of Engineering will inspect all oxygen storage room during his monthly environmental rounds to verify that no electrical outlets or switches are installed less than five feet from the floor. If any such installation is found, he will take the necessary step to correct same. This will be added to his Monthly Environmental Audit Tool.
IV. Monitoring of Corrective Action.
A. Engineering staff will be instructed to check the Oxygen Storage Room on the floor that they are assigned to and verify that the signage on the door is present. This will be done on a daily basis during their routine rounds. Negative findings will be reported to the Director of Engineering for corrective action. The Director of Engineering will also add this to his Monthly Audit Tool.
B.Engineering staff will check all Oxygen Storage Rooms located on each Unit to ensure no switches are added to these areas. This will be done on a weekly basis and will be added to the weekly Environmental Audit Tool. The Director of Engineering will also add this to his Monthly Environmental Rounds Audit Tool.

V. QA Monitoring
The Director of Engineering will report all findings to the Administrator for one year, and then quarterly to the QA Committee for eighteen (18) months.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2018
Corrected date: April 2, 2018

Citation Details

19.3.2 Protection from Hazards 19.3.2.1 Hazardous Areas. Any hazardous areas shall be safe guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 19.3.2.1.3 The doors shall be self-closing or automatic closing. 19.3.2.1.5. Hazardous areas shall include, but shall not be restricted to, the following: 1. Boiler and fuel-fired heater rooms 2. Central /bulk laundries larger than 100ft2 (9.3 m2) 3. Paint shops 4. Repair shops 5. Rooms with soiled linen in volume exceeding 64 gallon (242L) 6. Rooms with collected trash in volume exceeding (242L) 7. Rooms or spaces larger than 50 ft2 (4.6m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction 8. Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard. 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. Based on observation and staff interview, the facility failed to ensure that the hazardous areas were either protected with a 1 hour fire rating or were smoke resistant, and contained a self- closing door. This occurred on 1 of 4 floors of the facility, including the basement. The findings are: On 2/2/2018 and 2/5/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was observed: The gift shop, library and storage room located near the MPR room on the 1st floor lacked self- closing devices on the doors. Combustible storage was observed within these rooms. In the basement of the facility, rooms contained unsealed pipe penetrations. Locations include, but are not limited to: The Laundry Room Elevator Machine Room Maintenance Shop In an interview on 2/5/2018 at 10:45am, the Director of Engineering stated they will come up with a solution for the gift shop door. In an interview on 2/5/2018 at 10:55am, the Director of Engineering stated they bought a new bucket of firestopping and will seal around the conduits. 2012 NFPA 101:19 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 2, 2018

K321
I. Corrective Action for Affected Area
A. The doors to the Gift Shop, Library and Storage Room located near the MPR on the 1st floor that lacked self-closing devices will be corrected with the required self- closing device on the doors.
B. The unsealed pipe penetrations found in the Basement Laundry Room, Elevator Machine Room and the Engineering Maintenance Shop were immediately sealed with the approved fire stopping material. The area is fully restricted and not accessible to Residents.

II. Identification of Other Areas Potentially Affected
A. The Director of Engineering checked all doors to other hazardous areas with combustible storage. No other areas were found to be non-compliant.
B. The Director of Engineering inspected all other areas in the Basement for unprotected penetrations through the wall. No other areas were found to be out of compliance.

III. Systems changes and Measures to prevent Reoccurrence
A. The Director of Engineering will check all hazardous rooms in the Facility on a monthly basis to ensure that doors are self-closing or automatic closing. Any doors found to be out of compliance will be corrected immediately. The areas will include but not be limited to:
-Boiler and fuel fired heater rooms
-Laundry Room
-Engineering/Repair Shop
-Soiled Linen Rooms
-Rooms larger than 50 sq ft
-Gift Shop
-Barber Shop
-Library
B. The Director of Engineering will check all penetration throughout the Facility on a monthly basis to ensure that they are sealed with the approved fire stopping material. Any area found to be out of compliance will be corrected immediately.

IV. Monitoring of Corrective Action
A. Engineering staff will be instructed to check all areas where combustible materials are stored to ensure doors have self-closing or automatic closing device. This will be added to their weekly Environmental Rounds checklist. The Director of Engineering will also inspect these areas during his monthly Environmental Rounds and will add to his monthly audit tool.
B. Engineering staff will be instructed to check all areas where pipes penetrate through the wall and verify that the penetrations are sealed appropriately with the recommended fire stopping material. This will be added to their weekly Environmental Rounds checklist. The Director of Engineering will also be inspecting these areas during his monthly Environmental Rounds and will add to his monthly Audit Tool.

V. QA Monitoring
The Director of Engineering will report all findings to the Administrator monthly for twelve (12) months and quarterly to the QA Committee for eighteen (18) months.

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID 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.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC 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 annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 6, 2018
Corrected date: April 18, 2018

Citation Details

Based on record review and interview during the Emergency Preparedness survey, the facility did not ensure resident and family notifications were performed and documented. Specifically, there was no method of sharing information from the EP plan with residents and their families or representatives within the EP plan. The findings are: On 2/6/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was noted: During review of the Emergency Preparedness plan, there was no documented evidence that there was a method of sharing information from the EP plan with residents and their families or representatives. In an interview on 2/6/2018 at 11:00 AM, the Assistant Administrator stated that social services and recreation communicate with calls, texts and emails to residents and their families. She further stated on (MONTH) 29, (YEAR) a resident council meeting was held, she thinks emergency preparedness was discussed. At the time of the exit no documentation was provided verifying a method for sharing information from the emergency plan with residents and family members.

Plan of Correction: ApprovedMarch 2, 2018

E035
I. Corrective Action for Affected Areas
1. The Facility will continue to improve upon, clarify, develop and maintain the education and communication of our Emergency Plan with families and residents. This will include a method of sharing information from the Plan with them. Clear documentation on communication and education will be maintained.
2. The facility will continue to review the requirements of E035 regulations and make any other necessary changes to our Policy and Procedure.

II. Identification of Other Areas and Residents Potentially Affected
The corrective steps above will cover all affected residents in the Facility.

III. Systemic Changes and Measures to Prevent Reoccurrence
1. The Director of Safety and Security will continue to attend the Quarterly Family Council Meetings when invited by the President of the Council and ensure on-going education on the Emergency Preparedness Plan. The education, and lesson Plan will be documented clearly as well as signatures for the presentation. Handouts will also me made available during the meeting.
2. Signs will be posted throughout the Facility to further communicate the Emergency Preparedness Plan to families and residents.
3. Brochures will be made available to further communicate with residents and families. It will include pertinent contact numbers in the event of a disaster.

IV. Monitoring of Corrective Action
1. A Check List was developed by the Assistant Administrator to monitor compliance.
2. The Check List will be used to ensure that there is documented evidence that information on the Emergency Preparedness Plan is shared with residents and families.
3. The Check List will be filed in the Emergency Preparedness Manual for reference and validation.

V. QA Monitoring
The Assistant Administrator will conduct QA Monitoring quarterly for 6 months then at least annually thereafter to ensure compliance and report to the Administrator.

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 6, 2018
Corrected date: April 18, 2018

Citation Details

Based on document review and staff interview, the facility failed to ensure that the facility based and community based risk assessment included missing residents. This occurred while reviewing the facility's emergency preparedness documentation. The finding is: On 2/6/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was observed: Documentation review of the facility's emergency preparedness manual revealed that the risk assessment conducted did not include missing residents. In an interview on 2/6/2018 at approximately 10:45am with the Assistant Administrator, she stated the risk assessment was conducted in house and does not include missing residents.

Plan of Correction: ApprovedMarch 2, 2018

E006
I. Corrective Action for Affected Areas
The Facility will develop and maintain an Emergency Preparedness Plan to include missing residents, which will be reviewed and updated at least annually.

II. Identification of Other Areas and Residents Potentially Affected
The corrective steps above will cover all affected residents in the Facility.

III. Systemic Changes and Measures to Prevent Reoccurrence
1. The Facility will develop and maintain an Emergency Preparedness Plan. It will be based on and include a Facility-based and Community-based All Hazard Risk Assessment which will include missing residents
2. The Risk Assessment will be reviewed and updated by the Assistant Administrator at least annually or as frequently as needed.

IV. Monitoring of Corrective Action
1. A Check List was developed by the Assistant Administrator to monitor compliance for addressing emergency events identified by the Risk Assessment.
2. The Check List will be used to ensure that missing residents are addressed in the Risk Assessment. This will be updated annually during the Disaster Preparedness Plan review.
3. The Check List will be filed in the Facility?s Disaster Preparedness Manual for reference and validation.

V. QA Monitoring
The Assistant Administrator will conduct QA Monitoring quarterly for 6 months then at least annually thereafter to ensure compliance, and report to the Administrator.

POLICIES/PROCEDURES FOR SHELTERING IN PLACE

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:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 6, 2018
Corrected date: April 18, 2018

Citation Details

Based on documentation review and interview, the facility did not have a written policy and procedure to shelter in place residents, staff and volunteers who remain in the facility during an emergency or disaster event. The findings are: On 2/6/18 between the hours of 8:30 am and 3 pm during the recertification survey, revealed that there was no written policy and procedure to shelter in place residents, staff and volunteers who will remain in the facility during an emergency. In an interview on 2/6/2018 at approximately 10:50am with the Assistant Administrator, she stated that she does not think they have a written policy and procedures for sheltering in place.

Plan of Correction: ApprovedMarch 2, 2018

E022
I. Corrective Action for Affected Areas
The Facility will continue the process of reviewing and revising the Shelter In Place Policy and Procedure. The Disaster Preparedness Manual will be updated to include this Policy and Procedure.

II. Identification of Other Areas and Residents Potentially Affected
The corrective steps above will cover all affected residents in the Facility.

III. Systemic Changes and Measures to Prevent Reoccurrence
1. Based upon our identified risks, the Facility Policy and Procedure for Sheltering In Place will include the following:
-A means for sheltering all residents, staff and volunteers who remain in the Facility in the event that an evacuation is not possible.
-The criteria for determining which resident and staff would be sheltered in place.
-The ability of the building to survive a disaster and what proactive steps we will take prior to an emergency to ensure a safe shelter in place process.
-The appropriate facilities in the community to which residents could be transferred in an emergent event.
-Development of various approaches to shelter in place for some or all our residents and staff.

IV. Monitoring of Corrective Action
1. A Check List was developed by the Assistant Administrator to monitor compliance.
2. The Check List will be used to ensure that a clear policy and procedure is in place to address Shelter in Place for any emergency events identified on the Risk Assessment.
3. The policy and procedure will be reviewed at least annually for compliance when the Emergency Preparedness Plan is updated.
4. The Check List will be filed in the Facility?s Disaster Preparedness Manual for reference and validation.

V. QA Monitoring
The Assistant Administrator will conduct QA Monitoring quarterly for 6 months then at least annually thereafter to ensure compliance and report to the Administrator.

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: February 6, 2018
Corrected date: April 18, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the facility had policies and procedures for the provision of care, if evacuating to a non-health care facility under a waiver declared by the Secretary. This was noted during review of the facility's Emergency Preparedness plan. The finding is: On 2/6/2018 between the hours of 8am and 3:00pm during the Emergency Preparedness survey, the following was noted: Upon review of the facility's Emergency Preparedness documentation, it was revealed that the facility did not have a policy or procedure for the provision of care, if the facility needed to evacuate to an alternate care site under a waiver declared by the Secretary. In an interview with the Assistant Administrator at approximately 10:45am, she stated she is not aware of any of any policy and procedures that address this issue.

Plan of Correction: ApprovedMarch 2, 2018

E026
I. Corrective Action for Affected Areas
The Facility has begun the process of seeking alternate Contracts/Transfer Agreements with non-health care sites to include the provision of care, if evacuating to these types of alternate care sites under a 1135 waiver declared by the Secretary.

II. Identification of Other Areas and Residents Potentially Affected
The corrective steps above will cover all affected residents in the Facility.

III. Systemic Changes and Measures to Prevent Reoccurrence
1. The Facility will contact non-health care sites to enter into 1135 waiver Agreements with them for the provision of care to our residents in the event of an emergency declaration/evacuation.
2. All Transfer Agreements/Contracts with alternate non-health care sites will be reviewed and updated at least annually to ensure that they can still provide the level of care required for our transferred residents.
3. Signed Copies of the Transfer Agreements/Contracts will be filed in the Disaster Preparedness Manual.

IV. Monitoring of Corrective Action
1. A Check List was developed by the Assistant Administrator to monitor compliance.

2. The Check List will be used to ensure that Transfer Agreements and Contracts with non-health care receiving facilities are current with signatures of the receiving party. These contracts will be reviewed at least annually during the annual review and update of the Emergency Preparedness Plan.
3. The Check List will be filed in the Facility?s Disaster Preparedness Manual for reference and validation.

V. QA Monitoring
The Assistant Administrator will conduct QA Monitoring quarterly for 6 months then at least annually thereafter to ensure compliance and report to 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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2018
Corrected date: April 2, 2018

Citation Details

2010 NFPA 13: 8.5.6* Clearance to Storage. 8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. 2010 NFPA 13: 8.15.3.2.2 Where noncombustible stair shafts are divided by walls or doors, sprinklers shall be provided on each side of the separation. Based on observation and staff interview, the facility failed to ensure that sprinklers were installed in accordance with NFPA 13, 2010 edition. Specifically, clearance between the deflector and the top of storage was noted less than 18 inches and sprinklers were not installed on either side of a separation within a stairwell. This occurred on 1 of 4 floors within the facility. The finding is: On 2/2/2018 and 2/5/2018 between the hours of 8:30am and 3pm during the recertification survey, the following was observed: - Exit stair 3 and exit stair 2 lacked sprinklers on either side of the door that separated the 1st floor landing from the basement stair. - On the 2nd floor shower room, a mesh top curtain was installed within 18 inches of the sprinkler deflector. - The gift shop located on the 1st floor contained an awning that was within 18 inches of the sprinkler deflector. In an interview on 2/5/2018 at approximately 10:30am with the Director of Engineering, he stated he called the sprinkler company and they are coming onsite to see if the sprinkler within the stair is sufficient. In an interview on 2/2/2018 at approximately 12:45pm with the Director of Housekeeping, he stated he could change out the curtains. 2010 NFPA13 10NYCRR 711.2(a)(1

Plan of Correction: ApprovedMarch 2, 2018

K351
I. Corrective Actions for Affected Area
A. The fire alarm company was immediately notified and instructed to come in to inspect either side of the door on exit stair 2 and exit stair 3 for compliance. It was agreed that a new sprinkler head will be installed inside of both stairways 2 and 3 leading to the Basement from the first floor. This area is fully restricted and not accessible to Residents. No Residents are affected by this.
B. The Shower curtain in the 2nd floor Shower Room that was installed within 18 inches of the sprinkler deflector was immediately removed by the Housekeeping Supervisor.
C. The Sprinkler company was immediately notified to come in and inspect the location of the sprinkler head above the awning by the Gift Shop. After an assessment was done, it was determined that the sprinkler head would be eliminated as there were other sprinkler heads located within the proximity that will provide coverage in case of an emergency. The Sprinkler company maintained that we will be in compliance after removing the sprinkler head.

II. Identification of Other Areas Potentially Affected
A. The Director of Engineering inspected stairway 1 and stairway 4 for similar occurrence. No other areas were affected.
B. The Housekeeping Supervisor inspected all other Shower Rooms and shower curtains in the Facility. No other areas wee found to be out of compliance.
C. The Director of Engineering conducted a visual inspection of all sprinkler heads in the building to ensure that there is no obstruction within eighteen (18) inches from its? location. No other areas were found to be out of compliance. No Residents are affected by this.
III. System Changes and Measures to Prevent Reoccurrence
A. The Director of Engineering will check all other areas to verify that there is sprinkler coverage on both side of the door that separated the 1st floor from the basement. Any area found to be out of compliance will be reported to the Sprinkler company for corrective actions to be taken.
B. The Housekeeping Supervisor will ensure the installation of appropriate shower curtains at appropriate height and monitor for compliance.
C. Engineering staff were instructed to check for sprinkler heads that may have any obstructions within eighteen inches from its location. This will be added to their Weekly Audit Tool. Any areas found out of compliance will be reported to the Director of Engineering who will take the necessary steps to correct the concern. The Director of Engineering will add this to his Monthly Audit Tool for monitoring.
IV. Monitoring of Corrective Action
A. The Director of Engineering will ensure that the Sprinkler Company will inspect the Facility sprinkler system monthly for violations. Any area found to be out of compliance will be corrected by the company.
B. The Housekeeping Supervisor will conduct Weekly Environmental Rounds on Shower Rooms to ensure un-going compliance. This will be added to the Weekly Audit Tool.
C. Monthly checks will be conducted by Engineering staff to verify that we are within the guidelines of the requirements of the location of sprinkler heads in the Facility.

V. QA Monitoring
The Director of Engineering and the Housekeeping Supervisor will report all findings to the Administrator monthly for twelve months and quarterly thereafter.

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2018
Corrected date: April 2, 2018

Citation Details

7.1.3.2.1 Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following: (1)*The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories. (2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating. (3)*The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists: (a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating. (c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3). Based on observation and staff interview, the facility failed to ensure that exit stairs were provided with a 1-hour fire resistance rating. Reference is made to the lack of firestopping within the stairwells. This occurred in 2 of 4 exit stairs within the buildings. The finding is: On 2/2/2018 and 2/5/2018 between the hours of 8:30 am and 3pm during the recertification survey, the following was observed: On the 4th floor landing within stairwell 2, exposed fiberglass insulation was observed between the wall and the roof deck. The insulation lacked the appropriate fire stopping material to achieve a 1-hour fire resistance rating. The same issue occurred on the 4th floor landing in stairwell 4. In an interview on 2/2/2018 at approximately 10:15am, the Director of Engineering stated he will firestop the area and check all other locations. 2012 NFPA101:7 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 2, 2018

K225
I. Corrective Actions for Affected Area
The exposed fiberglass insulation on stairwell 2 and stairwell 4 were immediately covered with approved fire stopping material to achieve a 1 hour fire resistance rating. This area is fully restricted and not accessible to Residents. No residents are affected by this.

II. Identification of Other Areas Potentially Affected
The Director of Engineering inspected stairwell 1 and stairwell 3 for similar occurrence, all areas were found to be compliant.
III. System Changes and Measures to Prevent Reoccurrence
The Director of Engineering will inspect all other areas in the Facility for any exposed insulation between the wall and roof deck. Any area found to be out of compliance will be corrected immediately.

IV. Monitoring of Corrective Action
The Engineering staff will be instructed to check the insulation between the wall and the deck, during their weekly Environmental Rounds to ensure that the area is always covered with fire stopping material. This will be added to their Weekly Environmental Rounds Audit Tool. Any loose or damaged insulation will be reported to the Director of Engineering who will take the necessary steps to repair or replace the insulation and firestopping material. The Director of Engineering will also add this to his Monthly Environmental Rounds Check List.

V. QA Monitoring
The Director of Engineering will report all findings to the Administrator Monthly for twelve months and quarterly thereafter.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 6, 2018
Corrected date: April 2, 2018

Citation Details

713.1.9 Mechanical Requirements (I) All handwashing fixtures used by medical and nursing staff and food handlers shall be trimmed with valves that can be operated without the use of hands. Hand operated faucets may be fitted on lavatories in residents' rooms and residents' toilets. Based on observation and staff interview, the facility failed to ensure that handwashing sinks were equipped with valves that can be operated without the use of hands. This occurred on 1 of 4 floors, including the basement of the facility. The findings are: On 2/2/2018 and 2/5/2018 between the hours of 8:45am and 3pm during the recertification survey, the following was observed: In the Main Dining Room on the 3rd floor of the facility, a sink labeled handwashing was observed. The valves could not be operated without the use of hands. In the kitchen, three sinks labeled handwashing were observed. Two of the three faucets could only be operated with the use of hands. In an interview on 2/2/2018 at approximately 10:30am with the Director of Engineering, he stated he is thinking about what style faucet would work to meet the wrist blade handle requirement. 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedMarch 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1560
I. Corrective Action for Affected Area
The Director of Engineering placed an order for [REDACTED]. These areas are fully restricted and not accessible by Residents.

II. Identification of Other Areas Potentially Affected
The Director of Engineering conducted a survey of all hand washing sinks in the facility to ensure compliance. All other areas that lacked the recommended blade handle will be corrected. The appropriate blade handles for these sinks will also be replaced.
III. Systems changes and Measures to prevent Reoccurrence
Engineering staff will conduct weekly Environmental Rounds on all faucets to ensure on-going compliance. This will be added to their weekly audit tool. The Director of Engineering will also check all hand washing sinks on all floors to make sure that the sinks are equipped with the required long blade handles. This will be added to his Monthly Audit Tool.
IV. Monitoring of Corrective Action
Engineering staff will check all handwashing sinks for compliance during their weekly rounds on their respective units. Any sink that does not have the proper blade handle will be corrected immediately. This will be added to their Weekly Environmental Rounds checklist.

V. QA Monitoring
The Director of Engineering will report all findings to the Administrator monthly for twelve (12) months and quarterly to the QA Committee for eighteen (18) months.