Briarcliff Manor Center for Rehabilitation and Nursing Care
August 2, 2017 Certification Survey

Standard Health Citations

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that antipsychotic medications were used in excessive dose for 1 out 5 residents (#133) reviewed for unnecessary medications. Specifically, the dose of an antipsychotic medication was increased in response to an isolated episode of delusional thinking that did not present a danger to the resident, who has a [DIAGNOSES REDACTED]. The findings are: Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Initial Minimum Data Set (a resident assessment tool) dated 9/9/16 showed that the resident was moderately cognitively impaired, exhibited no [MEDICAL CONDITION] or behavioral problems and was on an antipsychotic medication ([MEDICATION NAME] 12.5 mg twice daily). The History and Physical record dated 9/12/17 revealed that prior to admission to the facility the resident was hospitalized due to increased agitation and [MEDICAL CONDITION] while living in the community and was not taking her medications. The comprehensive care plan for the use of antipsychotic medication dated 9/15/16 noted that one of the goals for the resident was to have her behaviors managed on the lowest dose possible. Interventions to achieve this goal included observing for behaviors and providing diversional activities and psychiatric follow-up. The nursing notes revealed no behavioral problems or delusional thinking from the time of admission to 1/25/17. On 1/26/17, a nursing note stated that the resident was found in her room in a paranoid state. The resident reported to staff that her hair was sprayed with an agent and there were bugs in her hair. This was not observed by staff and reassurance was given. After a few minutes the resident was more relaxed. Further review of nurses notes revealed no other delusional thinking by the resident or any incident of behavioral disturbances. The psychiatrist examined the resident on 2/2/17 and noted that the resident had dementia and [MEDICAL CONDITION] NOS (not otherwise specified) likely secondary to dementia. The psychiatrist recommended that [MEDICATION NAME] be increased to 25 mg twice daily and to follow-up in one week. There was no documented evidence that the psychiatrist evaluated the resident the next week. Subsequent psychiatric evaluations were conducted on 5/9/17, 6/5/17 and 7/1/17. None of these evaluations noted that the resident was exhibiting delusional thinking or any behavioral disturbances. The psychiatrist recommended on 7/1/17 that the [MEDICATION NAME] administered in the morning be reduced from 25 mg to 12.5 mg. daily. This note also stated that the staff reported no concerns. As of the date of the review on 8/2/17, the resident continued on 37.5 mg of [MEDICATION NAME], 12.5 mg more than the dose ordered prior to the one episode of delusional thinking on 1/26/17. The psychiatrist who recommended increasing the dose of [MEDICATION NAME] on 2/2/17 and the attending physician who gave the order for this to be done are no longer employed by the facility and were not available for interview. The resident's designated representative (DR) was interviewed in the afternoon of 8/1/17 and stated that the resident had no psychiatric history and that he was not informed that [MEDICATION NAME], which was started when the resident was hospitalized , was increased. The unit Registered Nurse manager was interviewed in the afternoon of 8/1/17 and stated that the DR was not notified of the increase in the dose of [MEDICATION NAME]. This interview also revealed no other behavioral problems was exhibited by the resident, excluding the incident on 1/26/17 mentioned above. The Director of Nursing (DON) was interviewed in the afternoon of 8/1/17 to determine if there were Quality Assurance measures to address the use of antipsychotic medications for residents with dementia. The DON stated there was no program by Quality Assurance and that the use of such medications for residents with dementia were based on recommendations by the psychiatrist and orders by the attending physician. The facility's policy and procedure on antipsychotic medications revealed that these medications can be given for dementia with associated psychotic features that is, (1) documented quantitatively to determine if the behavior is transitory or permanent or not easily altered; (2) persistent; (3) causing danger to the resident (continuously screaming, yelling) or others; and (4) has psychotic symptoms which cause the resident impairment in functional capacity. None of these conditions were met to justify increasing the dose of [MEDICATION NAME]. 415.12 (l)(1)

Plan of Correction: ApprovedAugust 24, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I - Immediate Corrective Action
A psychiatric consult was placed and completed on 8/19/17 and a decrease in [MEDICATION NAME] was recommended and was approved by the MD on 8/21/17. The designated representative was notified of the change in medication.
II ? Identification of Others
An audit was immediately started to ensure that all [MEDICAL CONDITION] medication changes in the last quarter were implemented correctly and that the policy and procedure of the facility was followed appropriately and justifiably. The audit is ongoing and at this point no other residents have been identified.
III ? Systematic Changes
The policy and procedure for unnecessary medications/[MEDICAL CONDITION] medications was reviewed and updated. A behavior note was added to the EMR to document any behaviors exhibited by residents and to monitor if interventions tried were successful. All psychiatric consults will be reviewed by the care plan team for the continued necessity of the drug. Inservices were started and continue to be ongoing.
The inservices will include the following information:
1. It is imperative that all residents who receive psychoactive medications, are seen at least quarterly by the psychiatrist in order to monitor resident?s response to the drugs, monitor behavioral symptoms and attempt gradual dose reductions (GDR) as per NYS Department of Health Guidelines.
2. All new residents admitted on psychoactive medications must have a psych order written and be seen within 30 days of admission. All other residents on psychoactive medications will be seen at a minimum of quarterly and more often as needed.
3. Nursing must write behavior notes as behaviors occur in the EMR under behavior note each shift that the behavior occurs. The nurse manager must encourage feedback from all staff to ensure that all behaviors are being captured.
4. A monthly behavior note must be completed on all residents receiving [MEDICAL CONDITION] medications
5. Target behaviors must be addressed. Eg.if a res. is receiving [MEDICATION NAME] for depression then s/s of depression must be ?targeted?, such as isolation, poor appetite, crying, poor sleep etc. If [MEDICATION NAME] is administered for [MEDICAL CONDITION] then the Target behaviors need to be addressed such as hallucinations, delusions, paranoia etc
6.Please note: having a resident on psychoactive medications without exhibiting behaviors can be considered an UNNECESSARY MEDICATION, for which we can be cited.
7.A gradual dese reduction (GDR) must be attempted for all residents on [MEDICAL CONDITION] meds. 2 GDRs must be attempted in the 1st year a resident is placed on a [MEDICAL CONDITION] med and annually thereafter.
8.A GDR note must be completed q shift

IV ? Quality Assurance
An audit tool was created by the Director of Nursing and will monitor 1)if the drug prescribes is given for the appropriate diagnosis, 2)Will monitor nursing documentation to support the continued assessment of the medication, 3)Documentation of targeted behaviors of the drug use, 4)GDRs and 5) if the designated representative has been notified of any changes in medications. The audit will be done weekly for 4 weeks and monthly thereafter. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Nursing.

FF10 483.45(c)(1)(3)-(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility?s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility?s medical director and director of nursing and lists, at a minimum, the resident?s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident?s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident?s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that recommendations made by the consultant pharmacist were responded to and acted upon by the primary care physician for 1 of 5 residents (#10) reviewed for unnecessary medications. The findings are: Resident #10 has [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The (MONTH) (YEAR) care plan for Psychotropic Medications indicated that the psychiatrist recommended to perform a GDR (Gradual Dose Reduction) for Ativan from 0.5 to 0.25 mg and to decrease Valproic Acid to 250 mg daily. The psychiatry consult dated 6/18/17 indicated a recommendation to monitor Depakote (valproic acid) and to do a Liver Function Test. There was no evidence in the progress notes that the primary care physician had responded to this recommendations. Review of the laboratory reports for the past year indicated neither a valproic acid level nor a liver function test had been done. The LPN (Licensed Practical Nurse) charge nurse was interviewed on 8/1/17 at 12:30 PM regarding the psychiatrist's recommendation and stated that the physician usually writes his comments on the consult. There was no evidence of a comment made by the physician on the consultation record. The pharmacy consultant report of irregularities for (MONTH) (YEAR) indicated a recommendation to do thyroid stimulating hormone (TSH) and valproic acid levels. According to the report, it had been more than 6 months since those levels were done. The report was signed by the physician with no indication if he agreed or disagreed with the recommendation. The physician was interviewed by telephone on 8/1/17 at 12:45 PM and was asked about the pharmacist's recommendation. The physician stated that according to the regulations, he is not required to do valproic acid levels for a resident who is receiving the medication for mood and behavior as opposed to seizures. He further stated that he does TSH levels annually. He had no response when asked why he had not indicated his disagreement with the rationale he just stated. 415.18(c)(1)

Plan of Correction: ApprovedAugust 23, 2017

I - Immediate Corrective Action
A full medical review of the resident identified was completed and Valporic Acid was discontinued on 8/4/17, a Gradual Dose Reduction of Paxil was implemented on 8/8/17 and a Liver Function test was ordered and scheduled for 8/25/17.
The Medical Director was notified immediately regarding the lack of documentation by the physicians and has set up a meeting with all physicians to reinservice them on following the facilities policy and procedure regarding appropriate documentation.
Inservices were started and are ongoing to all Physicians, Practitioners, the DON, Medical Director and Licensed Nursing Staff.
II ? Identification of Others
An audit was completed that reviewed all pharmacy recommendations for the last two months. Any issues identified was discussed with the medical director and a medical board meeting has been scheduled for 8/29/17 to review all finding with the MDs and inservice them on proper documentation.
The facility respectfully acknowledges that residents were potentially affected by this deficient practice. However, no residents were harmed.
III ? Systematic Changes
The policy and procedure was reviewed and updated. An audit tool was created and will be monitored by the Director of Nursing to ensure that all physicians are documenting appropriately as per the facility?s policy and procedure. The audit will monitor 4 items 1) If the MD documented a response to pharmacy recommendation(s), 2) If the MD agreed or disagreed 3)If the MD disagreed did they document a reason why and 4) Were all recommendations completed within a 2 week time frame of receipt of report from the pharmacy consultant.
Pharmacy consultant is revising their report to have an option for agree/disagree and a comment section should the physician disagree.
IV ? Quality Assurance
An audit tool was created by the Director of Nursing and will monitor the above mentioned items and ensure that all MDs are following the policy and procedure of the facility. The audit will be done monthly for 3 months then quarterly thereafter. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Nursing.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not ensure food was prepared and stored according to professional standards of food service safety practice. Specifically, (1.) foods that had been cooked and cooled were not monitored using cooling logs to ensure proper cooling times and temperatures; (2.) hamburgers being held for lunch service did not maintain the required holding temperature of 135 degrees Fahrenheit (F); and (3.) resident food stored in unit refrigerators was not labeled and dated in 1 of 3 resident units (Unit A). The findings are: 1. The kitchen was observed on 7/27/17 at 9:30 AM. A pan of frozen cooked roast beef was found in the freezer dated 6/24/17 with a label stating to discard if not used within 72 hours. At that time, the Food Service Director (FSD) was interviewed about the roast beef and cooling logs for cooked and cooled food and stated he would discard the roast beef and that he does not have cooling logs. When asked if it is common to cook, cool and store food items for a later date, he stated they do it frequently. Other precooked foods that were observed included a pan of rice and a pan of mixed vegetables both dated 7/26/17, a pan of cooked meatballs, and a pan containing two cooked quiches. 2. Hamburgers for lunch being served from the steam table were not holding the required temperature of 135 degrees F or above. When tested , the temperature of the hamburgers was 120 degrees F. The FSD stated he would get the hamburgers being held in the oven for the remainder of the meal service and have that section of the steam table checked to see if it is working properly. 3. The Unit A refrigerator was checked on 7/27/17 at 10:00 AM and the following resident food items were observed with no label or name, no date, or both - a plastic container of an unknown food, a Styrofoam cup of what looked like chicken or fish, a plastic container of fruit salad. Two plastic containers of rice pudding, 2 more plastic containers of unknown food, a Styrofoam box with lasagna, another Styrofoam box with salad. There was an unopened box of Lunchables with the expiration date of 5/22/17 and a container of rice pudding dated 7/1/17. The unit Registered Nurse manager was interviewed on 7/27/17 at 10:55 AM and stated that everyone knows that food should be thrown out after 72 hours as indicated by a sign on the refrigerator door. 415.14(h)

Plan of Correction: ApprovedAugust 24, 2017

I - Immediate Corrective Action
The Director of Food Services immediately implemented a Cooling Log, a Holding Temperature Log and a Food Storage Area Log. All unit refrigerators were inspected and any undated or unlabeled food was immediately discarded. Maintenance inspected the steam table for functionality and found one section to be inoperable. That one section is not being utilized and awaits repair/replacement.
II ? Identification of Others
An inspection of all other unit refrigerators was conducted and any unlabeled or undated food items were discarded immediately. The steam table was in proper operational order except for that one bay. All other residents were potentially affected by this.
III ? Systematic Changes
A Cooling Log, a Holding Log and a Food Storage Area log were implemented. All dietary staff was inserviced on the importance of maintaining these logs and how they are recorded. All unit refrigerators will be checked once a day for any undated or unlabeled food items.
IV ? Quality Assurance
An audit tool was created by the Director of Dietary and will directly monitor the affected areas and ensure that all logs are being filled out appropriately daily for 4 weeks then quarterly thereafter. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Food Services

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 21, 2017

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not provide adequate maintenance services necessary to maintain a sanitary and orderly interior. Specifically, walls, doors and closets in resident rooms were observed to be in disrepair which was evident in 2 of 3 units (B and C Units). Findings include but are not limited to the following: 1. On 7/31/17, from 9:00 AM to 11:00 AM the following were observed: C unit: - Room 4A - the room radiator pipe was misaligned and angled against wall; - Room 6A - the dresser was observed with chips, scratches and gouges; - Room 11B - the room door and door frame were noted to be scraped, scuffed, and the metal strip on door frame was bent. The radiator was scraped. 2. On 8/1/17 at approximately 10:00 AM, the following were observed: C Unit: - Rooms 9 and 11 - the door and door frames were scuffed and scraped; - Room 17 - the metal door frame was bent; - Room 21 - the closet door was misaligned; - Room 5 - the closet door was in disrepair. - Unit Shower (bathing) Room - the door frame was scraped and the bottom door panel was loose; - Unit Resident Lounge floor was soiled and was disrepair. B Unit: - Room 7 - the closet handle or knob was missing; - Room 20 - the door edge was chipped and the closer metal frame was in disrepair; - Room 6 - the door frame was chipped and scraped. The regional maintenance director was interviewed on 7/1/17 at 11:00 AM and stated that the work on Units B and C and repairs would be initiated and should be completed soon. 415.5 h) (2).

Plan of Correction: ApprovedAugust 24, 2017

I - Immediate Corrective Action
The Director of Maintenance reviewed all listed items and all issues will be fixed immediately.
II ? Identification of Others
The Director of Maintenance made full house rounds to identify areas requiring repair. A full review of all resident rooms was completed and all maintenance issues are being fixed.
III ? Systematic Changes
The policy and procedure for the maintenance log book was reviewed and updated. All staff members were inserviced on the use of the maintenance log books and reinserviced to record any damages in resident rooms or areas in the maintenance log book immediately. The Director of Maintenance added ongoing environmental rounds to the Preventative Maintenance List and will directly in order to ensure all areas will be maintained daily. Maintenance Log Books will be checked daily.
IV ? Quality Assurance
An audit tool was created by the Director of Maintenance in conjunction with the Administrator in order to monitor the overall appearance and functionality of all resident rooms. Monitoring of the environment will be done via direct observation from the Director of Maintenance/Designee. Any negative findings will have corrective actions implemented. The audit will be done by the Director of Maintenance/Designee daily for 4 weeks then quarterly thereafter. The results will be reported to the QA committee on a quarterly basis.
Responsible Person: Director of Maintenance

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 21, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that adequate monitoring of fluid intake for 1 of 1 resident (#104), on fluid restriction and reviewed for [MEDICAL TREATMENT] treatment, was implemented. Specifically, the amount of fluids allowed to be given with medications was not documented to ensure compliance with the fluid restriction. The findings are: Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (a resident assessment tool) dated 4/3/17 indicated the resident was receiving [MEDICAL TREATMENT] treatments. The care plan for [MEDICAL CONDITION] ([MEDICAL TREATMENT]) last updated on 5/22/17 indicated the resident receives [MEDICAL TREATMENT] treatment three times a week every Tuesday, Thursday, and Saturday secondary to [MEDICAL CONDITION] as demonstrated by decreased urine output. A 1000 ml. daily fluid restriction was included as one of the care plan interventions. The physician's orders [REDACTED]. - breakfast, 120 ml. - lunch, and 240 ml. - dinner, for a total of 720 ml. The remaining 280 ml. was to be given with medications. The MAR (Medication Administration Record) for (MONTH) (YEAR) indicated the resident is on Nepro (a nutritional supplement) 240 ml. twice daily and 30 ml LPS (Liquid Protein Supplement) twice a day. There was no documentation identifying how much fluid was consumed during the medication pass to determine if the resident was within the 1000 ml. fluid restriction. The Licensed Practical Nurse (LPN) who administers medication to the resident was interviewed on 7/31/17 at 1:30 PM and was asked how she knows how much fluid is allowed for the resident for the medication pass. The LPN stated they usually just give the resident 30 ml. with the medication pass. When asked how she would know if she could provide more fluid to the resident if he asks, she stated he knows the resident is on fluid restriction and was very compliant. She stated there was no place on the MAR where they document how much the resident consumes of the 280 ml. allowed. The Certified Nurse Aide (CNA) Accountability documentation for (MONTH) (YEAR) indicated the resident consumed between 50-100% of liquids at meals and most often, the consumption was between 76-100%. The care plan for Nutritional Status / Renal Diet indicated the resident is on [MEDICAL TREATMENT] and is offered a renal, no-concentrated-sweets diet with limited variety of food choices and 1000 ml. fluid restriction. A 2/17/17 update to the care plan indicated the resident is non-compliant with fluid restriction and often goes to the vending machine for soda. The Registered Dietitian (RD) was interviewed on 7/31/17 at 2:30 PM about how Nepro was calculated in the fluid restriction diet. The RD stated that Nepro provides 240 ml of the 360 ml at breakfast and all 240 ml. was allowed at dinner. The RD stated she doesn't count the 60 ml. of LPS since it's such a little amount. She further stated the CNAs document the amount of fluid consumed using the ranges 0-25%, 26-50%, 51-75% and 76-100%. The amount consumed of the Nepro was documented on the MAR. The Director of Nursing was interviewed on 7/31/17 at 2:45 PM regarding the documentation of the resident's fluid intake provided by the nurses and stated there was nothing in place to prompt them to do that. 415.12

Plan of Correction: ApprovedAugust 24, 2017

I - Immediate Corrective Action
The fluid restrictions for the resident specified was immediately reviewed by the Director of Nursing and Dietician. The amount of fluid allotted for medication pass was calculated for each medication pass and the nurse will document the amount scheduled and the amount given in the MAR per medication pass. An MD order was obtained for the amount of fluid to be given with each medication pass.
II ? Identification of Others
After conducting a full house audit, 6 other residents were identified as having fluid restrictions. Each resident on fluid restrictions was assessed by the Director of Nursing and the Dietician for the correct amount of fluid calculated for each medication pass and the nurse will document the amount scheduled and the amount given in the MAR per medication pass. All residents on fluid restrictions were updated to be in compliance with the updated policy and procedure. MD orders were obtained for the amount of fluid to be given with each medication pass for each resident.

III ? Systematic Changes
The policy and procedure for fluid restrictions was reviewed and updated in order to ensure compliance with medication pass. Doctors orders will be included for any resident on fluid restrictions that will break down the amount of fluid to be given with each medication pass. The nursing department and the dietician will work together to determine the allotment of fluids for meals and medication pass. All MDs, Licensed Nursing staff, Dieticians will be inserviced on the updated policy and procedure.
IV ? Quality Assurance
An audit was created by the Director of Nursing to monitor the compliance with the above listed systematic changes. The audit will include MD orders; 1)for the fluid restriction amounts, 2)for the amount to be given with meals, 3)for the amount to be given with med pass and 4)to see if the amounts were documented correctly in the MAR. This audit will be done weekly for 4 weeks then quarterly thereafter. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Nursing

FF10 483.10(f)(10)(vi):SURETY BOND - SECURITY OF PERSONAL FUNDS

REGULATION: (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 2, 2017
Corrected date: September 21, 2017

Citation Details

Based on interview and record review conducted during a recertification survey, the facility did not assure the security of all personal funds of residents deposited with the facility. The findings are: A review of the facility's most current balance report of 7/26/17 showed that the residents' funds managed by the facility totaled $35,411.00. There were nine residents with deposits that ranged from $1,000.00 to $6,280.00. The Administrator was interviewed in the afternoon of 8/1/17 for evidence to show that the facility had safeguarded all the residents' funds with a surety bond. The Administrator stated that he would provide this information on 8/2/17. On 8/2/17 at about 9:30 AM, the Administrator stated that the facility had not purchased a surety bond to secure the residents' funds and that one would be purchased. 415.26(h)(5)(v)

Plan of Correction: ApprovedAugust 24, 2017

I - Immediate Corrective Action
The Administrator contacted the Comptroller and advised him to obtain a Surety Bond at least equal to the amount of resident's funds. On 8/21/17 a new Surety Bond for $50,000 was obtained via the Platte River Insurance Company.
The Comptroller was inserviced regarding the requirement to have a Surety Bond of a value that would sufficiently cover the security of all personal funds of residents deposited with the facility.
II ? Identification of Others
The facility respectfully submits that all residents were affected by this deficiency with no actual harm.
III ? Systematic Changes
The Administrator reached out to the comptroller to assure the value of the Surety Bond covered the amount in resident funds. The Administrator/Designee and the Comptroller will be in contact weekly for 4 weeks then monthly for 2 months and quarterly thereafter to ensure the amount of resident funds will not exceed the amount of the Surety Bond. Should the amount of resident funds meet or exceed the amount of the Surety Bond, an increase in coverage of the Surety Bond will be obtained.
IV ? Quality Assurance
The comptroller will monitor the Surety Bond against the amount of resident funds and email the administrator weekly for 4 weeks then monthly for 2 months and quarterly thereafter to ensure the amount of resident funds does not exceed the amount of the Surety Bond. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Administrator

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 25, 2017

Citation Details

2012 NFPA 101 Life Safety Code 7.1.10 Means of Egress Reliability. 7.1.10.1 * Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in case of fire or other emergency. Based on observations and interview, the facility did not ensure that all required exit passageways are maintained readily accessible at all times and free of all obstructions or impediments to full instant use in the case of fire or other emergencies in accordance with NFPA 101. This was evidenced by gravel in sections of the path of egress at the end of the Center Stairwell and North stairwell emergency exit discharge. The findings are: On 8/1/17 at approximately 1:35 PM, an examination of the emergency exit from the center stairwell revealed that gravel was placed in a section of the pathway. This pathway measured approximately 83 ft. long and leads to a public way. This was also noted at the end of the pathway from the emergency exit from the kitchen which is the North stairwell. This situation would not ensure the safe, instant use of the paths of egress. In an interview at the time of the findings, the Regional Engineer could not provide an explanation. The Director of Maintenance stated that the damaged concrete and the pathway from the emergency exit will be cleared. 2000 NFPA 101: 19.2, 7.1.10, 7.1.10.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 25, 2017

I - Immediate Corrective Action
The Director of Maintenance has reached out to an outside vendor to contract with in order to have the sections of the path of egress at the end of the center stairwell and north stairwell repaired and bring it in compliance with NFPA 101. The Director of Maintenance will oversee all repair work performed by the outside contractor for appropriateness and compliance. The Director of Maintenance will keep a list of all work and repairs completed by the outside contractor for reference and validation.
II - Identification of Others
The Director of Maintenance did a full inspection of outside paths of egress to ensure that they are all in compliance. One other area was determined to be a potential risk, the area outside of the Boiler Room, and will be included in the repair work done by the outside vendor. No other areas were identified.
III - Systematic Changes
The Director of Maintenance added the monitoring of exit paths to his list of Engineering Daily Rounds Log. The Director of Maintenance/Designee will directly observe and monitor all exit paths to ensure that all paths of egress at the emergency exits are in compliance.
IV - Quality Assurance
The Director of Maintenance developed an audit tool to track all the paths of egress to ensure all of them are maintained safe and ready for instant use. The audit will be done weekly for the next month then monthly thereafter. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Maintenance

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 25, 2017

Citation Details

Based on observation, interview, and record review, the facility did not have established policies and procedures for testing intervals for all patient care and non-care related electrical equipment in accordance with NFPA 99. The findings are: On 8/1/17 at approximately 1:30 PM, the facility provided manufacturer's specifications for various resident care equipment for oxygen concentrators, air mattress pumps, electric beds and suction machines. Although inspection stickers were noted on the patient care related equipment and non patient care related electrical equipment, the facility could not provide documentation of established policies and procedures for preventive maintenance. In an interview at the time of the finding, the Regional Engineer stated that a policy will be developed for testing intervals for all patient care electrical equipment. 2012 NFPA 99: 10.5.2.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 25, 2017

I - Immediate Corrective Action
The Director of Maintenance put together a Policy and Procedure regarding testing intervals for all patient care and non-care related electrical equipment in accordance with NFPA 99. All Maintenance staff were inserviced on the new policy and procedure.
II - Identification of Others.
The facility respectfully submits that all residents were potentially affected. However, no residents were harmed by this.
III - Systematic Change
All Maintenance staff were inserviced on the importance of maintain a comprehensive Policy and Procedure manual.
IV - Quality Assurance
The Director of Maintenance created an audit to monitor and review his Policy and Procedure Manual to ensure that all policies are checked monthly to see if they need to be updated or if anything needs to be added.
Person Responsible: Director of Maintenance

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 25, 2017

Citation Details

Based on observation and interview, the facility did not provide documentation that the non-hospital grade electrical receptacles installed in resident care rooms were tested at intervals not exceeding 12 months in accordance with NFPA 99. The findings are: On 8/1/17 at approximately 2:35 PM, the facility's maintenance audit logs did not indicate that the non-hospital grade outlets in the resident rooms were tested at intervals not exceeding 12 months. In an interview at the time of the findings, the Regional Engineer stated that the electrical outlets are tested but that he was unable to locate the documentation. 2012 NFPA 99: 6.3.4.1.3 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 25, 2017

I - Immediate Corrective Action
The Director of Maintenance/designee tested all the residents rooms electrical outlets. A log was created to document all outlets were tested .
II - Identification of Others.
The facility respectfully submits that residents were affected by this documentation omission but that no residents were harmed.
III- Systematic Changes
The Director of Maintenance/Designee started a documentation log regarding the testing of electrical outlets in residents rooms and will directly monitor the testing of the outlets and maintain appropriate documentation monthly.
IV - Quality Assurance
The Director of Maintenance developed an audit tool to monitor all electrical outlets in resident rooms to ensure the documentation of the annual testing of all electrical outlets in a timely and appropriate manner. The Director of Maintenance/Designee will conduct an initial audit of all electrical outlets in resident rooms and will then continue to test in intervals not exceeding 12 months in accordance with NFPA 99. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Maintenance

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 2, 2017
Corrected date: September 25, 2017

Citation Details

7.8 Illumination of Means of Egress. 7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2 7.8.1.2.1 Artificial lighting shall be employed at such locations and for such periods of time as are necessary to maintain the illumination to the minimum criteria values herein specified. 7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. Based on observation and interview, the facility did not ensure that the illumination of the means of egress was installed and maintained in accordance with 7.8. This was evidenced by manually operated wall-mounted switches installed in the main dining room and in the PT/OT room. When these switches were manually turned to the off position, the lights in the rooms would be turned off. This would not ensure that required and sufficient lighting would be continuously in operation and capable of automatic operation without manual intervention. The findings are: During the life safety tour conducted on 8/1/17 between the hours of 11:30 and 2:00 PM, manually operated wall mounted light switches were noted in the kitchen corridor, main dining room and PT/OT room. When these switches were manually turned to the off position, all lights in these areas and rooms were turned off. There are required emergency exits located within each of these rooms. In an interview at the time of the findings, the Regional Engineer stated that the lights lights will be changed to remain in continuous operation in the areas mentioned. 2012 NFPA 101: 19.2.8, 7.8.1.1, 7.8.1.2.1, 7.8.1.4* 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 25, 2017

I - Immediate Actions
An electrician was contacted to ensure that all identified areas would be connected to a continuous electrical power source to ensure that the sufficient lighting would be continuously in operation without manual intervention. The lights identified were set to the On position and the manual controls were removed pending the electricians visit.
II - Identification of Others
The facility was put on a full generator load test and no other areas were found to be deficient.
III - Systematic Change
The Director of Maintenance added the direct monitoring of illumination at the paths of egress to his list of Engineering Daily Rounds Log. The Director of Maintenance/Designee will directly observe and monitor all exit paths to ensure that all paths of egress are illuminated and in compliance.
IV - Quality Assurance
The Director of Maintenance developed an audit tool to track that all the paths of egress are illuminated and to ensure all of them are maintained in a safe and ready for instant use manner. The audit will be done weekly for the next month then monthly thereafter. The results will be reported to the QA committee on a quarterly basis.
Person Responsible: Director of Maintenance