Hudson Valley Rehabilitation & Extended Care Center
February 27, 2019 Certification Survey

Standard Health Citations

FF11 483.20(b)(1)(2)(i)(iii):COMPREHENSIVE ASSESSMENTS & TIMING

REGULATION: §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

Based on record review and interview conducted during a recertification survey, the facility did not ensure that 4 out of 12 residents reviewed for Resident Assessment had the required Comprehensive Minimum Data Set (MDS; a resident assessment and screening tool) conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. The findings are: The MDS records of the following residents were reviewed and revealed that the following comprehensive assessments were not completed within the ARD (assessment reference date) +14 days or 366 days from the most recent comprehensive assessment. 1-Resident #06 -Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the last section was completed on 2/23/19. 2-Resident #16- Had an Annual MDS assessment with an ARD date of 1/10/19 indicated the last section was completed on 2/23/19. 3-Resident #25- Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the last section was completed on 2/17/19. 4-Resident #114-Had an Annual MDS assessment with an ARD date of 1/21/19 indicated the last section was completed on 2/22/19. In an interview with the Director Of Nursing on 2/28/19 at 1:47 PM she stated the MDS assessments were supposed to be completed within 14 days of the ARD and that she was aware they were not being completed on time. She stated the MDS coordinator left in (MONTH) (YEAR) and has not yet been replaced. 415.11(a)(3)(iii)

Plan of Correction: ApprovedMarch 22, 2019

F636
483.20(b)(1)(2)(i)(iii) Comprehensive Assessments & Timing
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.
The facility will ensure all residents reviewed for Resident Assessment had the required Comprehensive Minimum Data Set (MDS; a resident assessment and screening tool) conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process.
The facility will ensure all residents have the required minimum data set conducted within the regulatory time frames using the CMS- specified resident assessment instrument process as evidenced by:
1. The four resident identified were (#06, #16, #25,#114) all accepted by CMS late with warnings and any attempt to resubmit was rejected and considered duplication. The ZO500 cannot be modified. Completed: 3/7/2019
2. All members of the IDT who work on MDS completion were re-educated regarding the requirements of CMS that MDS comprehensive assessments be completed within the ARD +14 days or 366 days from the most recent comprehensive assessment. Completed: 3/19/2019
3. The DNS and data entry clerk(s) will generate from the software data base a daily list of comprehensive assessment due dates in order to ensure MDS assessments are completed in a timely manner. These reports will be provided to and reviewed with the MDS completion team daily Monday ? Friday at morning meeting. Completion: 3/19/2019 and ongoing
4. Audits will be performed weekly for 3 months and monthly thereafter as needed by the Administrator/Designee to ensure timely completion of Comprehensive assessments. Any negative findings will be addressed immediately. Completion: 3/29/19 and ongoing
5. Overall Responsibility: Administrator

FF11 483.20(h)-(j):COORDINATION/CERTIFICATION OF ASSESSMENT

REGULATION: §483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. §483.20(i) Certification. §483.20(i)(1) A registered nurse must sign and certify that the assessment is completed. §483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. §483.20(j) Penalty for Falsification. §483.20(j)(1)Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. §483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not ensure that the completion date as indicated in section Z0500 ( date Registered Nurse (RN) assessment coordinator electronically signed the assessment as complete) reflected the actual completion date. Specifically, section Z0400 (signature and date for persons completing the assessment) was later than the completion date indicated by the RN coordinator in section Z0500. This was evident for 11 of 12 residents reviewed for resident assessment. The findings are: 1--Resident #03- Had a Quarterly MDS assessment with an ARD date of 12/23/18 indicated the last section of the MDS was completed on 2/16/19 and the RN assessment coordinator signed the assessment was completed on 1/2/19 2-Resident #04- Had a Quarterly MDS assessment with an ARD date of 12/24/18 indicated the last section was completed on 2/25/19 and the RN assessment coordinator signed the assessment was completed on 12/31/18. 3-Resident #06 -Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the last section was completed on 2/23/19 and the RN assessment coordinator signed the assessment was completed on 1/28/19. 4-Resident #08- Had a Quarterly MDS assessment with an ARD date of 1/12/19 indicated the last section was completed on 2/14/19 and the RN assessment coordinator signed the assessment as completed on 1/21/19. 5-Resident #11-Had a Quarterly MDS assessment with an ARD date of 1/10/19 7 indicated the last section was completed on 2/23/19 and the RN assessment coordinator signed the assessment as completed on 1/23/19. 6-Resident #12- Had a Quarterly MDS assessment with an ARD date of 1/10/19 indicated the last section was completed on 2/25/19 and the RN assessment coordinator signed the assessment as completed on 1/14/19. 7-Resident #16- Had an Annual MDS assessment with an ARD date of 1/10/19 indicated the last section was completed on 2/23/19 and the RN assessment coordinator signed the assessment as completed on 1/14/19. 8-Resident #19- Had a Quarterly MDS assessment with an ARD date of 1/21/19 indicated the last section was completed on 2/24/19 and the RN assessment coordinator signed the assessment as completed on 1/24/19. 9-Resident #25- Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the last section was completed on 2/17/19 and the RN assessment coordinator signed the assessment as completed on 1/23/19. 10-Resident #31- Had a Quarterly MDS assessment with an ARD date of 1/14/19 indicated the last section was completed on 2/25/19 and the RN assessment coordinator signed the assessment as completed on 1/21/19. 11-Resident #114- Had an Annual MDS assessment with an ARD date of 1/21/19 indicated the last section was completed on 2/22/19 and the RN assessment coordinator signed the assessment as completed on 1/24/19. In an interview with the Director Of Nursing on 2/28/19 at 1:47 PM she was asked why section Z0500 was dated and signed with a date prior to the actual completion of the MDS. She stated the computer program being used by the facility would not allow her to sign using the actual completion date. She further stated she dated and signed section Z0500 using the last date the computer allowed and then she wrote a note on the paper MDS indicating the actual completion date. 415.11

Plan of Correction: ApprovedMarch 22, 2019

F642
483.20(h)-(j) Coordination/Certification of Assessment
483.20(h) Coordination.
483.20(i) Certification.
483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
The facility will ensure that the completion date as indicated in section Z0500 ( date Registered Nurse (RN) assessment coordinator electronically signed the assessment as complete) reflected the actual completion date.

1. Director of Nursing understood that the submission dates were late and has resolved the sign date with the vendor software company. DON received re-education by software programmer regarding section Z0500 completion sign off and accuracy. Software education included to force lock section Z0500 to open field and attest accurate completion date of the last completed section of the MDS team members.
All 11 residents cited were submitted and accepted by CMS with warnings of being late. Any attempt to force lock these was unsuccessful and rejected because the Z0500 date can not be modified. Any unsubmitted MDSs or not accepted by CMS allowed for the force lock so the correct date was placed in Z0500.

2. All open MDS?s as of 3/1/2019 dated with inaccurate dates of completion as shown in the Z0500 section of the MDS were unlocked and the Force lock function use to correct the date with the last sign off completion date of all MDs team members completion date. These MDS were then resubmitted with the accurate completion date entered and force locked to correct the Z0500 section of the MDS. Completion: 3/8/19
3. All members of the IDT who are responsible for MDS completion were re-educated regarding the requirements of CMS that comprehensive assessments be completed within the CMS guidelines that all Quarterly assessments are to be completed within 92 days of the last scheduled quarterly assessment date. The DNS was re- educated by the administrator regarding timely the requirements of CMS that quarterly assessments be completed within the CMS guidelines. Completion: 3/19/19
4. Audits will be performed weekly for 3 months and monthly thereafter by the Administrator/Designee to ensure accuracy of Z0500 section to ensure compliance with the CMS guidelines and reported to the QAPI Committee. Any negative findings will be corrected immediately and resubmitted to ensure compliance with CMS guidelines. A Completed: 3/29/2019 and ongoing

5. Overall Responsibility: Administrator

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not implement interventions to prevent the development of pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. Specifically, pressure relieving interventions were not implemented per the physician's orders [REDACTED]. The findings are: Resident #71 was admitted with [DIAGNOSES REDACTED]. Review of the 12/14/18 significant change MDS (Minimum Data Set: a resident assessment tool) indicated Resident #71 had a BIMS (Brief Interview for Mental Status) score of 5/15 (severe cognitive impairment), received extensive assist of 2 staff support for bed mobility, had impairment to bilateral lower extremities, had a stage 2 pressure ulcer that was not present on admission, had pressure relieving devices for the bed and chair, was on a turning and positioning schedule, and received pressure ulcer care. Review of the physician's orders [REDACTED]. Review of the comprehensive care plan dated 12/20/18 revealed the resident to be at risk for skin impairment related to functional [MEDICAL CONDITION] and neuropathies. Intervention to prevent skin breakdown was for the resident to wear heel lift booties at all times. Observations on 2/22/19 at 10:30 AM, 12:00 PM and 1:45 PM and 2/26/19 at 10:30 AM, 11:15 AM and 12:40 PM revealed Resident #71 was observed sitting in a recliner geri chair without wearing heel booties. In an interview conducted on 2/26/19 at 12:45 PM with Certified Nursing Assistant (CNA #1) she stated she did not know she was supposed to use heel booties to off load the heels of the resident. After checking the CNA assignment book, she stated the resident was supposed to have heel booties on at all times. She added that she had been removing the heel booties in the morning because she thought they were only supposed to be worn at night. During an interview conducted on 2/26/19 at 12:58 PM with Registered Nurse-Unit Manager (RN #1) she stated the heels of the resident were supposed to be off loaded using heel booties as per the physician's orders [REDACTED]. 415.11(c)(1)

Plan of Correction: ApprovedMarch 22, 2019

F656
483.21(b)(1) Develop/Implement Comprehensive Care Plan
483.21(b) Comprehensive Care Plans
483.21(b)(1)
The facility will ensure that interventions are implemented to prevent the development of pressure ulcers as evidenced by:
1. The DNS had an education with the CNA on the importance of following the care plan and review of care sheet before assignment started to ensure that all preventive skin devices are in place as directed by the CNA care sheet. Completion: 2/26/19
2. A review of all residents? comprehensive care plans will be done in order to ensure that all preventative skin devices are in place as the care guide instructs. Completion 3/27/19
3. CNAs will be reeducated to ensure that they review their resident care sheets and follow the instructions for residents at high risk of skin impairment as these are MD orders. CoOmpletion: 4/5/19
4. Audits will be conducted on all the identified residents for 4 weeks and then monthly for 3 months to ensure that care plan is being followed and that skin preventative measures are in place as instructed on the care plan and care sheets and must be followed. Completed: 3/29/19 and on-going

5. Overall Responsibility: Director of Nursing

FF11 483.20(f)(1)-(4):ENCODING/TRANSMITTING RESIDENT ASSESSMENTS

REGULATION: §483.20(f) Automated data processing requirement- §483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not electronically transmit encoded and completed MDS (Minimum Data Set; a federally-mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) to the CMS (Centers for Medicare and Medicaid Services) system within 14 days of the final MDS completion date as indicated in section Z0500 ( date the Registered Nurse (RN) assessment coordinator signed assessment as complete). This was evident for 11 of 12 residents reviewed for resident assessment. The findings are: 1--Resident #03- Had a Quarterly MDS assessment with an ARD date of 12/23/18 indicated the assessment was complete on 1/2/19 and was submitted on 2/26/19. 2-Resident #04- Had a Quarterly MDS assessment with an ARD date of 12/24/18 indicated the assessment was complete on 12/31/18 and was submitted on 2/26/19. 3-Resident #06 -Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the assessment was complete on 1/28/19 and was submitted 2/26/19 4-Resident #08- Had a Quarterly MDS assessment with an ARD date of 1/12/19 indicated the assessment was complete on 1/21/19 and was submitted on 2/20/19. 5-Resident #11-Had a Quarterly MDS assessment with an ARD date of 1/10/19 indicated the assessment was complete on 1/23/19 and was submitted on 2/26/19. 6-Resident #12- Had a Quarterly MDS assessment with an ARD date of 1/10/19 indicated the assessment was complete on 1/14/19 and was submitted on 2/26/19. 7-Resident #16- Had an Annual MDS assessment with an ARD date of 1/10/19 indicated the assessment was complete on 1/14/19 and was submitted on 2/26/19. 8-Resident #19- Had a Quarterly MDS assessment with an ARD date of 1/21/19 indicated the assessment was complete on 1/24/19 and was submitted on 2/26/19. 9-Resident #25- Had an Annual MDS assessment with an ARD date of 1/18/19 indicated the assessment was complete on 1/23/19 and was submitted on 2/20/19. 10-Resident #31- Had a Quarterly MDS assessment with an ARD date of 1/14/19 indicated the assessment was complete on 1/21/19 and was submitted on 2/26/19. 11-Resident #114-Had an Annual MDS assessment with an ARD date of 1/21/19 indicated the assessment was complete on 1/28/19 and was submitted on 2/26/19. In an interview with the Director Of Nursing on 2/28/19 at 1:47 PM she stated the MDS assessments were supposed to be completed within 14 days of the ARD and that she was aware they were not being completed on time. 415.11

Plan of Correction: ApprovedMarch 22, 2019

F 640 Encoding/Transmitting within 7 days of completion
483.20(f)(1)-(4) Encoding/Transmitting Resident Assessments
483.20(f) Automated data processing requirement-
The facility will electronically transmit encoded and completed MDS (Minimum Data Set; a federally-mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) to the CMS (Centers for Medicare and Medicaid Services) system within 14 days of the final MDS completion date as indicated in section Z0500 ( date the Registered Nurse (RN) assessment coordinator signed assessment as complete as evidenced by:
1. All 11 residents identified as not in compliance were submitted and accepted by CMS as late with warnings. Any attempt to resubmit was rejected and considered duplication. The ZO500 cannot be modified. Completed: 3/7/2019
Director of Nursing met and counselled Data Entry Clerk regarding timeliness of transmitting/ encoding completion of Minimum Data Sets and Submitting within 14 days of the complete Minimum Data Set per CMS guidelines. Completion: 3/20/19
2. Data Entry Clerk and Director of Nursing will generate an MDS completion report of all completed MDS and a Submission/ transmitting will be done 3 times a week to ensure all complete MDS are transmitted. Encoded and submitted in a timely manner in compliance with CMS regulatory guidelines.
3. All Submission and Validation reports will be forwarded to the Director of Nursing and newly hired MDS Coordinator (start week 3/25/19) to review and cross check with completed MDS rosters to ensure submission and validation reports and done in a timely manner ensuring timeliness within the allotted days for submission within CMS guidelines. Submission. Encoding and Transmittal will take place at least three times weekly.

4. An Encoding, Submission, transmitting audit will be conducted weekly by the Admininistrator of all submitted reports to ensure timeliness of submission and completion for three months of MDS target dates within CMS guidelines and then monthly thereafter. Completion: 3/29/19 and on-going

5. Overall Responsibility: Administrator

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that the call bell was in reach for one of two residents (Resident #81) reviewed for accidents. Resident #81 had [DIAGNOSES REDACTED]. A Fall assessment dated [DATE] and noted to be signed on 1/24/19 identified the following interventions: bilateral side rails, call bell within reach and bed at proper height. Environmental rounds were conducted on 2 West on 2/21/19 at 9:30 AM. Resident #81, assigned to the A bed in room [ROOM NUMBER], was seated between the bathroom door and the head of the resident's bed. The resident's call bell was on the floor on the other side of the bed. During rounds on 2/22/19 at 9:45 AM, the resident was observed in bed with the call bell on the floor, the cord tucked under the resident's pillow. An occurrence report for 2/23/19 documented the resident was found on the left side of the bed on the floor. She sustained a skin tear to left forearm, was treated with normal saline and a medicated dressing covered with a dry sterile dressing. The direct cause was documented as non-compliance with transfers, continues to ambulate without staff assistance. The call light was observed on the floor next to the bed while the resident was in bed on 2/27/19 at 9:36 AM. Four minutes later, at 9:40 AM, the resident's bed alarm sounded and the resident was observed sitting in her wheel chair beside the bed. The call bell remained on the floor. The unit manager was interviewed on 2/27/19 at 11:41 AM and stated that the resident's call bell did not have a clip on the cord to clip to the bed. 415.12(h)(1)

Plan of Correction: ApprovedMarch 22, 2019

F689
483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
415.12(h)(1)
483.25(d)(2)
The facility will ensure that the call bells are in reach for resident use as evidenced by:
1. The clip was added to the room of Resident #81 Completed: 2/27/19
2. All other residents? rooms were checked to ensure that clips are on cords and that call bells are attached to the center of bed and any missing clips were replaced Completion: 3/15/19
3. Reeducation will be conducted with nursing staff to ensure that call bells are within reach at all times when residents are in their rooms or in bed, proper placement of the call bells, as well as notifying maintenance when clips are missing. Extra clips will be available on the units. Completion: 4/5/19
Maintenance Director modified his PM work order to check call bells to include clips present and will educate his workers on importance of assuring clips are present or replace when requested. Completion: 3/22/19
4. Nursing will audit all rooms weekly on different shifts for one month and then monthly for three months thereafter to assure call bell is placed within reach and have clips in place. Negative findings and nay corrective measures will be reported to QAPI Committee. Completion: 3/29/19 and ongoing.
5. Responsibility Director of Nursing

FF11 483.70(a)-(c):LICENSE/COMPLY W/ FED/STATE/LOCL LAW/PROF STD

REGULATION: §483.70(a) Licensure. A facility must be licensed under applicable State and local law. §483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. §483.70(c) Relationship to Other HHS Regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

483.70 (b) Compliance with Federal, State, and Local laws and Professional Standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Based on observation and interview, the facility was not in compliance with Section 915 of the (YEAR) edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. A carbon monoxide monitor was not installed in the room housing the facility's diesel-powered emergency generator. The findings are: On 2/26/19 at approximately 12:10 PM, a tour of the generator room was conducted, and a carbon monoxide detector was not observed in the room. The emergency generator housed in this room is diesel-powered. In an interview with the Director of Facilities on 2/27/19 at approximately 12:30 PM, he confirmed that a carbon monoxide detector was not in the generator room and stated that there were no carbon monoxide detectors on the basement level. He further stated that he will contact a vendor to install the carbon monoxide detectors and will consult with the vendor for the proper location of the carbon monoxide detectors. 483.70 (b)

Plan of Correction: ApprovedMarch 20, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F836
483.70(a)-(c) License/Comply w/ Fed/State/Locl Law/Prof Std
Section 915 of the (YEAR) edition of the International Fire Code as adopted by New York State.
The facility will ensure that the installation of carbon monoxide detectors in areas/buildings with fuel ? fired appliances as evidenced by:
1. On 3/8/19, the Town Of(NAME)building inspector advised facility to install a carbon [MEDICATION NAME] detector in the generator room and one outside of Laundry room as well as one on each floor above these areas. Completed: 4/5/19
2. There are no other areas requiring a carbon monoxide detector in facility. Completed: 3/8/19
3. All staff will be educated on the new smoke head that includes carbon monoxide detection. 4/12/19
4. Maintenance will check for 3 months and report to the QAPI Committee any updates on installation, negative findings and corrective measures taken that the new fixtures are on and operating as designed. Completed: 3/29/19 and on-going
5. Overall Responsibility: Director of Maintenance

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure that residents or their representatives and the Office of the State Long Term Care Ombudsman were given written notification of the resident's transfer to the hospital. This was evident for 1 of 4 residents reviewed for hospitalization . (Resident #152). Findings are: Resident #152 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/10/19 the resident notified nursing of right leg pain. Upon completion of the nursing assessment, the physician and the family were notified and the resident was transferred to the hospital. Resident #152 returned from the hospital on [DATE] with a [DIAGNOSES REDACTED]. Interviews were conducted with two Licensed Practical Nurses (LPN #1 and LPN #2) on 2/28/19 at 2:00 PM. When asked how family members or resident representatives are notified when a resident is transferred to the hospital, both stated they notify them by phone. On 2/28/19 at 2:12 PM, the Assistant Director of Nursing (ADON) was asked about notification of family or resident representatives upon transfer to the hospital, she stated that the family is notified via telephone. On 2/28/19 at 2:28 PM an interview with the Director of Social Work (DSW) was conducted. She presented a form that documented that written information regarding the transfer of the resident is mailed to the resident's family and the Ombudsman On 2/28/19 at 4:30 PM, the DSW was asked to provide proof of written notification of the hospital transfer that was sent to the resident, the resident's representative and the Ombudsman. She stated that she was unable to locate the written notification form regarding the transfer. 415.3(h)(1)(iii)(a-e)

Plan of Correction: ApprovedMarch 22, 2019

The facility will ensure that residents or their representatives and the Office of the State Long Term Care were given a copy of the transfer and discharge form as evidenced by:
1. Facility mailed the one discharge transfer notice missing to family representative of resident who had gone to the hospital. Completion: 3/15/19.
2. A review of the remaining facility transfer and discharge notices revealed that all others were in compliance and sent to the ombudsmen. Completed: 3/1/2019
3. SW and nurses will be reeducated on the importance of the notice of transfer papers being provided to residents and family members, nursing will continue to call family to notify of transfers and need for documentation of the notification. Completed: 4/5/19
4. Audits will be done weekly for the first three months and will be reported to QAPI meetings and then quarterly there after. Completion: 3/29/19 and on-going
5. Overall Responsibility: Director of Social Work

FF11 483.20(c):QRTLY ASSESSMENT AT LEAST EVERY 3 MONTHS

REGULATION: §483.20(c) Quarterly Review Assessment A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

F 638 Based on record review and interview conducted during the recertification survey, the facility did not ensure that the required Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) was conducted within the regulatory time frames using the CMS-specified (Centers for Medicare and Medicaid Services) resident assessment instrument process. This was evident for 7 of 12 residents reviewed for Resident Assessment. The findings are: The MDS records of the following residents were reviewed and revealed that Quarterly assessments were not completed within the ARD (Assessment Reference Date) +14 days or 92 days from the last Quarterly Assessment. 1-Resident #02 -Had a Quarterly MDS assessment with an ARD date of 12/18/18 indicated the last section was completed on 2/16/19 2-Resident #03- Had a Quarterly MDS assessment with an ARD date of 12/23/18 indicated the last section was completed on 2/16/19. 3-Resident #04- Had a Quarterly MDS assessment with an ARD date of 12/24/18 indicated the last section was completed on 2/25/19. 4-Resident #08- Had a Quarterly MDS assessment with an ARD date of 1/12/19 indicated the last section was completed on 2/14/19. 5-Resident #12- Had a Quarterly MDS assessment with an ARD date of 1/12/19 indicated the last section was completed on 2/25/19 6-Resident #19- Had a Quarterly MDS assessment with an ARD date of 1/21/19 indicated the last section was completed on 2/24/19. 7-Resident #31- Had a Quarterly MDS assessment with an ARD date of 1/14/19 indicated the last section was completed on 2/25/19. In an interview with the Director Of Nursing on 2/28/19 at 1:47 PM she stated the MDS assessments were supposed to be completed within 14 days of the ARD and that she was aware they were not being completed on time. 415.11(a)(4)

Plan of Correction: ApprovedMarch 22, 2019

F638 Quarterly Assessments at least every 3 months
483.20(c) Qrtly Assessment at Least Every 3 Months
483.20(c) Quarterly Review Assessment

The facility will ensure that the required Quarterly Minimum Data Set is conducted within the required regulatory timeframes using the CMS Specified resident assessment instrument process, as evidenced by:
1. The Data Entry Clerk(s) and DNS were reeducated by the software vendor and consulting MDS Nurse on use of scheduling tools and population of reports to ensure proper scheduling and completion of MDS Quaterly Assessments within the ARD +14 days or 92 days from the last quarterly assessment. Completed 3/19/2019
2. All members of the MDS completion team were re-educated regarding the requirements of CMS that comprehensive assessments be completed within the CMS guidelines that all Quarterly assessments are to be scheduled within 92 days of the last scheduled quarterly assessment date and to be completed within 14 days after the ARD date as per CMS guidelines. The DNS was re- educated by the administrator regarding timely the requirements of CMS that quarterly assessments be completed within the CMS guidelines. Completed: 3/19/2019)
3. The DNS and data entry clerk(s) will generate from the software data base a daily list of comprehensive assessment due dates in order to ensure assessments are completed in a timely manner. These reports will be provided to and reviewed with the MDS completion team daily Monday ? Friday at morning meeting. Completion: 3/19/19 and on-going
4. Audits will be performed weekly with a 7 day look back period for 3 months and monthly thereafter as needed by the Administrator/ Designee to ensure timely completion of Comprehensive assessments. Any negative findings will be addressed immediately. Completion: 3/29/19 and ongoing
thereafter.
5. Overall Responsibility: Administrator

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the re-certification survey, it was determined that treatment and care was not provided to meet a resident's physical needs. Specifically, the facility did not ensure that a resident was provided proper leg rests for positioning. This was evident for 1 of 6 residents reviewed for positioning and mobility. (Resident #178). The findings are: Resident #178 was admitted with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set: an assessment tool) dated 8/1/18 indicated Resident #178 had a BIMS (Brief Interview for Mental Status) score of 3/15 (indicating severe cognitive impairment), received extensive assist of one for bed mobility, extensive assist of 2 for transfers, had functional limitation ROM (range of motion) to both upper extremities and had no limitation to lower extremities. The physician's orders [REDACTED]. The comprehensive care plan dated 8/9/18 indicated the resident had an alteration in mobility related to medical conditions and was at risk for alteration in skin integrity due to skin fragility. Interventions included; Dermasavers to BLE (Bilateral Lower Extremities); may remove during cares. A Rehabilitation Screen form dated 7/25/18 indicated the resident had severe contractures of the shoulders and mild contractures of the hips, knees, and ankles. Recommendation for AROM (active range of motion) exercises during cares and positioning. Observations on 2/21/19 at 10:00 AM, 2/22/19 at 9:48 AM and 2/26/19 at 11:12 AM revealed the legs of Resident #178 to be dangling behind the leg rests and above the ground. During an interview conducted on 2/22/19 at 10:20 AM with Resident #178, she stated her legs were not comfortable. When asked if she would like someone to help position her legs she stated that would be good. In an interview conducted on 2/26/19 at 11:13 AM with the Registered Nurse Manager (RNM #1) she stated she would call the physician to obtain an order for [REDACTED]. In an interview conducted on 2/26/19 at 11:15 AM with Certified Nursing Assistant (CNA #2) she stated the leg rests on the chair of the resident were too long and her feet could not reach the foot rests. In an interview on 2/26/19 at 11:23 AM with a maintenance employee he stated the wheel chair leg rests were too long causing the legs of the resident to dangle. He further stated the leg rests could be shortened and if that did not work he would provide a new pair. 415.12

Plan of Correction: ApprovedMarch 22, 2019

F684
483.25 Quality of Care
483.25 Quality of care
The facility will ensure that residents are provided proper leg rests for positioning as evidenced by:
1. The Resident #178 leg rests were shortened for the resident in question allowing for the residents legs to be positioned more comfortably for her. Completed: 2/27/19
2. A review of all residents who needed leg rests was conducted by the ADNS and Rehab Director on 2/27/19. Any residents whose leg rests needed adjustment were adjusted at that time. Any resident who was contraindicated for leg rests was reflected on the CNA care guide. All CNA care guides were updated to reflect any changes made on this round. All residents who required leg rests and type are documented on the CNA care guide. Completed: 2/26/19
3. Rehab Director modified the Rehab Screen and added leg rests and any other leg rest device used and will be assessed on admission and quarterly . The CNA care sheet was modified to reflect the information on leg rests: site L/R or both, positioning and contraindications. The CNAs on day shift on the unit of resident #178 will be educated as well as all other CNAs and that any ill-fitting leg rests are to be reported to the nurse and rehab director to reevaluate and maintenance will be called to make any adjustments if indicated. All residents will be assessed on admission by rehab on their routine admission assessment for whether leg rests are indicated, and quarterly thereafter. Completion: 4/5/19
4. Random Audits will be done by Rehab/Nurse Coordinator of all residents with wheelchair leg rests weekly for 4 weeks and then 25 random residents monthly for 3 months to ensure that all residents indicated for leg rests have leg rests in place, are properly fitting and are indicated on the residents? care sheet. Findings will be reviewed at QAPI meetings. Completed: 3/29/19 and on-going.
5. Overall Responsibility: Director of Rehabilitation

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during a recertification survey, the facility did not ensure that housekeeping and maintenance services provided a comfortable home-like environment. Specifically, there were numerous instances of disrepair observed in multiple rooms. This was evident for 4 resident rooms including, but not limited to rooms #101, #113, #120, and #302. The findings are: Resident room observations were conducted on 2/22/2019 between 2:16 PM and 2:30PM on the first floor unit. The following was observed: - room [ROOM NUMBER] had chipped wall paint. The electrical heater/AC unit had a brownish substance on the outside. - room [ROOM NUMBER] had brownish water stains on the ceiling, cracked floor tiles, chipped wall paint, and cracked wall plaster near the heater/AC unit. - room [ROOM NUMBER] had scuff marks on the walls, cracked floor tiles, a soiled bathroom door, soiled, rusty bathroom door frame, and cracked floor tiles where the wardrobe was located. The Director of Maintenance (DOM) was interviewed on 2/28/19 at 3:02 PM and stated the staff document environmental problems in a maintenance log book on each floor and he was not aware of these issues. Licensed Practical Nurse (LPN # 3), and Registered Nurse-Unit Manager (RN-UM # 2) were interviewed on 2/28/19 at 4:41 PM and 4:35 PM, respectively and stated that they were not aware of the problems.
Observation of resident rooms and common areas on the third floor unit from 2/21/19-2/28/19 between the hours of 9:45 AM-2:30 PM revealed the following; -room [ROOM NUMBER]- faucet in the bathroom was leaking. Resident #68 was interviewed on 2/21/19 at 2:15 PM and stated that the faucet had been leaking for three months and she had already notified the nursing staff about the leak. LPN#2 was interviewed on 2/28/19 at 9:55 AM and stated that she was not aware the faucet was leaking. Upon review of the unit's environmental log book, she stated that she did not see a request to repair the leak and would notify maintenance. The Maintenance Supervisor was interviewed on 2/28/19 at 10:35 AM and stated the repair would be completed that day. 415.5 (h) (2)

Plan of Correction: ApprovedMarch 22, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F584
483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment
The facility will ensure that housekeeping and maintenance services provide a comfortable and safe environment as evidenced by:
1. room [ROOM NUMBER] had the chipped wall repaired and painted. The electrical heater/AC unit stains were cleaned up by housekeeping.
room [ROOM NUMBER] The ceiling tiles were replaced. The cracked wall plaster was repaired near the heater/A/C and repainted and the cracked floor tiles will be replaced. were replaced.
room [ROOM NUMBER] had walls repainted, cracked floor tiles replaced by the wardrobe closet and door frame addressed and door cleaned.
room [ROOM NUMBER] leaky faucet was repaired.
Completion: 3/29/19
2. Maintenance will audit all rooms for similar environmental problems and create a work list to address issues found. Completion: 4/29/19
Housekeeping Manager will audit units for any similar issues and create list for housekeeping crew to be done. Completion: 3/27/19
3. Maintenance will create and utilize an audit tool to check the condition of rooms on each unit every 3 months and make any repairs, replacements or paint on issues identified and educate his maintenance team on the expectations of the audit and corrective measures to be taken.
Housekeeping Manager will reeducate their staff to clean up any spills on doors, equipment in rooms, etc. Completed : 3/27/19
Nursing and housekeeping staff will be reeducated on the importance of using the maintenance log books on any issues or concerns they identify on their units that are in need of repair or replacement and alerting housekeeping of any cleaning needs. Completion: 4/5/19
4. Maintenance Director will report to the QAPI Committee for three months on audit findings and corrective measures taken and then report to QAPI quarterly thereafter. Completion: 3/29/19 and on-going
5. Overall Responsibility: Maintenance Director

FF11 483.25(b)(1)(i)(ii):TREATMENT/SVCS TO PREVENT/HEAL PRESSURE ULCER

REGULATION: §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

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 implement interventions for 1 of 5 residents reviewed for pressure ulcers. Specifically, a pressure relieving device was not implemented according to the physician's orders [REDACTED]. The findings are: Resident #71 was admitted with [DIAGNOSES REDACTED]. Review of the 12/14/18 significant change MDS (Minimum Data Set: an assessment tool) indicated the resident had a BIMS (Brief Interview of Mental Status: a tool to assess cognition) score of 5/15 (severe cognitive impairment), received extensive assist of 2 for bed mobility, had impairment to both lower extremities,had a stage 2 pressure ulcer that was not present on admission, had pressure relieving devices for the bed and chair, was on a turning and positioning schedule, and received pressure ulcer care. physician's orders [REDACTED]. Review of the comprehensive care plan dated 12/20/18 revealed the resident to be at risk for skin impairment related to functional [MEDICAL CONDITION], neuropathies, and contractures with the following intervention: heel lift booties at all times. Observations on 2/22/19 at 10:30 AM, 12:00 PM and 1:45 PM and on 2/26/19 at 10:30 AM, 11:15 AM and 12:44 PM revealed Resident #71 was observed sitting in the recliner geri chair without the use of heel booties for offloading the heels. During an interview with Certified Nursing Assistant (CNA #1) on 2/26/19 at 12:45 PM she stated she checked the CNA assignment book prior to providing resident cares and she did not know she was supposed to use heel booties to off load the heels of the resident. After checking the CNA assignment book, she stated the resident was supposed to have heel booties on at all times. She added that she had been removing the heel booties in the morning because she thought they were only supposed to be worn at night. During an interview conducted on 2/26/19 at 12:58 PM with the Registered Nurse Unit Manager (RN-UM #1) she stated the heels of the resident were supposed to be off loaded using heel booties as per the physician order [REDACTED]. 415.12(c)(1)

Plan of Correction: ApprovedMarch 22, 2019

F686
483.25(b)(1)(i)(ii) Treatment/Svcs to Prevent/Heal Pressure Ulcer
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
The facility will ensure that interventions are implemented for all resident?s identified as high risk for pressure ulcers.
1. DNS had an 1:1 education with CNA on the importance of following the care plan and review of care sheet before assignment started to ensure that all preventive skin devices are in place as directed by the CNA care sheet. Completion: 2/26/19
2. A review of all residents? comprehensive care plans will be done in order to ensure that all preventative skin devices are in place as the care guide instructs. Completion 3/27/19
3. Nurses will be reeducated by the DNS to ensure all MD orders are followed and implemented for each residents? plan of care. CNAs will be reeducated to ensure awareness that the care sheet reflects MD orders for devices which must be implemented as per the MD orders. Completion 4/5/19
4. Audit will done by Unit Coordinators/Supervisors on all residents weekly for 4 weeks and then monthly for 3 months thereafter and reported at the scheduled QAPI meeting, who are identified as at risk for skin impairments with skin preventative measures in place as instructed on the care plan and care sheets and and assure that MD orders are being followed.

5. Overall Responsibility: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDORS - AREAS OPEN TO CORRIDOR

REGULATION: Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse's stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2012 NFPA 101: 19.3.6.1 Corridor Separation. Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5 (see also 19.2.5.4), unless otherwise permitted by one of the following: (1) Smoke compartments protected throughout by an approved supervised automatic sprinkler system in accordance with 19.3.5.8 shall be permitted to have spaces that are unlimited in size and open to the corridor, provided that all of the following criteria are met: (a)*The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas. (b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers. (c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space. (d) The space does not obstruct access to required exits. Based on observation and interview, the facility did not ensure that open spaces were protected by an electrically supervised smoke detector in accordance with NFPA 101. Reference is made to 1 of 2 sitting areas on the first floor that is open to the corridor and lacked an electronically supervised smoke detector. The findings are: On 2/26/19 during the life safety recertification survey conducted at approximately 10:05 AM, it was noted that the sitting area on the first floor that is open to the corridor lacked an electronically supervised smoke detector. This was noted in 1 of 2 of the sitting areas on the first floor. In an interview at the time of the observation, Director of Facilities stated that a smoke detector will be installed in the area. 2012 NFPA 101: 19.3.6.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMarch 21, 2019

2012 NFPA 101: 19.3.6.1 Corridor Separation.
19.3.4,
The facility will ensure that open spaces are protected by an electronically supervised smoke detector in Accordance with NFPA 101 as evidenced by:
1. Smoke detector will be added to the sitting area on the first floor (1E Parlor) identified during survey by the fire alarm company AFA. Completed: 3/19/19
2. There are no other identified areas in which a smoke detector is absent. Completed: 3/15/19
3. The smoke detector was added to the fire panel by AFA. Completed: 3/19/19
4. Maintenance director will report any issues with the new smoke detector to the QAPI Committee. Completion: 3/29/19
5. Overall Responsibility: Maintenance Director

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: February 27, 2019
Corrected date: April 29, 2019

Citation Details

101 NFPA Section 7.1.10 Means of Egress Reliability. 7.1.10 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 observation and interview, the facility did not ensure that all emergency exits are maintained readily accessible at all times in accordance with 7.1. This was evidenced by metal patio chairs and a grill that were placed against the exterior wall in the path of egress from 1 of 2 emergency exits from the main dining room on the lower level. The findings are: On 2/26/19 at approximately 1:10 PM, a tour of the main dining room on the lower level revealed several metal chairs and a grill placed against the exterior wall in the path of egress from 1 of 2 emergency exits from the room. This same situation was noted again on 10/27/19 at approximately 10:10 AM. In an interview at the time of the finding, the Director of Facilities stated that the chairs and grill were removed from the patio area due to high winds and placed against the building to prevent the chairs from causing damage. He further stated that the grill and chairs will be removed and placed in the shed. 2012 NFPA 101: 19.2.1, 7.1.10.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMarch 18, 2019

101 NFPA Section 7.1.10 Means of Egress Reliability
The facility will ensure that all emergency exits are maintained readily accessible at all times as evidenced by:
1. The patio furniture chairs and grill were removed on 2/26/19.
2. There were no other emergency exits obstructed and were readily accessible. Completed : 3/4/19
3. The facility will add to the monthly preventative maintenance form for checking exterior lighting of exits to check all exterior emergency exits for obstruction on a monthly basis as well as after inclement weather and remove any obstacles immediately. Completed: 3/15/19
4. Maintenance Director will audit exit doors weekly for one month and report any negative findings to the committee and the corrective actions taken and will continue monitoring monthly thereafter. Completed 3/29/19 and on-going.
5. OVERALL RESPONSIBILITY: Maintenance Director

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2012 LSC 101: 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 42. 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. 7.8.1.3* The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated as follows: (1) During conditions of stair use, the minimum illumination for new stairs shall be at least 10 ft ft.- candle (108 lux), measured at the walking surfaces. (2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the floor. (3) In assembly occupancies, the illumination of the walking surfaces of exit access shall be at least 0.2 ft- candle (2.2 lux) during periods of performances or projections involving directed light. (4)* The minimum illumination requirements shall not apply where operations or processes require low lighting levels. 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. 7.9 Emergency Lighting 7.9.2.3* The emergency lighting system shall be arranged to provide required illumination automatically in the event of any interruption of normal lighting due to the following: (1) Failure of a public utility or other outside electrical power supply (2) Openings of a circuit breaker or fuse (3) Manual act(s), including accidental openings of a switch controlling normal lighting facilities. Based on observation and interview, the facility did not ensure that the illumination of the floors and means of egress was installed and maintained in accordance with 7.8. and 7.9. Reference is made to the single bulb light fixtures located at three of six emergency exits and the wall-mounted light switches installed at the entrance to the recreation room located on the lower level, that when turned to the off position, turned all of the lights except for two leading to the emergency exit in the room. The findings are: During the recertification survey conducted on 2/26/19 between the hours of 10:00 AM and 2:00 PM, the following issues with emergency lighting were noted: - At approximately 12:00 PM, a tour of the stairwell emergency exits on the first floor was conducted and revealed that single bulb light fixtures were installed on the exterior side of the emergency exits from stair 1, stair 2 and the center stairwell. In an interview at the time of the findings, the Director of the Facilities stated that the single bulb light fixtures will be changed to LED fixtures. - At 12:50 PM, wall mounted light switches were noted to be installed on the wall at the entrance to the recreation area (formerly the dining room) on the lower level. There are emergency exit doors located in the room. When these switches were turned to the off position, all of the lights in the room except two turned off. In an interview at the time of the observations, the Director of Facilities confirmed that several of the lights were tied into the emergency generator and that two bulbs had blown. He further stated that he would ensure that they were not operated by the manual switches. 2012 NFPA 101: 7.8.1.1, 7.8.1.3, 7.8.1.4*, 7.9.2.3* 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMarch 18, 2019

2012 LSC 101: 7.8 Illumination of means of Egress
The facility will ensure that the illumination of the floors means of egress will installed and maintained in accordance with 7.8 and 7.9 as evidenced by :
1. Maintenance replaced three single bulb fixtures on the exterior of the facility. Completed: 3/6/19.
Maintenance added two light fixtures in the large activity room and two light fixtures in the corridor adjacent to the large room to meet the 2 candle lit criteria to the circuit of the generator. Lights will stay on when the wall mounted switch is turned OFF. Completed: 3/20/19
2. There is no other area affected in illumination. Completed: 3/8/19
3. Maintenance Director will have rounds conducted for three months to assure illumination on floors and means of egress are checked every two weeks for three months and continue the PM on checking the exterior lighting every month thereafter.
4. Maintenance Director will report to the QAPI committee any negative findings and corrective measures for three months on floors and means of egress illumination and then continue the monthly PM schedule for illumination. Completion: 3/29/19 and on-going
5. OVERALL RESPONSIBILITY: Maintenance Director

K307 NFPA 101:MEANS OF EGRESS - GENERAL

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2012 NFPA 101: 7.2.1.9 Powered Door Leaf Operation. 7.2.1.9.1*General. Where means of egress door leaves are operated by power upon the approach of a person or are provided with power-assisted manual operation, the design shall be such that, in the event of power failure, the leaves open manually to allow egress travel or close when necessary to safeguard the means of egress. Based on observation and interview, the facility did not ensure that the power sliding doors at the main entrance were in compliance with Chapter 7. Reference is made to the exterior set of sliding doors that did not open as per the instructions posted on the door indicating IN AN EMERGENCY PUSH TO OPEN. The findings are: During the life safety tour conducted on 2/26/19 at approximately 2:00 PM, it was noted that there were two sets of power sliding doors at the main entrance to the facility. Upon testing the operation of the doors in the event of a power failure, i.e. pushing the doors as per the posted instructions, 2 of 4 panel doors from the exterior set of doors to exit to a public way did not open. In an interview at the time of the findings, the Director of Facilities stated that a build up of salt (used for melting ice) may be hindering the operation of the doors. He stated that he will have maintenance staff work on the doors or apply oil to ensure the doors open properly. 2012 NFPA 101: 7.2.1.9.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMarch 18, 2019

2012 NFPA 101: 7.2.1.9.1
The facility will ensure that the automatic sliding doors will open readily in case of an emergency as evidenced by
1. Maintenance lubricated the door immediately on 2/26/19 and door opened readily.
2. There is no other automatic sliding in the facility. Completed 2/26/19
3. A PM schedule was added to address lubrication of the automatic sliding doors. Maintenance staff will lubricate weekly for one month and monthly thereafter for a total of 3 months and then monthly going forward.
All maintenance personnel will have instruction on the PM. Completed on: 3/15/19
4. Maintenance Dir will audit and inform the QAPI COMMITTEE for three months on any negative findings and corrective measures done related to the sliding doors. COMPLETION: 3/29/19 AND ON-GOING
5. OVERALL RESPONSIBILITY: Maintenance Director

K307 NFPA 101:PORTABLE FIRE EXTINGUISHERS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2010 NFPA 10 Installation of Portable Fire Extinguishers 6.1.3.8 Installation Height 6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft. (1.53 m) above the floor. Based on observation, the facility did not ensure that the portable fire extinguishers were properly installed in accordance with NFPA 10. Reference is made to the portable fire extinguishers in recessed cabinets that were installed more than 5 ft. above the floor. This was noted on 2 of 3 resident floors. The findings include: During the recertification survey on 2/25/19 and 2/26/19 between the hours of 11:00 AM and 3:00 PM, a tour of the 2nd floor nursing unit revealed that the fire extinguishers on the unit were stored in recessed cabinets. The top of the extinguisher in the recessed cabinet adjacent to stairwell 4 measured more than 5 ft. above the floor instead of the maximum height of 5 feet above the floor. This was also noted in 1 of 5 recessed cabinets on the first floor. In an interview at the time of the finding, the Director of Facilities stated that the fire extinguishers will be placed at the appropriate height. 2012 NFPA 101 2010 NFPA 10: 6.3.8 10 NYCRR 711. 2 (a)(1)

Plan of Correction: ApprovedMarch 21, 2019

NFPA 101 Portable Fire Extinguishers
2010 NFPA 10 Installation of Portable Fire Extinguishers
6.1.3.8 Installation Height
The facility will ensure that the portable fire extinguishers are properly installed and no more than 5 feet above the floor as evidenced by:
1. Maintenance lowered the hooks or placed the extinguishers identified during survey on the bottom the enclosed cases so that all extinguishers were no higher than 5? off the floor to the top of the extinguisher. Completed: 2/26/19
2. All other fire extinguishers in the facility that were not in compliance were lowered to be 5? off the floor to the top of the extinguisher. Completed: 2/26/19
3. Any future extinguisher added to the facility will meet the requirement of no higher than 5? from the top of the extinguisher. Completed: 2/26/19 and on-going. Education of the maintenance on this height requirement. Completed: 3/19/2019.
4. Maintenance will report the corrective action of the fire extinguishers at the QAPI meeting. Completion: 3/29/19
5. OVERALL RESPONSIBILITY: Maintenance Director

K307 NFPA 101:SMOKE DETECTION

REGULATION: Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2012 NFPA 101 - 19.3.6 Corridors. 19.3.6.1.8 Protection of Fire Alarm System. 19.3.6.1.8* In areas that are not continuously occupied, and unless otherwise permitted by 9.6.1.8.1.1 or 9.6.1.8.1.2, automatic smoke detection shall be installed to provide notification of fire at the following locations: (1) Each fore alarm control unit. (2) Notification appliance circuit power extenders (3) Supervising station transmitting equipment Based on observation, the facility did not ensure that smoke detectors installed in areas not continuously occupied were maintained in accordance with 19.3.6.1.8. This was evidenced by an orange plastic factory installed cap that was noted on the smoke detector in the soiled linen room in the basement. The findings are: On 2/26/2019 at 12:30 PM during the recertification survey, the life safety tour of the soiled linen holding room was conducted and revealed an orange plastic factory installed cap on the smoke detector. The cap would prevent the smoke detector from functioning as designed. In an interview at the time of the finding, the Director of Facilities stated that the cap would be removed. 2012 NFPA 101 LSC: 19.3.6.1.8* 10 NYCRR 711.2(1)(a)

Plan of Correction: ApprovedMarch 21, 2019

2012 NFPA 101 - 19.3.6 Corridors.
19.3.6.1.8 Protection of Fire Alarm System.
The facility will ensure that smoke detectors installed in areas not continuously occupied were maintained in accordance with 19.3.6.1.8 as evidenced by:
1. Maintenance removed the orange caps placed over the smoke detector in the soiled room in the lower level and the 2 W shower room. Completed: 2/26/19
2. Maintenance Director and staff audited the entire facility and found no other occurrence of plastic covers on smoke detectors. Completed: 3/8/19
3. Facility will add to the monthly PM audit for sprinkler heads to check smoke detectors for functioning and not obstructed with any caps. Reeducation will be provided to maintenance staff on the removal of caps after a job that requires capping. completion: 3/22/19
4. Maintenance Director will report findings to the QAPI committee for three months any negative findings and the corrective action taken and continue monitoring every 6 months. Completed: 3/29/19 and on-going
5. Overall Responsibility: Maintenance Director

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2011 NFPA 25 Chapter 5 Sprinkler Systems. 5.2.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendant, or sidewall). 2010 NFPA 13 8.5.5 Obstructions to Sprinkler Discharge. 8.5.5.2.1 Continuous or non continuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2. 8.5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special requirements of section 8.6 through Section 8.12 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures. Based on observation, the facility did not ensure that automatic sprinkler heads installed in required areas were maintained in accordance with NFPA 13 as evidenced by: 1. Storage less than 18 inches from sprinkler heads in the medical records storage room, 2 of 3 walk-in refrigerators in the kitchen, and the walk-in freezer located outside of the building adjacent to the kitchen; 2. A bent pendent style sprinkler in the elevator machine room; and 3. A sprinkler head was obstructed by a large water tank in the main sprinkler room located on the lower level. The findings are: During the life safety tour of the facility conducted during the recertification survey on 2/26/19 between the hours of 11:00 AM and 3:00 PM, the following issues with the sprinklers were noted: - At approximately 11:50 AM, a tour of the medical records storage room located on the first floor revealed that the storage boxes in the caged area of the room were stacked high on the wall, less than 18 inches below the sprinkler, obstructing the sprinkler spray pattern from reaching the exterior walls in the area. - At approximately 1:05 PM, a tour of the kitchen revealed storage less than 18 inches from sprinkler heads in 2 of 3 walk-in refrigerators and in the outdoor walk-in freezer. - At approximately 12:35 PM, a tour of the East elevator machine room revealed the pendent style sprinkler in the room was bent. - At approximately 1:15 PM, a tour of the main sprinkler room located on the lower level revealed a sprinkler obstructed by the large water tank in the room. This condition would prevent the sprinkler spray pattern from reaching the exterior wall of the room. In an interview at the time of the findings, the Director of Facilities stated that the storage in the areas mentioned will be removed, and that he will contact the vendor to replace the sprinkler in the elevator machine room. He further stated that an extension will be placed on the existing pipe in the main sprinkler room to provide sprinkler coverage to the area where the sprinkler is obstructed. 2012 NFPA 101 2011 NFPA 25: 5.2.1.1* 2010 NFPA 13: 8.5.5, 8.5.5.2.1, 8.5.5.2.2 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMarch 22, 2019

2011 NFPA 25 Chapter 5 Sprinkler Systems.
5.2.1.1*
2010 NFPA 13
8.5.5 Obstructions to Sprinkler Discharge.8.5.5.2.1 Continuous or non continuous obstructions less than or equal to 18 in.
8.5.5.2.2
The facility will ensure that automatic sprinklers heads installed in required areas are maintained in accordance with NFPA 13 as evidence by:
1. Medical records will re-reorganized and placed less than 18? from the sprinkler head. Completion: 4/8/19.
The maintenance staff will lower the shelving in the kitchen coolers to allow less than 18? from the sprinkler heads. Completion: 4/8/19
The bent head will be replaced by the fire sprinkler company and install the extra sprinkler head in the water heater room. Completion: 4/12/19
2. The facility will reorganize any identified areas with storage above 18? from the sprinkler heads and correct so that it will be lower than 18?. Completion: 4/12/19.
3. Maintenance Director will audit all areas of storage for monthly for three months to assure compliance with items remaining below 18? from sprinkler heads and then continue quarterly thereafter. Completion: 3/ 29/19 and on-going
4. Maintenance Director will report and negative finding and corrective measures to the to the QAPI committee for three months and continue monitoring areas every 6 months thereafter. Completion: 3/29/19 and on-going.
5. OVERALL RESPONSIBILITY: Maintenance Director

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 27, 2019
Corrected date: April 29, 2019

Citation Details

2012 NFPA 101 7.2.2.5.5 Exit Stair Path Markings. Where exit stair path markings are required in Chapters 11 through 43, such markings shall be installed in accordance with 7.2.2.5.5.1 through 7.2.2.5.5.11. 7.2.2.5.5.1 Exit Stair Treads. Exit stair treads shall incorporate a marking stripe that is applied as a paint/coating or be a material that is integral with the nosing of each step. The marking stripe shall be installed along the horizontal leading edge of the step and shall extend the full width of the step. The marking stripe shall also meet all of the following requirements: (1) The marking stripe shall be not more than 1/2 in. (13 mm) from the leading edge of each step and shall not overlap the leading edge of the step by more than 1/2 in. (13 mm) down the vertical face of the step. (2) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm) and a maximum width of 2 in. (51 mm). (3) The dimensions and placement of the marking stripe shall be uniform and consistent on each step throughout the exit enclosure. (4) Surface-applied marking stripes using adhesive-backed tapes shall not be used. Based on observation, the facility did not ensure that the stairwells were maintained in accordance with NFPA 101. Reference is made to the unapproved marking stripe (i.e. adhesive backed- tape) noted on each step in 6 of 6 stairwells. The findings are: During the recertification survey conducted on 2/25/19, 2/26/19, and 2/27/19 between the hours of 11:00 AM and 3:00 PM, it was noted that the marking stripes on the steps in 6 of 6 stairwells were applied with unapproved material (i.e. adhesive backed tape). In an interview at the time of the findings, the Director of Facilities stated that the adhesive backed tape will be removed and replaced with approved material. 2012 NFPA 101: 7.2.2.5.5, 7.2.2.5.5.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedMarch 18, 2019

2012 NFPA 101 7.2.2.5.5.1 Exit Stair Treads
The facility will ensure that approved materials will be used for the marking stripes on stairwell as evidenced by:
1. Maintenance will remove the existing adhesive marking stripes on the identified stairwells and use approved materials (paint) on stairwell treads.
Completion: 4/26/19
2. There are no other stairwells in facility. Completed: 2/26/19
3. Maintenance will add to the Stairwell PM the stair markings on the stairwells and repaint if needed. Completed: 3/15/19
4. Maintenance Director will report to QAPI committee the progress and completion of stair wells. Completed by : 3/29/19 and on-going.
5. OVERALL RESPONSIBILITY: Maintenance Director