Safire Rehabilitation of Southtowns, LLC
July 26, 2018 Certification/complaint Survey

Standard Health Citations

ZT1N 711.1:APPLICABILITY

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation, interview, and record review during a Standard survey completed on 7/26/18, construction projects were underway within the facility and the facility did not have documentation that verified they had received approval for construction prior to their implementation. Specifically, construction/ renovation: of the therapy suite and the atrium/ fish tank projects had started and were ongoing prior to the facility receiving approval to construct, alter or renovate the facility. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The findings are: 1.a) Observations on the First Floor, on 7/17/18 at 8:55 AM, revealed four approximate 11-foot long by six-foot wide fish tanks had been installed in the atrium. Further observation revealed cabinets had been installed around and between the tanks and the project was currently under construction. Observations in the Basement, on 7/17/18 at 12:22 PM, revealed an approximate 115-inch long by four-inch wide unprotected steel column was installed in the medical records storage room located next to the elevator equipment room. Observation in the Basement, on 7/17/18 at 1:34 PM, revealed an approximate 115 inch-long by four-inch wide unprotected steel column was installed in the corridor near the maintenance shop. During an interview, at the time of the observations, the Regional Chief Engineer and the Maintenance Director stated the steel columns and beams were installed in the building approximately three to four months ago by an outside contractor as part of atrium fish tank project. Observation in the Basement, on 7/17/18 at approximately 1:48 PM, revealed an approximate five-foot long by 12-inch wide unprotected steel column installed in the janitor's closet located near the women's locker room. Observation in the Basement, on 7/17/18 at approximately 2:06 PM, revealed an approximate 109-inch long by 12-inch wide unprotected steel beam installed in the men's locker room. Further observation revealed an approximate 115-inch long by four- inch wide and an approximate 111-inch long by four-inch wide unprotected steel column installed in this room. During an interview on 7/18/18 at 8:45 AM the Regional Administrator and the Administrator stated, they had not submitted any documentation for the atrium/ fish tank project or the therapy suite project to the New York State Department of Health and they had not received an approval to construct, for the projects from the New York State Department of Health. During an interview on 7/19/18 at approximately 1:12 PM the Construction Project Manager for the outside contractor that was overseeing the atrium/fish tank construction project stated construction started on 9/16/17 and the structural steel was installed in the areas of the Basement to support the weight of the fish tanks that were installed in the atrium on the First Floor. The Construction Project Manager further stated his company installed the fish tanks and cabinets in the atrium between 9/16/17 and 4/20/18 and another outside contractor installed the structural steel in the Basement between 1/18/18 and 4/27/18. b) Observation on the Second Floor on 7/17/18 at 9:30 AM revealed the Therapy suite was under construction. Further observations revealed a temporary wall and door were constructed to separate the Therapy suite from the Second Floor corridor, near the resident lounge. During an interview on 7/24/18 at 8:25 AM the Construction Project Manager for the outside contractor that was working in the building stated the Therapy suite construction project started during (MONTH) of (YEAR). As of 7/26/18 the facility had not provided the New York State Department of Health with Architectural or Engineering certifications, plans or drawings, Engineer sign off letters, manufacturer's specifications for all materials used in the projects or patient safety plans for the projects. 10 NYCRR 711.1(a) 10 NYCRR 711.1(b)(1)(2)(3)(4)(5) 10 NYCRR 711.1(6)(c)

Plan of Correction: ApprovedAugust 24, 2018

The corrective action that will be accomplished for the residents found to have been affected by the deficient practice will include notification of the NYSDOH with architectural and / or engineering certifications / plans/drawings or other materials for the construction project, along with Engineer sign - off letters , manufacturers specifications for all materials used in the projects or patient safety plans
All residents have the potential to be affected by the same deficient practice.
On 7/18/18 NYSCON was notified on an $800,000 project for the:
Rehab Gymnasium
Vivarium / Aquarium
Central Hall and Atrium project
The number assigned # 2457.
Also submitted was the Safety Plan and the Construction Project Notice

A complete review of the requirements will be completed to ensure that the appropriate documentation is submitted .All outside contractors and vendors will be contacted to obtain the necessary information.
All information will be brought to the monthly QA and A committee to ensure compliance with the regulations for construction.

Responsible person:Project Manager

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: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Standard survey completed 7/26/18 the facility did not ensure a registered nurse conducted or coordinated each assessment with the appropriate participation of health professionals. Three (Residents #3, 4, 5) of three residents reviewed for resident assessments did not have discharge assessment and/ or tracking records completed when discharged from the facility. The findings are: During an interview on 7/26/18 at 1:00 PM the facility Administrator stated the facility did not have any policy and procedures for the completion of MDS' (Minimum Data Set - a resident assessment tool). 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, rarely/ never understands, and is rarely/ never understood. Resident #3 was discharged from the facility on 3/10/18 and a return was not anticipated. Review of the MDS 3.0 - Resident Assessment and Care Screening included the following: - Entry record tracking dated 2/9/18. - Admission assessment dated [DATE]. During an interview on 7/25/18 at 8:49 AM, the Registered Nurse (RN) MDS Coordinator stated, a discharge return not anticipated should have been done for 3/10/18 and wasn't. 2. Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, is understood, and understands. Resident #4 was discharged from the facility on 3/28/18 and a return was not anticipated. Review of the MDS 3.0 - Resident Assessment and Care Screening included the following: - Entry record tracking dated 10/3/17. - Admission assessment dated [DATE]. - Quarterly review assessment dated [DATE]. - Quarterly review assessment dated [DATE]. During an interview on 7/25/18 at 8:49 AM the Registered Nurse (RN) MDS Coordinator stated, the resident was transferred to another SNF (Skilled Nursing Facility) a discharge should have been done. 3. Resident #5 was admitted to the facility 2/22/18 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, is understood, and understands. Resident #5 was discharged from the facility on 3/13/18 and a return was not anticipated. Review of the MDS 3.0 - Resident Assessment and Care Screening included the following: - Entry record tracking dated 2/22/18. - Admission assessment dated [DATE]. During an interview on 7/25/18 at 8:49 AM the Registered Nurse (RN) MDS Coordinator stated, she went home and should have had a d/c (discharge) done. Review of the RAI (Resident Assessment Instrument) OBRA (Omnibus Reconciliation Act - the Federal Nursing Home Reform Act created a set of national minimal standards of care and rights for people living in certified nursing facilities) - required Assessment Summary published (MONTH) (YEAR) included the following: - Discharge Assessment - return not anticipated. MDS completion date no later than discharge date + 14 calendar days. - Discharge Assessment - return anticipated. MDS completion date no later than discharge date + 14 calendar days. - Death in facility tracking record. MDS completion date no later than discharge (death) date + 7 calendar days. 415.11

Plan of Correction: ApprovedAugust 31, 2018

F 642 Coordination Certification of Assessment
Residents #3, #4 and #5 have been discharged from Safire South.
All resident records have the potential to be affected by the same deficient practice.
A 100% audit with a 90 day look back period will be completed by the MDS Coordinator of all resident discharged from Safire South to identify deficient practice.
The MDS Coordinator who did not complete Discharge MDS Tracking has resigned from the facility 8/31/18.
A new MDS Coordinator will start training 8/27/18.
All Discharge Assessment/Tracking records will be printed /placed in the residents discharged records.
An audit will be completed by medical records on going for all discharge records.
The DON will analyze and trend data.
Results will be reviewed monthly by the QA & A committee.

Responsible person for compliance: Director of Nursing (DON)

E3BP 402.6(d):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (d) A provider may temporarily approve a prospective employee while the results of the criminal history record check are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on interview and record review during the Standard survey completed on 7/26/18, the facility did not verify that a prospective employee was supervised pending results of the New York State (NYS) Department of Health (DOH) Criminal History Record Check (CHRC). One (certified nurse aide (CNA)) of three employees reviewed, who received a negative determination from the NYS DOH CHRC program since the last survey, was not supervised after hire and after a negative determination letter was issued. The finding is: 1. Review of NYS DOH Criminal History Record Check (CHRC) program information revealed Employee #3 (CNA) received a Pending Denial letter dated 9/8/17. Review of Employee #3's employee file revealed the employee was hired on 9/20/17, after the Pending Denial letter was issued. The file did not contain documentation of the Pending Denial letter dated 9/8/17. Additional review of the file revealed it contained a final Denial letter from the NYS DOH CHRC program dated 11/27/17. Review of Employee #3's time cards revealed the CNA worked at the facility for 11 days between 9/20/17 and 11/26/17. The file did not contain documentation that the employee was supervised following hire and after the Pending Denial letter was issued. During an interview on 7/23/18 at approximately 2:16 PM, the Human Resources Generalist (Authorized Person) stated she was not working as the Authorized Person or reviewing (CHRC) information for employees who worked at the facility when Employee #3 was hired and she was not sure why Employee #3's Pending Denial letter dated 9/8/17 was not in the employee's file. The Human Resources Generalist (Authorized Person) further stated that Employee #3 worked at the facility for 11 days between 9/20/17 and 11/26/17 and the facility had no documentation for the supervision of the employee. Review of a Criminal History Form Completion/ Submission/Retention Process policy dated 6/26/18 revealed: Provisional supervision will be initiated for those employees and agency employees providing direct care or supervision to residents on hire and until the criminal history check is completed and the facility is notified by CHRC of the employee's employment determination eligibility. A facility will provide direct supervision of the applicant while the applicant is in the facility or with residents. The supervision monitoring checks must be completed be completed by a licensed person holding a supervisory position. The Human Resources Director will complete the employee tracking form weekly and file it with supervision of the temporary employee supervision monitoring form when reviewing the weekly supervisor monitoring forms and maintained in the temporary employee's Human Resources file. 402.4(b)(2)(i) 402.6(d) 402.9(a)(1)(v)

Plan of Correction: ApprovedAugust 31, 2018

The employee # 3 was immediately removed from the facility after it was determined that the employee had a denial form the CHRC
All residents have the potential to be affected by the same deficient practice
The facility will ensure that all documentation is reviewed for any /all pending denials and/or denials for any employees . The HR Generalist will keep an ongoing record of new hires and their CHRC status .Any pending denials and /or denials will be reviewed by the Administrator for immediate removal of that said employee or to contact the tentative employee about their inability to proceed with employment.
A Random audit of 6 employee records per month for all new hires will continue on an ongoing basis . A retrospective review of all new hires back to (MONTH) 28, (YEAR) will be completed .
The policy Criminal History Form Completion/Submission/Retention Process was reviewed with no revisions necessary.
The results of the audits will be reviewed at the monthly QA and A meeting to review data and analyze any trends .
Responsible person: Administrator

ZT1N 415.17:DENTAL SERVICES

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/18 the facility did not ensure that each resident receives a complete oral examination, by a licensed and currently registered Dentist or Dental Hygienist, within 7 days following completion of the initial comprehensive assessment. Specifically, one (Resident #69) of three residents reviewed for dental services did not receive an initial dental examination within 21 days after admission. The finding is: The policy and procedure entitled Dental Services dated 2/1/17 documented all residents will have a dental exam within 20 days of admission, as needed and annually. 1. Resident #69 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/27/18 revealed the resident is moderately cognitively impaired, usually understood, sometimes understands. The Interdisciplinary Care Plan dated 5/22/18 documented the resident was on a therapeutic diet. Interventions included to provide mechanical soft diet, monitor appetite and intake and monitor weights. The care plan did not address the residents dental status. During an observation on 7/20/18 the resident was ambulating on the unit and noted to have no teeth. Review of the entire medical record revealed there was no documented evidence the resident saw the dentist. During an interview on 7/20/18 at 8:30 AM, the Unit Clerk #1 stated she was unsure if the resident saw the dentist. She does not save the schedules by the dentist and will have to look for any documentation. During an interview on 7/23/18 at 2:04 PM, the Unit Clerk #2 stated she contacted the dental company used by the facility and they have no documentation the resident was seen by the dentist. During a telephone interview on 7/26/18 at 10:46 AM, the Regional Director of the dental company used by the facility stated they were never given the resident's name to be seen and she has not been seen by the dentist. 415.17(c)

Plan of Correction: ApprovedAugust 24, 2018

I190 Dental Services
The corrective action that will be accomplished for those residents found to have been affected by the deficient practice.
Resident #69 no longer resides at the facility. The resident would have been placed on the Dental list for the next dental visit date.A record review of the resident was completed for any / all issues and concerns.
Other residents having the potential to be affected by the same deficient practice will be identified by:
A 100% Facility audit will be completed to ensure all residents have been seen by the Dentist upon admission and yearly thereafter.The audit will be completed by the unit clerks.
The Unit Clericals will make and keep a Master List for all Dental visits.Also any new resident must offered a dental visit even if sub - acute . If the resident refuses , appropriate documentation must be completed.
Any resident found to have missing teeth / Dentures/or impaired chewing ability, will be placed on the next Dental visit by the unit clerks.
Monitoring so that the deficient practice does not recur will be completed by
Random Dental audits will be completed on six(6) residents per month for 3 months.The policy has been reviewed with no revisions necessary. All nursing staff will be inserviced on the policy regarding dental visits to include , but not limited to chewing problems , weight loss etc. The dental audits will include but not limited to , the resident name , date of admission ,last dental visit - where and when, any significant issues that have been identified specific to the resident and any follow up that may have been needed to be addressed .
Audits will be reviewed at the Monthly QA&A meeting for any and all concerns related to any area of the dental policy and procedure.
Person responsible will be the Administrator

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on interview and record review during the Standard survey completed on 7/26/18, the facility did not immediately remove an employee from direct care of residents upon receiving a New York State (NYS) Department of Health (DOH) Criminal History Record Check (CHRC) negative determination letter for one (certified nurse aide (CNA)) of three employees who received a negative determination from the NYS DOH CHRC program since the last standard survey. The finding is: Review of NYS DOH CHRC program information revealed Employee #3 (CNA) received a Pending Denial letter dated 9/8/17. Review of Employee #3's employee file revealed the CNA was hired on 9/20/18. The file contained no documentation of the employee's Pending Denial letter dated 9/8/17. Further review of the file revealed it contained a Final Denial letter from NYS DOH CHRC program dated 11/27/17. Review of Employee #3's time cards revealed the employee worked at the facility for 11 days between 9/20/17 and 11/26/17. During an interview on 7/23/18 at approximately 2:16 PM, the Human Resources Generalist (Authorized Person) stated she was not working as the Authorized Person or reviewing (CHRC) information for employees that worked at the facility when Employee #3 was hired. The Human Resources Generalist (Authorized Person) further stated she was not sure why Employee #3's Pending Denial letter dated 9/8/17 was not in the employee's file and the employee had worked for 11 days at the facility between 9/20/17 and 11/26/17. Review of a Criminal History Form Completion/Submission/Retention Process policy dated 6/26/18 revealed: Disqualifying Offenses (may not be employed by the facility) - Upon receipt of the CHRC report or Rap Sheet, the nursing home operator must review it to determine the applicant's suitability for employment. If the CHRC reveals a conviction for criminal offences, then the operator is prohibited from hiring the individual in a direct care or patient supervision capacity. Unfavorable CHRC legal determinations require immediate action and the removal of the employee from a position of providing direct care or having access to residents and their belongings. Hold in Abeyance, Pending Denial, and Final Denial letters for employee requires the facility to immediately remove the employee from providing direct care or supervision to the resident and facility policy is to immediately terminate the employee on the same day letter the is received. 402.7(2)(i) 402.7(3)(i)

Plan of Correction: ApprovedAugust 24, 2018

Employee # 3 was immediately termed from the facility.
All residents have the potential to be affected by the same deficient practice.
The facility will ensure that all documentation is reviewed for any/all pending denials for employees.
Audits and monitoring will take place as R722 indicates for employee records .
The Human resource generalist will notify the administrator any/all denials and /or pending denials.Refer to R722
An audit of any / all time cards will be completed by the Human resource generalist, of any/all denials to ensure the employee has either not been employed / and or/ will not be employed . The tentative employee will be removed immediately form the payroll system.
The results of the audit will be brought to the monthly QA and A meeting for data and trending .

Responsible person : 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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview conducted during the Standard survey completed on 7/26/18, the facility did not develop and implement a comprehensive person- centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs that are identified in the comprehensive assessment for six (Residents #10, 35, 92, 93, 113, 117) of 29 residents reviewed. Specifically, the issues involved the lack of care plan devolvement to address wandering behaviors (#117), oxygen use (#35), open wounds (#92). Resident #93 did not have a comprehensive care plan developed within 7 days of completion of the comprehensive assessment. Additionally, Resident #10 was not put back to bed after lunch as planned and Resident #113 was not gotten up for breakfast to be in the main dining room as planned. The issues include: 1. Resident #10 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) documented the resident has severe cognitive impairment. The Pocket Care Plan (guide used by the CNAs to provide care) identified as current on 7/19/18 by the Licensed Practical Nurse (LPN #1) Unit Manager (UM) documented the resident should go back to bed after lunch. Observations of the resident on 7/23/18 revealed from 8:30 AM until 2:00 PM the resident remained in a wheel chair and was not put back to bed after lunch as planned. After lunch at 12:38 PM the resident was brought out of the dining room to the nurse's station and remained there until 2:00 PM. The resident looked very uncomfortable hunched over in the wheel chair starring at the floor. During an interview on 7/23/18 at 2:15 PM, the LPN #1 UM stated the resident should have been put back to bed earlier. During an interview on 7/23/18 at 3:00 PM, the Registered Nurse (RN) from hospice stated we care planned for her to go back to bed right after lunch for comfort. The wheel chair isn't comfortable for her. I had recommended a Geri-chair, but they told me it was a restraint. 2. Resident #113 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. The Pocket Care Plan identified as current on 7/19/18 by LPN #1 UM documented the resident eats all meals in the main dining room. During an interview on 7/18/18 at 2:18 PM, the resident stated in the morning there was not enough staff to get him up in the morning. He had to eat in his room and he does not like to eat in his room. The resident further stated he wanted to eat all his meals in the main dining room and that included breakfast. During an interview on 7/23/18 at 8:35 AM, the resident stated he was upset because he did not get out of bed for breakfast on Saturday 7/21/18 or Sunday 7/22/18. During an interview on 7/23/18 at 11:00 AM, LPN #2 stated there was only one Certified Nurse Aide (CNA) for 40 residents when she came in on Saturday morning. They did not get another CNA in until 8:30 AM. We couldn't get residents out of bed with that kind of staffing. During an observation of the resident on 7/24/18 at 8:10 AM revealed the resident was eating breakfast in bed. Interview with the resident at that time revealed he wanted to get out of bed for breakfast. During an interview on 7/24/18 at 8:50 AM, the Agency CNA #1 stated she was the only CNA for 20 residents and there was only one CNA for 20 residents on the adjacent unit. Additionally, this resident was a two person assist and the CNA could not get the resident out of bed by herself. During an interview on 7/24/18 at 8:51, LPN #1 UM revealed the resident was care planned to be out of bed for breakfast and should have been gotten up for breakfast. 3. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident has severe cognitive impairment, is usually understood and sometimes understands. The physician's orders [REDACTED]. Observation of the resident in her room on 7/20/18 at 9:10 AM revealed an oxygen concentrator (device which concentrates the oxygen from a gas supply (typically ambient air) to supply an oxygen-[MEDICATION NAME] gas stream) with tubing and humidified water bottle dated 7/19/18. Resident #35 was not utilizing the oxygen at that time. The current Interdisciplinary Care Plan dated 5/8/18 had no documentation regarding the usage of PRN oxygen. The undated Pocket Care Plan (guide used by the CNAs to provide care) did not include instructions for the usage of PRN oxygen. During an interview on 7/23/18 at 10:28 AM, the Director of Nursing (DON) stated, everything should be on the comprehensive care plan. 4. Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident has severe cognitive impairment, is understood, and sometimes understands. The MDS documented the resident wandered four to six days, but less than daily. Review of Wander/ Elopement Risk assessment dated [DATE] included the following: documented the resident wandered without a specified course or direction) and had exit-seeking behaviors and a history of unsafe wandering. A Wander guard placed on 7/11/18. Intermittent observations of the resident throughout the survey 7/17/18 through 7/26/18 revealed a WanderGuard bracelet on the left wrist. The undated Pocket Care Plan (guide used by the CNAs to provide care) did not address or document the use of a WanderGuard bracelet. Review of medical record revealed there was no comprehensive Interdisciplinary Care Plan (CCP) developed for Resident #117. During an interview on 7/23/18 at 10:28 AM, the DON stated, everything should be on the comprehensive care plan, high risk for wandering, elopement risk, the use of a WanderGuard. The pocket care plan should have also been updated. During an interview on 7/23/18 at 10:12 AM, the Assistant Director of Nursing (ADON) stated, there is no nurse manager (on the unit) the DON has been doing the care plans. This is the start of my fourth week here and I'm just starting to take over (care plans). During an interview on 7/23/18 at 10:12 AM the Director of Social Services stated, the CCP and care plan meeting are due on day 21 (from admission) we had some that got missed, Resident #117 was one of the ones missed. 5. Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident is cognitively intact, understood, and understands. Review of medical record revealed there was no comprehensive Interdiciplinary Care Plan (CCP) developed for Resident #93. During an interview on 7/23/18 at 10:12 AM, the Assistant Director of Nursing (ADON) stated, there is no nurse manager (on the unit) the DON has been doing the care plans. This is the start of my fourth week here and I'm just starting to take over (care plans). During an interview on 7/25/18 at 10:14 AM, the RN MDS Coordinator stated the resident has been re-hospitalized twice since his original admission on 6/7/18, he continued on his previous schedule and should have been care planned the week of the fourth. I have a schedule I send out every time there's a new admit with the dates of when things are due. During an interview on 7/23/18 at 10:12 AM, the Director of Social Services stated, the CCP and care plan meeting are due on day 21 (from admission) we had some that got missed, Resident #93 was one of the ones missed. 6. Resident #92 was admitted to the facility on [DATE] with a subsequent admission date of [DATE]. The resident was admitted with a [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident is cognitively intact, understands and is understood. The Admission Nursing assessment dated [DATE] documented the resident had bruises, staples, open areas and surgical incisions. Additionally, the resident had an open area (surgical wound) to the right groin area which had a white base and measured 5 centimeters (cm) x 1 cm. The residents right great toe was also open and measured was 1 cm x 1 cm. The Interdisciplinary Care Plan dated 7/8/18 documented the resident had impaired skin integrity related to an unstageable heel ulceration. Interventions included to apply skin treatment as per the physician's orders [REDACTED]. There was no documented evidence of an open surgical wound to the right groin or the open area to the right great toe. The physician's orders [REDACTED]. There was also an order [REDACTED]. During an interview on 7/24/18 at 11:26 AM, the DON stated she took over the weekly skin documentation on 6/28/18. The unit manager that worked at the facility prior was responsible for care planning and the weekly skin documentation. She would expect all skin issues to be on the resident care plan. 415.11 (c)1,2(i),3(i)(ii)

Plan of Correction: ApprovedAugust 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 656 Development / Implement Comprehensive Care Plan
Resident #10 remains in facility. Comprehensive care plan was reviewed and remains appropriate. CNA assigned was educated and counseled on use of Pocket Care Plans and resident preference.
Resident #35 remains in the facility. The Comprehensive Care Plan was reviewed and revised as appropriate. Oxygen use was care planned as appropriate. Oxygen use was care planned as appropriate.
Resident #92 remains in the facility. The Comprehensive Care Plan was reviewed on 7/24/2018 by the DON. The Care Plan CAA#16 Arterial/ Venous/[MEDICAL CONDITION] was completed prior on 7/9/2018.
The location of area of impairment to the right great toe was not checked and was corrected at the time of review. Resident is (L) AKA. Goals and interventions were previously completed as appropriate.
Interdisciplinary Care Plan #59 Surgical incision was care planned as appropriate on 7/24/18.
Resident #93 has been discharged from Safire South.
The MDS Coordinator responsible for the MDS / Care Plan Schedule has resigned from the facility.
Resident #117 remains at this facility. The Resident's medical record and Comprehensive Care Plan date of 7/24/2018 CAA #29 Elopement prior unit / facility was noted in resident record as appropriate.
Goals as follows: Safety and well-being will be maintained.
Interventions as follows: Assess and apply wander-guard as appropriate.
Orient to the environment
Orient to the call bell system
Introduce care givers by name to resident
Offer reassurance to the resident about placement
Explain out on pass system to the resident and that we will work together to set up an acceptable plan with the resident if she is capable.
Post a picture of the resident at the front desk.
Wander-guard left wrist issued 7/11/18 was added 8/20/2018.
Resident #113 remains at this facility. Resident record was reviewed by the IDT 8/22/18 and revised as necessary / appropriate.
Staff responsible for deficient practice will be counseled and educated as appropriate.
When staffing is at a minimal level, the nurse will assist Certified Nursing Assistants (CNAs) with assisting resident pout of bed per his preference in the morning, as well as assist him back to bed in the evening per his preference.
The Nursing Supervisor/Nurse Manager will ensure that resident's preferences are respected daily and on-going.
A 100% audit will be completed on all residents currently residing at Safire South to ensure timely completion of comprehensive care plans as well as accuracy.
The IDT team will be educated on timeliness, completion and accuracy of resident comprehensive care plans.
Random audits of comprehensive /pocket care plans, 5 from the care plan schedule, will be done weekly by the DON/ADON to identify deficient practice.
The results of the audit will be reported to the QA&A meeting
monthly.
DON will analyze and trend data.
Person responsible will be the Director of Nursing (DON)

FF11 483.21(c)(2)(i)-(iv):DISCHARGE SUMMARY

REGULATION: §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: November 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an Standard Survey completed on 7/26/18, the facility did not ensure completion of the discharge summary to included but not limited to a recapitulation of the residents stay and any arrangements that have been made for the resident's follow up care and post-discharge medical and non-medical services for one (Resident #103) of two residents reviewed for discharges. Specifically, the resident was discharged to home without a recapulation of the resident's stay, a final summary of the resident's status or a post discharge plan of care. Additionally, there was no physician's order to discharge. The findings is: 1. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/4/18 revealed the resident is usually understood, sometimes understands and is severely cognitively impaired. Further review of the MDS revealed the resident required extensive assist of two staff members for ambulation, transfers and bed mobility. Review of the Interdisciplinary Care Plan dated 7/6/18 revealed the resident was anticipating discharge to the community. Interventions included to inform resident/ designated representative of resident's progress and readiness for discharge and educate resident and/ or support person as needed. Review of the Nursing Progress Notes the last documented entry of 7/15/18 revealed there was no documented evidence the resident was discharged to home, the physician was notified, or a physician's order was obtained for discharge. Review of the Social Progress Notes dated 7/17/18 revealed the social worker met with the resident's representative to review the resident's progress in therapy and plan of care. The Social Progress Note documented a discharge date of [DATE] was put in place. Review of the Social Progress Notes dated 7/19/18 revealed the resident was discharged to home today 7/19/18 via representative's car. All discharge procedures were completed, and a discharge transfer form was provided. Review of the Physicians Order Form dated as of 7/24/18 revealed there was no documented evidence a physician's order was obtained for the resident to be discharged to home. Review of the Discharge Instruction form dated 7/18/18 revealed the resident's current activities of daily living (ADL) status and diagnosis. There were no recommendations from the physician, and documents given upon discharge included a Discharge Instruction Medication form. There was no documented evidence of a recapulation of the resident's stay, a final summary of the resident's status, or a post discharge plan of care. Review of the Discharge Instructions Interdisciplinary Care Needs form dated 7/19/18 revealed the resident's current ADL status, nursing recommendations to include to take medications as ordered and to follow up with the primary care physician and recommendations from dietary. There were no recommendations from the physician and there was no documented evidence of a recapitulation of the resident's stay, a final summary of the resident's status, or a post discharge plan of care. Review of the Physician Discharge Summary undated revealed there was no documented evidence the physician completed the form. The form was blank except for the resident's name, physician's name, date of discharge and discharge destination. During an interview on 7/23/18 at 9:47 AM, the Medical Director stated he did not see the resident prior to discharge. He thought the facility notified him of the discharge and an order should have been written for the resident to be discharged to home. During an interview on 7/24/18 at 11:37 PM, the Director of Nursing (DON) stated she would expect the physician to be notified if a resident was going to be discharged and a physician's ordered obtained. The DON reviewed the physician's orders in the electronic medical record and stated there was no physician's order for the resident to be discharged . During an interview on 7/24/18 at 12:54 PM, the Director of Social Service revealed she was responsible for the resident discharge process, each discipline writes their part on the discharge instruction form, it is review with the resident and/or representative and a copy is sent with them. She was unaware that a recapitulation of the resident's stay, a final discharge summary of the resident's status was required. 415.11(d)(1)(2)Based on interview and record review conducted during the Offsite Post Survey Revisit #1 conducted 10/26/18 through 11/9/18, the facility did not ensure the approved Plan of Correction (P(NAME)) for F661 - Discharge Summary cited during the 7/26/18 Standard Survey was fully implemented. The finding is: 1. Review of the Statement of Deficiencies Form - CMS 2567 from the Standard Survey completed 7/26/18 revealed the facility did not ensure that a recapitulation of the resident's stay, a final summary of the resident's status or a post discharge plan of care was completed for one (Resident #103) of two residents reviewed for discharges. Review of the facility's Plan of Correction (P(NAME)) for F 661, approved on 9/11/18 with a compliance date of 9/24/18, revealed the physician will complete the Resident's Discharge Summary with documented evidence of a recapitulation of the resident's stay, a summary of the resident's status and post discharge plan of care. Review of a Department of Health (DOH) email sent to the Administrator dated 10/22/18 revealed the facility was requested to submit supporting documentation verifying that the facility's P(NAME) was implemented. The supporting documentation was to be submitted to the DOH by the close of business on 10/24/18. The email also documented instructions to include the steps taken to alleviate the deficient practice for the resident cited. Review of the submitted documents (provided by the facility as requested on 10/22/18) for F661 on 10/26/18 revealed there was no documented evidence to support that the physician completed the resident's discharge summary. There was no documented evidence of a recapitulation of the resident's stay, a summary of the resident's status and a post discharge plan of care. Review of a Department of Health (DOH) email sent to the Administrator dated 10/31/18 revealed a second request for the facility to send the physician's discharge summary with documented evidence of a recapitulation of the resident's stay, a summary of the resident's status and a post discharge plan of care. A Department of Health (DOH) email sent to the Administrator dated 11/5/18 revealed a third request to send the physician's discharge summary with documented evidence of a recapitulation of the resident's stay, a summary of the resident's status and a post discharge plan of care Review of emails sent from the Administrator the facility on 11/5/18 at 12:19 PM and 11/7/18 at 4:13 PM revealed that despite the facility's attempts to contact the physician to obtain the discharge summary, the facility was unsuccessful. During a telephone interview on 11/8/18 at 1:52 PM, the Administrator stated that despite multiple attempts to contact the physician they were unable to obtain the discharge summary for the resident as per the Plan of Correction. 415.11(d)(1-3)

Plan of Correction: ApprovedNovember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 661
Resident #103 no longer resides at Safire South.
All residents of Safire South have the potential to be affected by the same deficient practice.
A 100% audit with a 90 day look back period will be conducted of all residents with a planned discharge from the Facility to identify the deficient practice.
The Facility Discharge Packet was reviewed and revised to accommodate the need for a more comprehensive discharge review to be documented by the Interdisciplinary Team (IDT).
In-servicing will be completed with the IDT team.
The physician will complete the Resident's Discharge Summary
with documented evidence of a recapitulation of the resident's stay, a summary of the resident's status and post discharge plan of care.
The IDT will complete a comprehensive recapitulation of the resident's stay, status and post discharge plan of care.
A New Medical Director will be appointed as of (MONTH) 1, (YEAR). Also a physician has been designated exclusively for Sub Acute Rehab(SAR).
A printed copy of the physician order [REDACTED].
An audit of those resident records discharged home, to another facility or to the hospital will be completed by the Assistant Director of Nursing (ADON) weekly, with results being reported to the QA&A committee meetings.
The DON will analyze and trend data.
Person responsible will be the Director of Nursing (DON)

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: October 22, 2018

Citation Details

Based on observation and interview, during the Standard survey completed on 7/26/18, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included, roof top air handlers were broken, out of service, and not maintained to provide the required pressure relationships and ventilation for all areas of the building and a back-up boiler was broken, out of service, and not maintained as needed to supply services in case the main boiler broke down or was needed to be taken out of service for routine maintenance. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The findings are: 1. Observations in the Basement boiler room, on 7/17/18 at 1:06 PM, revealed one of the panel doors on the back-up boiler had been removed and a crack/hole was visible in an interior section of the boiler. During an interview at the time of this observation, the Regional Chief Engineer and the Maintenance Director stated, the back-up boiler was taken out of service during (MONTH) of (YEAR) because water was leaking out of the crack/hole in the boiler. The Regional Chief Engineer and the Maintenance Director further stated, the corporation that owned the facility had not fixed the boiler because it had not decided if it was going to make repairs or replace the boiler. 2. Intermittent observations from 7/17/18 through 7/20/18 revealed: strong odors of urine in the area between the Atrium and the Blue Unit's Nurses station, stale musty odors in the shower/bath rooms on the Blue, Green, and Yellow Units, and strong urine and fecal odors in the soiled utility rooms located in the shower/bath rooms on the Blue, Green, and Yellow Units. Observations on 7/17/18 at 3:03 PM, revealed the facility had two roof-top air handling units on the first-story roof top and two roof-top air handling units on the second-story roof top. During an interview at the time of the observations, the Regional Chief Engineer and the Maintenance Director stated, the four roof-top air handling units had been broken and out of service for at least two years. The Regional Chief Engineer and the Maintenance Director further stated, the roof top air handling units were supposed to supply tempered fresh air into the building, but since they were not working the facility had been opening windows throughout the year to supply the building with fresh air. During an interview on 7/24/18 at 3:45 PM the Administrator stated, she had no further information regarding the roof-top air handling units or the back-up boiler. 415.29(b) 415.29(h)(1)(2) 10 NYCRR 713-2.21(c)(1) 10 NYCRR 713-2.21(d)(2)(ii)

Plan of Correction: ApprovedSeptember 24, 2018

The corrective action for the Facility was to identify the deficient practice that would include all residents residing in the facility.
The facility was aware the boiler was in need of repair , however the second boiler was brand new and had just been replaced . The facility was unaware that the two boilers needed to be in full working order .
The corrective action for the the odors between the atrium and the blue nurses station, stale musty odors in the shower and bathrooms on the blue and yellow units and strong fecal odors in the soiled utility rooms.
The corrective action will also apply to the green shower / bath area .
A local company was immediately contracted to review and estimate the needed repairs for the roof top units . A contract was signed with the company to begin repair and replacement of roof top units and boiler repairs .
Monitoring of the work will continue until completion.Replacement will begin once the parts have been received .
The project will be reviewed Monthly by the QA and A committee .

Responsible person : 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: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during the Standard survey completed on 7/26/18, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents as possible for one (Resident #13) of four residents reviewed for accidents. Specifically, the resident was not provided with a smoking apron as planned resulting in a smoking accident. The findings is: The Smoking Policy for Residents dated 11/9/16 documented any smoking-related privileges, restrictions and concerns (for example, need for close monitoring) shall be noted on the care plan and the CNA (certified nurse aide) care card to ensure all personnel caring for the resident shall be alerted to the issues. Residents will be care planned in accordance with identified leisure of smoking, supervision required and as indicated in the smoking evaluation. Residents will be care planned for any smoking equipment deemed necessary for safe smoking (i.e., smoking apron, cigarette holder/extenders). Smoking articles for residents without independent smoking privileges may not have or keep any types of smoking articles including cigarettes except when they are under direct supervision. All residents requiring supervision will be supervised by designated staff at all times while ensuring the care plan is followed. A list identifying residents with smoking privileges and required level of supervision and care plan interventions will be distributed to all units and separately maintained by Social Services. Social Services will ensure smoking lists are updated whenever a new resident is admitted or level of supervision and or care plan interventions are implemented. 1. Resident #13 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 7/17/18 revealed the resident was usually understood and understands. The resident's BIM (Brief Interview for Mental Status) score was documeted as zero (0) indicating severe cognitive impairement. The resident required extensive assistnce from staff for dressing and personal hygeine. An Accident and Incident Report dated 6/11/18 at 2:00 PM documented the Director of Nursing (DON) heard the Activities Aide yelling she is on fire. There was a burning smell along with light smoke coming from the Geri-chair. The LPN Charge Nurse dumped a pitcher of water on the resident's torso/waist and upper thighs. A body assessment was completed by Registered Nurse Manager and there were no injuries. The summary of investigation concluded the resident was brought down to smoke without her smoking apron. The investigation documented the care plan was not followed. The untitled document dated 6/10/18 and identified as a certified nurse aide care guide documented the resident was to utilize a smoking apron. The Safe Smoking Assessment Tool completed by Social Workers documented the following: - 5/31/18 The resident is alert and oriented, agitated easily, hands shake and tremble, tactile sensation present, does not light own cigarette safely and is likely to drop smoking material. The resident was to have supervision. - 6/6/18 The resident was confused and had impaired judgement. Her hands shake and tremble, does not light own cigarette safely, does not hold own cigarette safely,[MEDICAL CONDITION] on fingers or clothes, is likely to drop smoking material. The resident was to have supervision and required a smoking apron. Interview with the Activities Director on 7/26/18 at 8:00 AM revealed the Activities Aide takes smokers out at designated times or the CNA's. She stated usually the smokers are lined up near the Activities Office waiting to go out. However, Resident #13 was in a Geri-chair and the activities aide would go to the unit and get her. The Nurse was responsible for supplying the cigarettes and smoking apron before the resident left the unit. Interview with the Activities Aide on 7/26/18 at 8:05 AM revealed that she transported the resident to smoke on 6/11/18 and she was not aware the resident needed a smoking apron until after the incident on 6/10/18. She stated the nurse was responsible for providing the apron and cigarette for the resident before leaving the unit. There was no smoking apron provided to her before she left the unit that day. She stated the resident was shaky but did hold her own cigarette. When she brought the resident back into the facility, she smelled smoke. She looked down at the resident and saw smoke coming from a tissue on the resident's lap. She reported staff responded immediately and put the fire out. The resident was not injured. She stated she was not the only staff assigned to take residents out to smoke. When the activities department was not there, CNA's took the residents out. Interview with the Director of Nursing (DON) on 7/25/18 at 12:00 PM revealed the resident was issued a smoking apron due to her decline in status and her insistence to smoke. She stated the resident used to ambulate out to smoke but was now using a Geri-chair. The resident should have had a smoking apron on 6/10/18. A nurse would have provided a cigarette and the smoking apron before the resident left the unit. She stated when she brought the resident back to the unit to fully assess her, the smoking apron was observed on the medication cart. 415.12(h)(1)

Plan of Correction: ApprovedAugust 24, 2018

F689 Free of Accident Hazards/Supervision Devices
The facility must ensure that the resident environment remains as free of accidents hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents.
Resident #13 remains at Safire South. Residents medical record was reviewed for further deficient practice.
Any current smokers that reside at Safire South have the potential to be affected by the same deficient practice.
The medical records of all current smokers residing at Safire South will be reviewed for deficient practice.
The RN Manager who brought the resident down to smoke was educated / counseled on the resident specific care needs. She no longer works at this facility.
The list of current smokers will be updated to include a column for assistive / safety devices. Social Work / Nursing will be responsible for information on this form. A copy will be supplied to Activities Department as appropriate.
A random audit will be completed weekly by the Nurse Manager of all Safire South residents who smoke to ensure all safety/assistive devices are in place as per care plan.
The DON will analyze and trend data.The results of the audit will be reported to the QA&A monthly.

Person responsible for compliance: Director of Nursing (DON)

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on interview and record review during a Standard survey completed on 7/26/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not activate their Legionella water sampling plan per state regulations. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The finding is: During an interview on 7/19/18 at 10:05 AM, the Regional Chief Engineer and the Maintenance Director stated, they were not aware of the Legionella regulations until a representative for the corporation that owned the facility informed them during (MONTH) of (YEAR). During an interview on 7/19/18 at 10:27 AM, the Administrator stated the assessment of the facility's water systems and the sampling for Legionella was not started until (MONTH) of (YEAR) because she had started working at the facility during (MONTH) of (YEAR) and she was trying to catch-up with all the regulation changes. The Administrator further stated she was not aware of the Legionella regulations until a representative for the corporation that owned the facility informed her during (MONTH) of (YEAR). Record review of the facility policy, Protection Against Legionella, issue date 9/16/16, revealed the facility would perform an environmental assessment of the facility no later than 9/1/16. Further review of the policy revealed the facility would implement a sampling and management plan for their potable water system by 12/1/16 and the sampling and management plan must be reviewed and updated annually. Record review of the facility policy, Identify and/ or Prevent Nosocomial Legionnaires Disease, issue date 11/2017, revealed: The facility will adhere to all necessary maintenance and operational requirements of the water system and comply with all applicable regulations. The facility would conduct surveillance on the potable water system by sampling for Legionella quarterly for the year, then annually and as needed thereafter. Record review of the facility's Legionella documents revealed a New York State Department of Health Environmental Assessment of Water Systems in Healthcare Settings (Form DOH-5222) dated 2/13/18. Record review of the facility's documentation for water sample collection and analyzation for Legionella, revealed water samples were collected on 5/11/18 and analyzed on 5/23/18. According to the New York State Department of Health's Health Advisory called, Regulation for the Protection Against Legionella dated 8/12/16, Part 4 of the New York State Sanitary Code Protection Against Legionella, became effective on (MONTH) 6, (YEAR). Subpart 4-2 of the regulations require all general hospitals and residential health care facilities to adopt and implement a Legionella culture sampling and management plan for their potable water systems by (MONTH) 1, (YEAR). It further states the plan shall include a schedule to conduct routine Legionella culture sampling and analysis at intervals not to exceed 90 days in the first year and annually thereafter. 415.19(a)(1) 10 NYCRR Subpart 4-2.4

Plan of Correction: ApprovedAugust 24, 2018

1210 Infection Control
The Regional Engineer had secured a laboratory to conduct testing on 05/11/2018 which will be conducted quarterly and annually thereafter.
The Legionella policy was reviewed by the Administrator and the Corporate Director of Nursing and no revision was needed.
All residents who have the potential to be affected by the same deficient practice, no residents have been affected at this time.
Any/ all issues/ testing will be reviewed at the monthly QA &A meeting.

Responsible Person: Maintenance Director

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on interview and record review during a Standard survey completed on 7/26/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not implement water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The findings are: Review of the facility policy entitled Protection Against Legionella, dated 9/16/16 revealed the facility would perform an environmental assessment of the facility no later than 9/1/16. Further review of the policy revealed the facility would implement a sampling and management plan for their potable water system by 12/1/16 and the sampling and management plan must be reviewed and updated annually. Review of the facility policy entitled Identify and/ or Prevent Nosocomial Legionnaires Disease, dated 11/2017 revealed the facility will adhere to all necessary maintenance and operational requirements of the water system and comply with all applicable regulations. The facility would conduct surveillance on the potable water system by sampling for Legionella quarterly for the year, then annually and as needed thereafter. 1. During an interview on 7/19/18 at approximately 10:05 AM, the Regional Chief Engineer and the Maintenance Director stated, they were not aware of the Legionella regulations until a representative for the corporation that owned the facility informed them in (MONTH) of (YEAR). During an interview on 7/19/18 at approximately 10:27 AM, the Administrator stated the assessment of the facility's water systems and the sampling for Legionella was not started until (MONTH) of (YEAR) because she had started working at the facility in (MONTH) of (YEAR) and she was trying to catch-up with all the regulation changes. The Administrator further stated she was not aware of the Legionella regulations until a representative for the corporation that owned the facility informed her in (MONTH) of (YEAR). Record review of the facility's Legionella documents revealed it contained a New York State Department of Health Environmental Assessment of Water Systems in Healthcare Settings (Form DOH-5222) dated 2/13/18. Record review of the facility's documentation for the water sample collection and analyzation for Legionella revealed water samples were collected on 5/11/18 and analyzed on 5/23/18. Review of the Centers for Medicare & Medicaid Services Survey and Certification Letter S & C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 revised 6/9/17 with an effective date of Immediately revealed: Healthcare facilities must implement a water management program that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. 415.19(a)(1) 10 NYCRR Subpart 4-2.4

Plan of Correction: ApprovedAugust 24, 2018

F 880 Infection Prevention & Control
The corrective actions that will be accomplished for those residents found to have been affected by the deficient practice:
The Legionella testing was conducted on 05/11/2018.
The facility will conduct quarterly testing x 1 year and yearly thereafter.
The policies and procedures were reviewed and no revision was necessary.
All residents have the potential to be affected by the deficient practice.
No residents have been affected by this deficient practice.
The legionella testing will be completed quarterly x 1 year and yearly thereafter.
Any/ all issues/ testing will be reviewed at the monthly QA &A meetings.
Responsible Person: Administrator

FF11 483.80(d)(1)(2):INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

REGULATION: §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that- (i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Standard survey completed on 7/26/18, it was determined that for three (Resident #46, 83, 219) of five residents reviewed for immunizations, the facility did not provide documentation that the resident received the influenza (flu) and/or pneumococcal (pneumonia) immunizations or documentation regarding medical contraindication or refusal of immunizations. The findings are: The facility's policy entitled Immunization: Pneumococcal Vaccination (PPV) of Residents dated 2/1/17 documented all residents in the facility should receive the pneumococcal vaccination if they are [AGE] years of age or older or under [AGE] years old with underlying conditions. Each resident's pneumococcal immunization status will be determined upon admission of soon afterward and documented in the resident's medical record. The facility's policy entitled Immunization: Influenza (Flu) Prevention and Disease Transmission dated 10/25/16 documented the facility will follow guidelines set for the by the Centers for Disease Control and Prevention (CDC) Review of the Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, (YEAR) - (YEAR) available at https://www.cdc.gov/flu/professionals/acip/2017-18summary.htm. recommended routine annual influenza vaccinations for persons older than six months with emphasis of high risk groups including residents of nursing homes and other long-term care facilities. 1. Resident #46 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/6/18 revealed the resident has severe cognitive impairment. review of the resident's medical record revealed [REDACTED]. During an interview on 7/24/18 at 8:28 AM, Licensed Practical Nurse (LPN #4), Unit Manager stated there was no information in the resident's medical record regarding her pneumococcal vaccination status. 2. Resident #83 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. Review of the resident's medical record on 7/25/18 revealed there was no vaccination information available about the influenza vaccine for (YEAR) - (YEAR) or the pneumococcal vaccination. The source documents were blank. During an interview 7/25/18 at 9:58 AM, LPN #4 stated she could locate the vaccination information in the resident's medical record. 3. Resident #219 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment. Review of the resident's medical record on 7/25/18 revealed there was no vaccination information available about the influenza vaccine for (YEAR) - (YEAR) or the pneumococcal vaccination. The source documents were blank. During interview on 7/25/18 at 3:10 PM, the Director of Medical Records stated the source documents are to be completed by the admitting nurse on the day of admission. However, to complete the document it may take longer if family or physician contact was required. Complete vaccination documentation was expected within 30 days. 415.19(a)(1)

Plan of Correction: ApprovedAugust 24, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents #46 and #83 remains at Safire South in stable condition.
Resident # 219 was discharged from Safire South in stable condition.
All residents have the potential to be affected by the same deficient practice.
A 100% audit will be completed to identify any further deficient practice.
Resident # 46 immunization records were requested from residents Primary Care Physician - Dr.(NAME)(NAME) on 7/24/2018.The information was provided to the facility on [DATE].The information was provided to the DOH survey team on 7/24/2018 by thew unit clerk and also forwarded via fax on 7/26/18 @ 3 :30 pm.
Resident # 83 immunization status was discussed via phone with responsible party by the LPN manager.
The responsible party stated that they were declining the immunization for their loved one.
The nurse responsible for admissions will be educated on the Immunization Policy and Procedures.
The RN unit Manager employed at the facility at the time the residents # 46,83 and 219were at the facility is no longer employed.
The LPN unit Manager will be educated on the importance of reconciling the immunization /consent status of any resident that is moved to their unit.
An audit will be conducted by the nurse managers not more than five days after their admission to the facility or moved to another unit.Any deficient practice will be corrected immediately.
Upon completion of the residents first MDS assessment - The MDS coordinator will forward in an e mail the names of those residents missing immunization information.
All licensed nurses will be educated on the Immunization Policy and Procedure
A Random audit of 3 residents records per week will be completed by nurse managers /ADON to monitor for completion of immunization information.
The DON will analyze and trend data.
The results of the audit will be brought to the monthly QA and A meeting.
Responsible Person : ADON




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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Complaint investigation (Complaints #NY 345 and #NY 858) conducted during a Standard survey completed on 7/26/18, the facility did not have evidence that all alleged violations of abuse, neglect were thoroughly investigated for two (Residents #31, 219) of two residents reviewed. Specifically, the facility did not investigate an alleged violation of mistreatment/ abuse, and did not investigate a bruise of unknown origin (Resident #31). Additionally, the lack of an investigation when a resident was found kneeling on the floor next to the bed (Resident #219). The findings are: The policy and procedure entitled Identification and Initiation of Investigation dated 11/9/16 documented all reports of resident abuse, neglect and injuries of unknown source shall be promptly thoroughly investigated by the facility management. Additionally, the Director of Nursing (DON)/ investigator will give a copy of the completed documentation to the Administrator within five working days of the reported incident. 1. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 6/3/18 documented the resident is moderately cogitatively impaired, understood, understands. The Interdisciplinary Care Plan dated 2/7/18 documented the resident required two assist with a mechanical lift for transfers, was non- ambulatory and preferred to stay in her room most of the time. a.) During an observation on 7/17/18 at 2:20 PM revealed the resident's call light was missing the button to activate the call light and the call light was nonfunctional. During an interview with the resident and the HCP with the ADON (Assistant Director of Nursing) present on 7/17/18 at 2:20 PM, the HCP stated, the resident put on her call light to go to the bathroom last night and the aide took her call bell and threw it on the floor and broke it and pulled her phone out of the wall and closed her door. The resident could not recall the aides name. Review of a hand-written statement by the ADON dated 7/18/18 revealed the resident's call bell was broken by nurse's aide the previous evening when the nurse's aide was in the room to provide care, the ADON was informed the aide threw it on the ground and the red push button broke. The hand-written statement also documented the social worker was notified and would follow up with the resident and the DON was notified. During an interview on 7/25/18 at 9:50 AM, the Director of Social Service stated she went to see the resident on 7/17/18 the day the ADON reported the alleged incident to her and the resident had no complaints. Additionally, she stated if a resident complained about an aide she would expect nursing to investigate the allegation. During an interview on 7/25/18 at 11:13 AM, the DON stated she was aware of the broken call light and it was replaced. She did not see the ADON's hand written statement and was unaware of the resident's complaint about the aide. The DON also stated she would expect the ADON to report the complaint to her, and that she would look into the complaint now. During an interview on 7/25/18 at 1:55 PM, the Administrator stated she was aware of the broken call light but not aware of the resident's complaints about the aide. She would speak to the ADON and look into the complaint at this time. Review of the New York State Department of Health (NYS DOH) Nursing Home Incident Reporting Manual dated 8/2016 revealed Federal and State regulations require the facility to report alleged violations of mistreatment, neglect and abuse including injuries of unknown origin and misappropriation of resident property, immediately to the administrator of the facility and to other officials in accordance with state law. Per Centers of Medicare and Medicaid Services (CMS) immediately means as soon as possible, but not to exceed 24 hours. The results of the investigation must be reported to the facility administrator and the NYS DOH, if required within 5 working days of the incident. b.) Review of the Resident/ Visitor Accident and Incident Report (A&I) dated 3/26/18 revealed when giving the resident a shower the resident kicked the doorway and cut her left great toe. Further review of the A&I revealed the shower chair was too wide for the door, so the aide turned the chair sideways so that it would fit, and the resident stuck her foot out hitting her toe on the door way. There was no documented evidence of any bruising to the resident's left foot. The Nursing Progress Notes dated 3/26/18 documented the resident kicked the door frame while getting a shower, resulting in a laceration to her left great toe. The responsible party and the MD (medical doctor) were notified. The toe was cleansed, and a band aid was applied. The Nursing Progress Notes dated 4/5/18 timed 7:00 AM to 7:00 PM documented upon a skin check the resident was noted to have bruising to the top of her left foot with old bruising noted. The band aide was removed from her toe and the area was healed. An interview on 7/17/18 at 2:25 PM with the resident and the health care proxy (HCP) revealed a few months ago the aide was giving the resident a shower. When the aide was pushing her out of the shower room, the chair wouldn't fit, and the door closed on her foot before they could get her out of the room. The interview further revealed she wanted an x-ray taken because the residents foot was black and blue and painful. Review of the Daily Unit Reports from 3/26/18 through 4/9/18 revealed there was no documented evidence of bruising to the residents left foot. Further review of the Daily Unit Report dated 4/10/18 revealed the x-ray was negative. Review of an x-ray report dated 4/9/18 revealed there was no acute [MEDICAL CONDITION] foot. During an interview on 7/25/18 at 1:55 PM, the Director of Nursing (DON) revealed she was unaware of the bruising to the resident's left foot noted on 4/5/18. The former unit manager that was at work at the facility did not inform her. She remembered the resident requiring an x-ray and was unsure if it was related to the incident on 3/26/18. The DON stated there was no documented A&I or investigation completed. During an interview on 7/25/18 at 2:19 PM, the Licensed Practical Nurse (LPN #3) stated she recalled finding the bruise on the resident's left foot during a weekly skin check. She was unaware of how the bruise happened and she reported it to the unit manager at the time. 2. Resident #219 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident has moderate cognitive impairment. The MDS documented there were no falls since admission, and required limited assist of one staff member for bed mobility, transfers and toileting needs. The undated Daily Unit Report documented the resident was admitted to the facility at 5:30 PM. The Fall Risk Assessment Tool dated 4/4/18 documented the resident was at moderate risk for a fall. The Baseline Care Plan dated 4/5/18 documented the resident required assistance of one staff member for bed mobility, transfers and ambulation. The Physical Therapy Evaluation dated 4/6/18 documented nursing recommendations as the resident was to transfer and ambulate with contact guard assist of one staff member. The Nursing Progress Notes dated 4/4/18 untimed documented the resident was found at the end of the shift on her knees by the side of the bed. The resident stated she was praying and could not back up. Review of the facility Resident/ Visitor Accident and Incident reports from 4/4/18 through 7/22/18 revealed there was no investigation into the resident being found on her knees on 4/4/18. During interview on 7/25/18 at 11:07 AM the Licensed Practical Nurse (LPN #5) stated upon entering the resident's room the resident was kneeling on the floor next to the bed and stated it took three staff members to assist in getting her up off her knees. LPN #5 then stated he did not fill out an Accident and Incident report because the resident said she was praying. During interview on 7/25/18 at 11:30 AM, the DON (Director of Nurses) stated, the RN (Registered Nurse) Supervisor should have been notified, an RN assessment conducted, an investigation initiated. Intervention to avoid reoccurrence would be put into place and recorded on the care plan. In addition, the DON stated falls are monitored on the 24-hour report (Daily Unit Report) for three days. During interview on 7/26/18 at 10:33 AM the Administrator stated she was unaware the resident was found on her knees. The Administrator then stated when a fall was suspected an investigation should be started and documented in the resident medical record. In addition, the RN Supervisor was to be notified and the resident would be placed on the 24-hour report. The physician and the family would be notified. Typically, interventions would be implemented, and the care plan would be updated to prevent re-occurrence. 415.4(b)(2) (3)(4)

Plan of Correction: ApprovedSeptember 4, 2018

F 610 Investigate/ Prevent/ Correct Alleged Violation
The facility will ensure that it fully implements the investigation component of the Abuse Prevention Protocol and thoroughly investigate all injuries of unknown origin. Also, any incident that is not a normal occurrence will be investigated as above.
Resident #219 no longer resides at Safire South. Resident with a MMSE 24/30 was discharged home, after successful completion of sub acute rehabilitation. During resident stay there were no further occurrences upon review of resident record. the resident record was reviewed and a complete investigation of the bruise was completed with no negative findings
Resident #31 still resides at Safire South in stable condition. The medical record of resident #31 was reviewed. Documentation was noted 7/17/18 at 8:43pm and at 8:57pm. resident did not have any recollection to staff of any incident.
Resident was noted to be receiving Aspirin therapy which would potentiate the likelihood of bruising and bleeding under the skin from a simple injury
Resident was interviewed and denies abuse, neglect or mistreatment. She denied being fearful.
Residents Comprehensive Care Plan was reviewed and revised as necessary.
All residents who reside at Safire South have the potential to be affected by the same deficient practice.
The DON and Administrator will conduct a 100% audit with a 90 day look back for resident accident/incident to ensure they were investigated thoroughly and statements of other individuals that may have witnessed the occurrence were obtained, statements of employees that cared for the resident for the last 72 hours in the case of injury of unknown origin were obtained, care plan interventions were immediately implemented as appropriate.
Policies were reviewed as follows:
1. Abuse, Neglect, Exploitation, Injury of Unknown Origin and Misappropriation of Resident Property Prevention/Prohibition dated 11/20/2017.
2. Identification and Initiation of an Investigation including Accidents/Incidents and Abuse Allegations dated 11/9/2016.
3. Investigation Guide on How to Conduct a through Investigation dated 11/9/2016.
4. Abuse, Neglect Clinical Protocol dated 11/20/2017.
They remain appropriate with no revision needed.
* The licensed nurse who noted resident on her knees praying no longer works here.
All Accidents & Incident Reports as well as corresponding resident records will be brought to morning meeting Monday thru Friday for review and completion as needed.
Residents who have experienced an Accident or Incident will have a Body Evaluation completed for three days post incident to evaluate for any evolution/ development of injuries. This will be documented accordingly in the resident record.
An audit will be conducted by the ADON/DON weekly of all Accident & Incident Reports to ensure a complete investigation as warranted.
Audit Results will be brought to QA meeting. DON will analyze and trend data.
The Regional RN Educator will In-service the Administrator, DON, Licensed Nursing Staff, Interdisciplinary Team and Clinical Staff on the Policy and Procedures entitled Abuse Neglect, Mistreatment, Exploitation, Injuries of Unknown Origin and Misappropriation Prevention Prohibition Program dated 11/20/2017.
Responsible person will be the Director of Nursing (DON)

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 minimal harm
Citation date: July 26, 2018
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 7/26/18, the facility did not ensure that before a facility transfers or discharges a resident, the facility must 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. Specifically, one (Resident #120) of five residents reviewed for admission, transfer, discharge notice requirements did not have a copy of the discharge notice sent to a representative of the State Long-Term Care Ombudsman. The finding is: Review of facility policy and procedure entitled Transfer or Discharge Notice dated 11/1/17 revealed the facility shall provide a resident and/ or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Additionally, a copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. 1. Resident #120 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/12/18 revealed the resident had severe cognitive impairments, understands and was understood. Review of the Nursing Progress Notes dated 6/14/18 revealed the resident was transferred to the hospital via ambulance at 11:40 PM. Review of the Nursing Progress Notes dated 6/15/18 included the resident was admitted to the hospital with [REDACTED]. Review of the MDS accepted into the database included a Discharge Return Not Anticipated dated 6/14/18. Review of the entire medical record revealed no documented evidence that a copy of the Discharge Notice dated 6/14/18 was sent to the Office of the State Long-Term Care Ombudsman. During an interview on 7/26/18 at 11:07 AM the Director of Social Services stated, I've talked to the Ombudsman's office and she (Ombudsman) said they don't want a copy of the notice. The notices are available in the chart if needed. During an interview on 7/26/18 at 11:09 AM the Ombudsman stated, We are not receiving the discharge notices from this nursing home. We give the nursing homes three options: fax, mail, or email. 415.3(h)(1)(iii)(a-c)

Plan of Correction: ApprovedAugust 21, 2018

A plan of correction is not required for deficiencies at scope and severity level A. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Please submit this information to the Department to acknowledge this message.
F 623
Resident #120 is no longer at the facility.
All residents of Safire South have the potential to be affected by deficient practice.
A 100% audit with a 90 day look back of all discharges will be completed by social work to identify any further deficient practice.
The Transfer/Discharge Policy dated 11/1/17 was reviewed and no revision was needed.
The social workers were counseled and educated on the above policy and procedure.
At discharge, Notices will be emailed to the Office of the State Long Term Care Ombudsman weekly. A copy of the email correspondence will be kept in the Social Work Department.
An audit will be completed weekly by Medical Records of every resident discharged from the facility. Audits will be done for a period of at least three months with all results being reported to the QA&A meeting. The Director of Nursing (DON) will analyze and trend data.

Person responsible will be the Administrator.

FF11 483.45(a)(b)(1)-(3):PHARMACY SRVCS/PROCEDURES/PHARMACIST/RECORDS

REGULATION: §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: November 30, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/18, the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; determine that drug records are in order; and that an account of all controlled drugs is maintained and periodically reconciled. Four (Director of Nursing's office, Nursing Supervisors office, Green Unit) of six narcotic cabinets observed for discontinued controlled substances had issues. Specifically, the lack of control and accountability of controlled drugs upon delivery to the facility and when discontinued drugs were surrendered and awaiting final disposition. In addition on the Green Unit there were two liquid medications with an unidentifiable liquid. The findings are: Review of a facility policy and procedure entitled Storage of Medications dated 12/17 revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Review of a facility policy and procedure entitled Inventory Control of Drugs (point of entry/ exit) dated 7/17 revealed the Nursing Supervisor will log the following information into the Inventory/ Narcotic Destruction Log whenever a controlled substance is received. The unit nurse surrendering the controlled substance will count off narcotics with the DON (Director of Nursing) and witnessed by the ADON (Assistant Director of Nursing) or Consultant Pharmacist. All personnel will sign the individual pharmacy control sheet and Inventory Narcotic Destruction Log verifying the count for the narcotic medications surrendered for destruction. The DON/ ADON and Consultant Pharmacist (2 personnel) receiving the controlled substance from the unit nurse will immediately enter the narcotic into the electronic narcotic destruction DEA (Drug Enforcement Administration) inventory form as outlined in controlled substance on site destruction policy. Review of a policy and procedure entitled Medication Disposal/ Destruction dated 9/17 revealed the facility will adhere to all federal, state, and local regulations related to medication destruction/ disposal when discarding any medication and medical waste. 1. Observation on 7/18/18 at 8:47 AM revealed there were two locked cabinets secured to the walls in a small bathroom located in the DON's office. Upon request of the surveyor, the cabinets were opened by the DON. The cabinets were completely filled with discontinued controlled drugs. The medication-controlled substance count sheets (untitled) were attached to each medication with a rubber band. The controlled substance count sheets revealed the sheets were dated from (YEAR) through 7/2018. Observation on 7/18/18 at 9:31 AM revealed there was one locked cabinet secured to the wall in the Nursing Supervisor office. Upon the request of the surveyor, the cabinet was opened by the DON and observation revealed the cabinet was filled with discontinued controlled drugs and the medication-controlled substance sheets (untitled) were attached to each medication with a rubber band. Observation of the controlled substance count sheets revealed the sheets were dated from (YEAR) through 7/2018. Review of the facility Inventory/ Narcotic Destruction Log, used to document incoming controlled drugs from the pharmacy and surrendered drugs intended for destruction, located in the Director of Nursing's (DON's) office on 7/18/18 revealed there were incomplete and omitted entries in the Log book. During an interview on 7/18/18 at 8:47 AM, the DON stated controlled substances are immediately logged into the facility's controlled drug inventory log upon delivery from pharmacy. The nurse receiving the controlled substance signs off in the inventory log. The DON stated she knew the medications in the cabinet were for destruction because the forms attached to the drugs documented surrendered. The DON stated the last scheduled drug destruction pick-up was (MONTH) 17, (YEAR) and stated she had requested a destruction in (MONTH) (YEAR) and in (MONTH) (YEAR) but did not receive approval from Albany. During an interview on 7/19/18 at 8:53 AM, the DON stated when discontinued controlled drugs are brought to her office for destruction. The DON stated that several medication blister packs were removed from the nursing units for destruction in (MONTH) and placed in the cabinets (in her office and Nursing Supervisor's office), but the medications have not been logged onto a tracking record because she forgot about the log. The DON stated that she and the Pharmacy consultant are present in her office when the Unit Manager brings the discontinued medications and the corresponding control substance count sheets to the office for surrendering. Review of a controlled substance count sheet for [MEDICATION NAME] (Schedule IV narcotic anxiety medication), obtained from the cabinet in the DON's office, revealed there were three signatures at the top of the second page revealed the medication was received from pharmacy on 9/8/17 and surrendered to the DON and the Pharmacist Consultant on 1/5/18. Review of the Inventory/ Narcotic Destruction Log from 9/2017 through 10/2017 revealed [MEDICATION NAME] was not logged into the inventory/narcotic destruction log upon delivery from the pharmacy and there was no record of surrendering the medication to the DON/ Pharmacy Consultant. During an interview on 7/19/18 at 9:05 AM, after the DON reviewed the controlled substance count sheet and inventory log, she stated the [MEDICATION NAME] should have been logged in when the supervisor received it from the delivering pharmacy. She should have identified the issue when the nurse surrendered the medication, but she did not have the book and was unaware it was not logged in. Review of the Inventory/ Narcotic Destruction Log dated 1/23/18 revealed [MEDICATION NAME]/ APAP ([MEDICATION NAME] - Schedule 2 narcotic pain medication), logged in when received from the pharmacy and revealed on 5/17/18 was surrendered to the DON. The columns on the log sheet that were labeled Nurse surrendering Narcotics to the DON, Signature of DON receiving Narcotics and Signature of ADON/ Pharmacy Consultant receiving Narcotics were blank. During an interview on 7/20/18 at 9:17 AM, the Administrator stated she was unaware of the amount of controlled substances in the DON's and Nursing Supervisor's office. The expectation was for all controlled substances to be logged in upon delivery from pharmacy, and again when the nurse on the unit surrenders them to the DON. During telephone interview on 7/20/18 at 10:25 AM, the Pharmacy Consultant stated the process for surrendering controlled drugs was for the medications to be brought down from the nursing units to the DON's office. The Control Substance Count Sheet was supposed to be signed by the DON/ ADON and Pharmacy Consultant and the nurse surrendering the medication immediately. The information was to be logged into the Inventory/ Narcotic Destruction Log book. The Pharmacy Consultant stated she would expect the DON to have a record to know what was in the cabinets for destruction. The Inventory/ Narcotic Destruction Log book was to be completed when a control substance was delivered to the building and when it was surrendered for destruction to maintain an accountability of all control substances in the building. The Pharmacy Consultant stated there was a poor system in place that was being utilized to assure accountability of control substance medications. During and additional interview on 7/26/18 at 9:15 AM, the Administrator stated she was not aware the controlled drugs were not being logged into the Inventory/ Narcotic Destruction Log book upon receiving or surrendering the medications. The expectation was that the destruction of the controlled substances was to be completed every three months. 2. During an observation/interview on the Green Unit 7/18/18 at 9:51 AM of discontinued narcotic medications with Licensed Practical Nurse (LPN #3) revealed: - Bottle of [MEDICATION NAME] Oral Solution 100 mg (milligrams) per 5 ml (milliliter) containing 6.75 ml of a clear liquid. National Drug Code (NDC - universal product identifier for drugs) 0406-8003-15. - Bottle of [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 12.5 ml of a clear, slightly tinged blue liquid. NDC 0406-8003-15. - Bottle of [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 14.25 ml of a clear, light blue liquid. NDC 0406-8003-15. - Bottle of [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 28.5 ml of a clear, light blue liquid. NDC 0406-8003-30. - Bottle of [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 27 ml of a clear, light blue liquid. NDC 0406-8003-30. During the observation/ interview on 7/18/18 at 9:51 AM, LPN #3 stated she did not know why the [MEDICATION NAME] were of different colors, but that she has seen [MEDICATION NAME] in several different colors. During an observation/ interview on 7/19/18 at 10:57 AM on the Green Unit, the Director of Nurses (DON) identified the following: - [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 6.75 ml of a clear liquid. - [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 12.5 ml of a slightly tinted bluish grey liquid. - [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 14.25 ml of a sky-blue liquid. - [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 28.5 ml of a sky-blue liquid. - [MEDICATION NAME] Oral Solution 100 mg per 5 ml containing 27 ml of a sky-blue liquid. The RN DON stated she could not say why the [MEDICATION NAME]'s were of different colors but has seen [MEDICATION NAME] dark blue, clear, and dark orange. Review of product website revealed the [MEDICATION NAME] Oral Solutions with the NDC 0406-8003-15 and NDC 0406-8003-30 are produced by the same manufacturer. During a telephone interview on 7/18/18 at 1:18 PM with the manufacturing pharmacy Medical Detail Department revealed all the [MEDICATION NAME] manufactured by the pharmacy, is a clear, light blue liquid. It is not cloudy. All of our [MEDICATION NAME] solutions are the clear, light blue liquid. During a telephone interview on 7/19/18 at 11:22 AM with the dispensing pharmacy, Pharmacist #1 stated, the liquid contained within the [MEDICATION NAME] bottles was blue in color when the bottles left the pharmacy. In addition, the pharmacist was unaware of any issues or recalls with the product. During an interview on 7/19/18 at 1:18 PM, the Consultant Pharmacist he stated, typically a bacterial or fungal contamination would change the liquid to a darker color, a brownish or browner color. I cannot say what's in the bottle unless it was sent to a lab to test or do a specific gravity (the ratio of the density of a substance to the density of a standard). Diversion would be another reason why the color isn't what it should be. He further stated that the expectation was the nurses that are administering and reconciling medications are aware of the appearance of the medications and would report any irregularities. 415.18(a)Based on interview and record review conducted during the Offsite Post Survey Revisit #1 conducted 10/26/18 through 11/9/18, the facility did not ensure the approved Plan of Correction (P(NAME)) for F755 - Pharmacy Services/ Procedures/ Pharmacist/ Records cited during the 7/26/18 Standard Survey was fully implemented. The finding is: 1. Review of the Statement of Deficiencies Form CMS 2567 from the Standard Survey revealed the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; determine that drug records are in order; and that an account of all controlled drugs is maintained and periodically reconciled. Review of the facility's Plan of Correction (P(NAME)) for F755, approved on 9/11/18 with a compliance date of 9/24/18, revealed the narcotic cabinets in the facility would be inspected monthly by the Pharmacy Consultant for appropriate documentation and storage. Review of a Department of Health (DOH) email that was sent to the Administrator dated 10/22/18 revealed that the facility was requested to submit supporting documentation verifying that the facility's P(NAME) was implemented. The supporting documentation was to be submitted to the DOH by the close of business on 10/24/18. The email also documented instructions to include the steps taken to alleviate a deficient practice for the resident cited. Review of the submitted documents (provided by the facility as requested on 10/22/18) for F755 on 10/26/18 revealed there was no information provided to verify the implementation of the P(NAME) for F755. Review of a Department of Health (DOH) email sent to the Administrator dated 10/31/18 revealed a second request for the facility to send verification of the implementation of their P(NAME) for F755, as no information regarding this tag was provided. A Department of Health (DOH) email sent to the Administrator dated 11/5/18 revealed a request to send the Pharmacy Consultants monthly narcotic cabinet inspections. Review of a signed statement by the Administrator provided by the facility on 11/5/18 revealed the Pharmacy Consultant (#1) had a contract with the facility for the monthly reviews. Despite repeated attempts by the facility to contact the Pharmacy Consultant, the facility was unsuccessful. The only inspection provided to the Administrator was for (MONTH) (YEAR). The facility recently hired a new Pharmacy Consultant (#2). During a telephone interview on 11/8/18 at 1:55 PM, the Administrator stated that despite multiple attempts to contact Pharmacy Consultant #1, they were unsuccessful and they had no completed medication room inspections other that what was already provided to the DOH (June (YEAR)). A new Pharmacy Consultant (#2) started approximately two weeks ago, however she has not completed any narcotic cabinet inspections. 415.18(a)

Plan of Correction: ApprovedNovember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All the narcotics have the potential to be affected.
Copies of DOH - 2340 (Request for Destruction )and DOH - 166 (Controlled Substance Inventory Log)were present in the binder entitled Narcotic Destruction, located in the DON office.
A Narcotic Destruction was completed on 7/25/2018 by the DON and ADON , as per policy. All narcotics were destroyed as appropriate and reconciled as indicated by the facility policy.
A call was placed to the previous pharmacy consultant who is no longer a consultant at this facility.The Bound Inventory Destruction log was reconciled as appropriate on that date. The nurses will be inserviced by the DON / Designee if there are any medications (IE) [MEDICATION NAME] and other controlled substances that may be of a different color , shape etc from previous medications of like kind. This would need to re reported to the DON immediately.
The narcotic cabinets will be inspected monthly by the Pharmacy consultant for appropriate documentation and storage.
Narcotic destruction will be requested no less than every three months.
All licensed nurses will be educated on the narcotic POLICY AND PR(NAME)EDURE.
Results of the audits will be reviewed at the monthly QA and A meeting.

Responsible person: DON

FF11 483.30(c)(1)-(4):PHYSICIAN VISITS-FREQUENCY/TIMELINESS/ALT NPP

REGULATION: §483.30(c) Frequency of physician visits §483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. §483.30(c)(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. §483.30(c)(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally. §483.30(c)(4) At the option of the physician, required visits in SNFs, after the initial visit, may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist in accordance with paragraph (e) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during the Standard survey completed on 7/26/18, the facility did not ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 thereafter. Specifically, ten (#10, 13, 16, 20, 22, 35, 60, 62, 63, 83) of twenty-nine residents reviewed for frequency of physician's visits had an issue involving physician visits that were not completed as required. The findings include but not limited to: 1. Resident #13 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 7/17/18 revealed the resident was usually understood and understands. The resident's BIM (Brief Interview for Mental Status) score was documeted as zero (0) indicating severe cognitive impairement. The resident required extensive assistnce from staff for dressing and personal hygeine. Review of the entire medical record revealed the last physician note was dated 4/4/18 and the last Physician Assistant (PA) note was dated 4/10/18. There was no documented evidence of any further physician, PA or NP (nurse practitioner) notes for this resident after 4/10/18. Review of the Accident and Incient reports dated 11/24/17 through 6/11 /18 revealed the resident had multiple falls with major injuries with multiple transfers to the emergency room . During an interview on 7/23/18 at 9:15 AM, the Physician stated he was aware of the resident's falls and decline in status. However, he had no current documentation to date because he was behind in charting. 2. Resident #10 was admitted [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. Review of the entire medical record revealed there were no documented physician visits from 6/2017 through 6/2018. During an interview on 7/20/18 at 10:30 AM, the Licensed Practical Nurse (LPN #1) Unit Manager stated the physician had not seen any residents on the Yellow Unit and that the Nurse Practitioners see the residents. During an interview on 7/23/18 at 11:00 AM, the Physician stated he was sure he wrote a note, but he would need to search files on his computer to find it. In a follow up interview on 7/24/18 at 9:30 AM, the Physician he stated he had not located progress notes for Resident #10. 3. Resident #16 was admitted [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. Review of the entire medical record revealed the resident was seen by the physician on 11/13/17 and was seen monthly by the Nurse Practitioner through 6/15/18. There was no documented evidence the resident was seen by the physician since 11/13/17. During an interview on 7/23/18 at 11:05 AM, the Physician stated he has been behind in his charting. During an interview on 7/20/18 at 11:22 AM, the Director of Nursing stated the physician should see the resident every 30, 60 and 90 days and every other month thereafter. Additional interviews: During an interview on 7/20/18 at 1:02 PM, the Medical Records Dircetor stated they use a calendar to schedule the visits. The unit clerks have the schedule and to give it to the physicians. The medical records department used to track the physicain visits but once they transitioned to the EMR (electronic medical record) they stopped tracking. Once we get settled with the physicians we will be able to start tracking again. The Medical Records Director could not locate a schedule for (MONTH) or (MONTH) of (YEAR). During an interview on 7/20/18 at 11:26 AM, the Administrator stated they knew there were problems with the physician (Medical Director) meeting his required visits. Things stated to get out of hand in April. Visits should have been conducted by the physician every 30, 60, and 90 days; then every 60 thereafter, they can alternate with an Nurse Practitionior. Additionally, the facility tried to get the physician and his team to work with the facilities system to track visits, but the physician and his team decided they would own tracking. 415.15(b)(2)(ii)

Plan of Correction: ApprovedAugust 24, 2018

F 712
Residents #10, #13 and #16 were identified for the deficient practice. The corrective action accomplished for the above residents was to assign a new physician/medical doctor.
Other residents have the potential to be affected by the same deficient practice.
The same deficient practice was identified by a chart audit to determine the last MD visit.
All those residents affected were given a new Physician/MD who will follow the current 60 day visit schedule.
Currently the physician/MDs assigned do 30 day visits.
Measures that will be put into place to ensure the deficient practice does not recur will include but not limited to a schedule of Physician/MD visits due. A monthly schedule for the Attending physician/MD will be maintained by the Medical Records Director/Unit Clericals.
The Physician/MD will be updated as to when the 60 day visit is required by regulation. The physician/MD currently assigned continue on a 30 day visit schedule per their request. As the MD requests supersedes the regulation, that schedule will be followed.
The corrective action will be monitored by a random audit of MD visits of 10 charts per month times 3 months for accuracy and timeliness of visits.
The results of these audits will be brought to the QA&A committee for review and/or revision.
A new Medical Director is also being assigned 9/1/2018.

Person responsible for compliance: Administrator

FF11 483.75(g)(1)(i)-(iii)(2)(i):QAA COMMITTEE

REGULATION: §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; §483.75(g)(2) The quality assessment and assurance committee must: (i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on record review and interview conducted during the Standard Survey completed on 7/26/18, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee consisted at a minimum of the Director of Nursing Services, the Medical Director or his/ her designee and at least three other members of the facility's staff in a leadership role. Specifically, the Medical Director did not attend the facility's QAA meetings. The finding is: The policy and procedure entitled Quality Assurance and Performance Improvement Plan dated 2/1/17 documented the committee would consist of representation from nursing, dietary, medical director, housekeeping, laundry, maintenance, health information management, activities, and staff education. The policy and procedure entitled Medical Director dated 4/17 documented the Medical Director was responsible for overseeing and helping develop and implement care-related policies and practice and participate in efforts to improve quality of care and services. The Medical Director should take a leadership role on the committee to enhance his/ her awareness of issues of quality and general trends in resident care in the facility. Review of the Monthly Meeting Attendance Sheets entitled Quality Assurance and Assessment Committee revealed the Medical Director did not attend the following QA meetings: 10/25/17, 12/13/17, 1/17/18, 2/27/18, 3/27/18, 5/1/18, 5/30/18. During an interview on 7/24/18 at 2:30 PM, the Medical Records Director stated emails are sent to all members of the Quality Assurance (QA) Committee with an invite to attend the meeting with the date, time, and location. Additionally, the Medical Director did not attend quarterly QA meetings. During an interview on 7/24/18 at 3:00 PM, the Director of Nursing (DON) stated the Medical Director does not attend quarterly QA meetings. During an interview on 7/25/18 at 2:43 PM, the Medical Director stated he had not attended the facility's Quality Assurance committee meetings for approximately one year and could not recall the date he last attended. Prior to his contract in (MONTH) he oversaw five facilities and could not find the time to attend the meetings. The Medical Director stated his contract was through a practitioner's service and further stated his boss did not feel it was necessary for him to attend quarterly QAA meetings. During interview on 7/26/18 at 8:29 AM, the Administrator stated the expectation was that the Medical Director was to assure the residents receive adequate services to their needs and assuring he complies with current rules, regulations and follows guidelines. The QA meetings were held monthly and expected the Medical Director to attend the QA meetings at least quarterly, and that was not happening. 415.15(a)

Plan of Correction: ApprovedAugust 24, 2018

F 868 Quality AA comittee
The corrective action for the deficient practice identified:
A new Medical Director will be in place 09/01/2018.
All residents have the potential to be affected by the same deficient practice.
The measures that will be put into place to ensure the deficient practice does not recur:
The Medical Director will be notified of each QA meeting date.

The corrective actions that will be in place so this deficient practice does not recur are:
Monitoring of QA schedule and the Medical Director?s attendance:
Should the Medical Director not attend the QA meeting the facility Administrator will notify the Medical Director and/ or the regional Administrator, if need be for compliance.
The QA & A committee will monitor attendance of the Medical Director at the monthly QA & A.
If the MD is unable to attend the QA minutes will be reviewed with the Medical Director. The Medical director will also be notified of any/ all QA issues that may arise between scheduled QA & A meetings.
The Medical Director will be actively involved with facility policies and procedures, and the over sight of other providers.
Responsible Person: Administrator

FF11 483.45(f)(2):RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 7/26/18, the facility did not ensure that residents are free of significant medication errors. One (Resident #120) of six residents reviewed for medication administration had an issue involving the delay in obtaining an antipsychotic medication resulting in the omission of eleven doses of the medication. The finding is: The facility policy and procedure entitled Identifying and Managing Medication Errors and Adverse Consequences dated 2/1/17 documented the facility will ensure that residents are free of significant medication errors and medications are administered as ordered by the practitioner. The Licensed Nurse will document appropriately detailed accounts of any medication errors and incidents on a Medication Discrepancy Report Form. Medication Discrepancy Reports will be completed for the omission (drug ordered and not administered) of a medication. 1. Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/12/18 revealed the resident was understood, understands, and had severe cognitive impairment. Review of the Daily Orders Report Between 6/6/18 and 6/14/18 included orders for the following medication: - [MEDICATION NAME] (atypical antipsychotic medication used to treat [MEDICAL CONDITION]) Oral Tablet 200 mg (milligram) 1 tablet(s) by mouth at bedtime. - [MEDICATION NAME] Oral Tablet 50 mg 1 tablet(s) by mouth daily. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] - [MEDICATION NAME] Oral Tablet 50 mg was scheduled to be administered daily at 10:00 AM. - [MEDICATION NAME] Oral Tablet 200 mg was scheduled to be administered daily at 10:00 PM. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The [MEDICATION NAME] 200 mg was not signed as administered at 10:00 PM on 6/6/18, 6/9/18, 6/10/18, and 6/11/18. Review of the automated medication dispensing system Inventory on Hand, revealed [MEDICATION NAME] was not on the list of available medications. Review of a pharmacy Packing Slip dated 6/11/18 included the following medications for Resident #120: - 28 tablets [MEDICATION NAME] 50 mg - 28 tablets [MEDICATION NAME] 200 mg Registered Nurse (RN) #1 signed the Packing Slip on 6/12/18 acknowledging receipt of the medications. During an interview on 7/26/18 at 8:32 AM, Pharmacist #2 stated the pharmacy cannot dispense [MEDICATION NAME] until blood work has been completed by the facility. In addition, she stated the pharmacy notified the facility on 6/6/18 at 5:10 PM that a CBC with diff (complete blood count with differential) was required prior to dispensing. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 7/26/18 at 10:11 AM LPN #3 stated, that (signing MAR) was probably an accident because I know I didn't have it. That was an error on my part. I had to fight with pharmacy to get the med (medication) here. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Attempts to contact RN #1 on 7/26/18 were unsuccessful. During an interview on 7/26/18 at 10:16 AM, the Director of Nursing (DON) stated she did not have an answer as to why there was a delay in obtaining the medication. The medication may not have been dispensed because blood work was needed prior to the initiation [MEDICATION NAME]. The admitting nurse should have gotten blood work the next day, two days tops. During an interview on 7/26/18 at 10:24 AM the Physician stated, usually as long as a prescription is sent to pharmacy we will have the meds (medication) in time for the evening dose, if not should be getting the meds by the next day. [MEDICATION NAME] ([MEDICATION NAME]) is an exception as you need labs (blood work) or pharmacy won't send it. Labs should have been done the next day even if it's not a normal lab day. [MEDICATION NAME] stays in the system, it has a long half-life, missing a dose or two isn't that significant. Eleven doses, that would be significant and should be a med error. During an interview on 7/26/18 at 10:37 AM, the Administrator stated, we probably should have gotten the blood work STAT (immediately) as soon as we knew pharmacy couldn't fill the prescription. 415.12(m)(2)

Plan of Correction: ApprovedAugust 24, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #120 no longer resides at Safire South. A full record was review was completed of the resident record .
All residents have the potential to be affected by the same deficient practice.
Medication errors were completed for [MEDICATION NAME] not administered on 6/7/18, 6/ 8/18,6/9/18,6/10/18 and 6/11/18 at 10:00 AM.As well as [MEDICATION NAME] not administered on 6/6/2018, 6/9/2018, 6/10/2018 and 6/11/18 at 10:00 PM.
The nurse that was pharmacy notified on 6/6/2018 @ 5:10 PM regarding appropriate bloodwork was educated on the importance of obtaining information and follow - thru to ensure continuity of care.
LPN # 3 was educated on the proper procedure for medication administration and what to do when a medication is not available from pharmacy. A medication error a
was completed for the medication not being administered o 6/7/2018.
RN # 1 was educated on the proper procedure for medication administration and what to do when the medication is not available from pharmacy. a medication error was completed for the medication not administered on 6/8/2018 at 10:00 PM.
A 100% audit with a retrospective review of 60 days was completed to identify further deficient practice.
The Nurse Managers will complete audits on all new admissions to confirm timely arrival /administration of medication.
Audit results will be brought to the monthly QA and A meetings where the DON will analyze and trend data.
Responsible person : DON

FF11 483.35(a)(1)(2):SUFFICIENT NURSING STAFF

REGULATION: §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during Standard survey completed on 7/26/18, the facility did not have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. One (Yellow Unit) of three resident care units reviewed for sufficient staff did not have adequate staff to get residents up in the morning. This involed Resident #113. The undated Facility Assessment Tool provided by the facility included a general staffing plan to ensure that they have sufficient staff to meet the needs of the residents at any given time. The plan included to have 1 Registered Nurse (RN) per regulation, and 2 Licensed practical Nurses (LPN) in the building for each shift. Additionally, the certified nurse aides (CNA) range was 12 per 24 hours (number will change based on census and acuity). 1. Resident #113 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 6/26/18 documented the resident was cognitively intact. The Pocket Care Plan identified as current on 7/19/18 by LPN #1 Unit Manager documented the resident eats all meals in the main dining room. During an interview on 7/18/18 at 2:18 PM, the resident stated in the morning there was not enough staff to get him up in the morning. He had to eat in his room and he does not like to eat in his room. The resident further stated he wanted to eat all his meals in the main dining room and that included breakfast. During an interview on 7/23/18 at 8:35 AM, the resident stated he was upset because he did not get out of bed for breakfast on Saturday 7/21/18 or Sunday 7/22/18. Review of the Yellow Unit Assignment Sheet for the 6:00 AM to 2:00 PM shift dated 7/21/18 revealed there was one LPN and 3 CNAs assigned to the unit. Review of the Yellow Unit Assignment Sheet for the 6:00 AM to 2:00 PM shift dated 7/22/18 revealed there was one LPN and 2 CNAs assigned to the unit. Review of an undated Matrix for Providers provided by the facility on 7/17/18 revealed there were 31 residents resided on the Yellow Unit. During an interview on 7/23/18 at 11:00 AM, LPN #2 stated there was only one Certified Nurse Aide (CNA) for 40 residents when she came in on Saturday morning (7/21/18). They did not get additional staff until after 8:30 AM. We couldn't get residents out of bed with that kind of staffing. During an observation of the resident on 7/24/18 at 8:10 AM, the resident was eating breakfast in bed. Interview with the resident at that time revealed he wanted to get out of bed for breakfast. During an interview on 7/24/18 at 8:50 AM, the Agency CNA #1 (who worked 7/22/18 on the day shift) stated she was the only CNA for 20 residents and there was only one CNA for 20 residents on the adjacent unit. Resident #113 was a two person assist and the CNA could not get the resident out of bed by herself. During an interview on 7/24/18 at 8:51, LPN #1 Unit Manager revealed the resident was care planned to be out of bed for breakfast and should have been gotten up for breakfast. He was not eating in the dining room because they were short staffed. During an additional interview on 7/25/18 at 1:40 PM, the resident stated he doesn't get of bed for breakfast on many days. During an interview on 7/23/18 at 9:45 AM, the Administrator revealed the minimum number of staff for each unit and each shift was 1 Licensed Practical Nurse (LPN) and 2 Certified Nurse Assistants (CNA). Critical staffing would be 1 LPN and 1 CNA on each unit and each shift. If staff did not show up for their shift, the staff from the previous shift cannot leave until they are replaced. The Administrator revealed she had been using agency staff in order to sustain the schedule. Many times, staff was scheduled but they either call in or they do not show up. She had been offering staff extra time if they wanted it. They have been attempting to hire but it was difficult to hire and retain good staff. 415.13(a)(1)(ii)

Plan of Correction: ApprovedAugust 31, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 725 Sufficient Nursing Staff
The facility will ensure sufficient staffing with the appropriate competencies and skills to provided nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each as determined by the resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED].
Once insufficient staffing was identified on 7/24/18, the Administrator , DON, and staffing coordinator immediately reviewed the daily staffing schedules and the projected staffing for each shift to ensure that at least minimum staffing patterns were in place on each shift to meet the needs of the residents when nursing employees called off for their assigned scheduled shifts.
Resident #113's medical records, comprehensive care plan, pocket care plan was immediately reviewed by the DON on 7/24/18.
The DON meet with the resident on the same day. Resident was given a choice of getting out of bed on the 11pm-7am shift, AM care assignment, which he agreed to by the resident. The care plan revision occurred on the same day.
The IDT reviewed and revised the resident's person centered comprehensive care plan on 8/22/18. The CCP has been updated to be assisted out of bed by (2) 11pm-7am shift nursing staff during AM Care by either two CNAs or one CNA and a licensed nurse to ensure resident #113 is out of bed before breakfast and all meals. The resident participated in his plan of care and is in agreement with changes. Resident #113 has been out of bed before breakfast and in the dining room for all meals since care plan revision occurred on 8/22/18.
The RN Consultant reviewed the resident's medical record, CCP and Pocket care plan and met with the resident on 8/22/18 to validate and to ensure CCP revision occurred.
Resident #113 remains at the facility in stable condition.
The RN Supervisor will ensure resident #113 is OOB per the care plan on the 11pm-7am shift.
All residents residing at the facility have the potential to be affected by the same deficient practice. The facility will ensure there is enough Certified Nurses Aides (CNAs) to resident ratio to meet the needs of the residents.
The Administrator, DON/ADON and staffing coordinator will review on a continuous basis throughout the day and to include upcoming staffing for the upcoming shifts and days. The staffing sheets will be reviewed for sufficient licensed staff; certified nursing aides and ancillary staff meets the needs of the residents at the facility. This practice will allow the facility to anticipate upcoming needs on a timely basis.
The staffing coordinator and ADON will complete time and attendance audits weekly, including review of the daily 24 hour punch reports, staffing sheets, monthly schedules, reasons for call offs and current vacancies.
The ADON will analyze and trend the data collected and report findings as needed to the Administrator and to the QAPI committee at the next scheduled meeting.
The Administrator signed an additional nurse agency contract on 8/17/18 to ensure licensed nurses and CNAs are available for staff call offs and weekend coverage.
The facility will hold an Open House 2 times monthly to attract potential new hires. The Open House will be coordinated by the Regional recruitment and retention Specialist, and will be on going until nursing staff vacant positions have been filled.
On going mandatory over time will be utilized in conjunction with monetary bonuses to work over time. With this constant oversight of nursing administration and the Administrator will assure by review of the staffing sheets that there are sufficient staff scheduled to meet the needs of the residents in every 24 hours period.
The DON and Administrator will enforce and adhere to the on call system for nursing staff to come in to work or stay on additional shifts to meet minimum staffing needs during an emergency situation, i.e. excessive staff call offs, weather emergencies, etc.
The DON will receive progressive disciplinary for not ensuring the proper oversight of the staffing coordinator and not ensuring enough nursing staff with the proper skill set and competencies were scheduled on all shifts and completing progressive discipline.
The Administrator will counsel and re-educate on the policy & procedure. The Corporate DON will in-service DON on scheduling process.
The Facility Assessment tool will be reviewed and revised by the Corporate DON, DON/Administrator to identify the average number of nursing staff needed per day (discipline specific) to provide resident care for both minimum and maximum staffing patterns while accommodating staff call offs. The minimum staffing patterns, numbers will be determined by the Corporate DON and Administrator after review of the residents' activities of daily living, behavioral health needs, clinical acuity and facility population. The ratios of CNAs to residents based on the facility census will be reviewed weekly by the DON/ADON and Administrator and adjusted as needed to ensure the resident needs are met.
The Emergency On Call Nursing Policies & Procedures will be updated by the Corporate DON, DON and Administrator to include all licensed and non-licensed nursing staff.
The DON and Administrator will in-service the nursing department on the policy & procedure revision.

The Corporate DON will conduct a mandatory training / in-service with the Administrator, DON, ADON and staffing coordinator and shift supervisors on how to complete and over see the monthly, Nursing schedule, Daily Staffing sheets and oversight including, enforcing and tracking time and attendance violations for nursing employees call offs, and excessive absenteeism and tardiness.
The DON and the Administrator will in-service all nursing staff on the facility existing personnel policies and procedures pertaining to time and attendance policies and procedures.
The Administrator and Regional Administrator will develop a Nursing Employee Mandation Policy and Procedure to ensure nursing employees specific to their skill set are mandated to ensure minimum staffing levels are met in order to provide the resident care needs as stated in the Facility Assessment tool.
The Administrator and the Regional Administrator will meet with the facility union representative to review the Mandation Policy and Procedure prior to implementation.
The Administrator and DON will in-service the nursing staff on the Nursing Mandation Policy and Procedure.
The Administrator and Regional Administrator will develop a weekend administrator on duty program where as the Department Heads will participate and be on-site for (4) four hours on Saturday and Sunday. They will arrive to assist with staffing needs, resident concerns, audits and complete survey satisfaction reports, etc. The Regional Administrator will develop the Satisfaction survey and Weekend Administrator Report.
The Administrator and the DON will in-service the department heads on the Administrator on Duty program/policies and procedures including developing a weekend Report template that will be completed for the weekend and discussed with the IDT at the Monday morning AM meeting. The Administrator will review the weekend on call report with the Regional Administrator during the weekly on-site meeting.
The Administrator will meet with all contracted nurse staffing Agencies to discuss excessive absenteeism and weekend call offs to try to resolve the concerns.
The ADON, Administrator and the staffing coordinator will continue to review the daily staffing sheets and monthly schedules every am and pm which includes the current day and next days staffing schedules to ensure sufficient RNs, LPNs, and CNAs scheduled to work in that 24 hour period as well as the next 48 hour time frame so that staffing problems can be immediately addressed and include the next shift.
All potential issues/concerns that have been identified for future staffing will be reported to the administrator and addressed, audits are competed with the coordination of payroll vs actual worked schedules. A weekly report will be sent every week to the Corporate Administrator and the DON to ensure proper staffing is in place and immediate action is taken to correct the staffing concerns. The Regional Administrator will review the staffing with the Administrator on a weekly basis and will be on going.
The Corporate DON will conduct a random staffing audit monthly to ensure the Facility Assessment tool staffing requirements are in place and the residents care plan needs are being met. The audit will include review of staffing sheets on all shifts, monthly schedules, call off logs, Time card punches and progressive staffing disciplinary action for time and attendance violations and resident interviews.
This report will be analyzed and trended by the Corporate DON and forwarded to the QAPI Committee and Regional Administrator monthly for review.
This will occur monthly for 3 months, then quarterly thereafter.
The DON/ ADON and shift supervisors will conduct observation rounds and resident interviews on all units every shift to ensure resident needs are being met. Deficient practices identified will be immediately address.
The DON/RN supervisor will call in additional staff including but not limited to agency employees whenever the resident care need are not being met.
The DON/ADON and Shift Supervisors will conduct observation rounds and resident interviews on all units every shift to ensure resident Care Plan needs are being met.
The Administrator and DON will analyze and trend data collection.
All findings will be reported by the DON and the Administrator daily and the Regional Administrator and QAPI Committee monthly. This will be ongoing.
The DON/ADON/RN supervisor will audit the following care areas:
Residents are out of bed timely
Residents are allowed to go to bed when they request
Residents are toiled or checked and changed when incontinent timely per CCP and as requested
Resident call bells are answered in a timely manner
Morning and Evening care occur daily
Showers and Baths occur as scheduled
Residents are receiving meals and being assisted timely per the plan of care
Resident complaints are addressed and document on audit tool.
All findings will be forwarded to the Administrator and DON daily once completed.
The DON/Administrator will meet daily Monday-Friday to review all audit reports forwarded from the shift supervisors.
Weekend audits will be reviewed on Monday.
Staffing needs will be evaluated at that time.
The Regional Administrator will review these reports weekly.
The Administrator and DON will analyze and trend data collection and report findings to the QAPI committee monthly.
This will be on going.

The Administrator will be responsible for compliance.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 7/26/18, the facility did not ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing. One (Residents # 92) of three residents reviewed for pressure ulcers lacked documentation of ongoing weekly assessments, including measurement of size, by a professional registered nurse (RN). In addition, the resident's physician was not notified regarding the podiatrist's recommendations for the care and treatment of [REDACTED]. The finding is: 1. Resident #92 was admitted to the facility on [DATE] with a subsequent readmission date of [DATE]. The resident has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/25/18 revealed the resident is understood, understands and is cognitively intact. The MDS documented that the resident is non-ambulatory and requires the extensive assistance of two staff members for bed mobility and transfers. Review of a Nursing Admission assessment dated [DATE] revealed the resident had a Stage IV open area on the right heel measuring 4 x 3.2. Review of a comprehensive Interdisciplinary Care Plan dated 7/8/18 revealed the resident had an unstageable pressure ulcer on the right heel with interventions to monitor the area during dressing changes; notify the MD (medical doctor) of any changes; podiatry as needed; and provide treatment per MD order. Review of Weekly Dermal Lesion/Pressure Injury Assessment Forms dated 6/1/18 to 7/19/18 revealed there was no documented evidence that an RN assessed the right heel pressure ulcer from 6/2/18 to 6/27/18. Review of a Weekly Dermal Lesion/Pressure Ulcer Assessment Form dated 6/1/18 revealed the resident had a stage IV pressure ulcer on the right heel measuring 4 centimeters (cm) long x 3.2 cm wide with serosanguinous (blood and serum drainage) drainage and the wound bed was brown and soft. A Weekly Dermal Lesion/Pressure Ulcer Assessment Form dated 6/28/18 documented that the right heel wound was downgraded to a Stage III and measured 3.9 cm long x 4.4 cm wide x 0.7 deep with tan drainage and the wound bed had slough (soft, moist, dead tissue may be white, yellow, tan or green). Review of a Clinic Summary report, from the Podiatrist, dated 6/19/18 revealed the resident had an ulceration on the right heel; the area was debrided (removal of dead tissue and/or foreign matter in the wound), and treatment was applied. A Physician order [REDACTED]. A Clinic Summary report, from the Podiatrist, dated 7/17/18 revealed the resident had a decubitus ulcer (pressure ulcer) on the right heel, the ulcer was debrided, and a wet to dry dressing was applied. Continue Santyl daily, prefer dressings from xxx (medical supply company). Interview with the resident on 7/18/18 at 10:34 AM revealed he had a podiatry appointment; recommendations were made to continue the Santyl; and the podiatrist wants him to have Collagen (dressing derived from animal sources, which stimulate new tissue growth) dressings. Review of printed treatment recommendations given to the resident by the podiatrist on 7/17/18 revealed a recommendation for a Collagen dressing QD (every day). During the interview, the printed treatment recommendation sheet was given to the Assistant Director of Nursing (ADON). Interview with the Licensed Practical Nurse (LPN #3) on 7/24/18 at 10:29 AM revealed weekly skin documentation is located in the resident's medical record and the previous Green Unit Manager (UM) who left the facility in early (MONTH) (YEAR) was responsible for the weekly skin documentation. LPN #3 stated she was unsure who was responsible for completing pressure ulcer assessments and documentation at the present time. Interview with the ADON on 7/24/18 at 10:56 AM revealed she was unaware if the Physician was notified of the Podiatrist's recommendations for the Collagen dressing from 7/17/18. Interview with the Director of Nursing on 7/24/18 at 11:26 AM revealed that the previous Green Unit UM was responsible for the weekly skin assessments/ documentation. The DON was unaware of where the documentation would be prior to 6/28/18 when she (the DON) took over the reasonability of weekly skin/wound assessments but would try to locate the information. The interview further revealed that she would expect consultant recommendations to be brought to the physician's attention the same day it is received and reviewed. During further interview on 7/24/18 at 3:19 AM, the DON stated she was unable to locate weekly skin documentation for the pressure ulcer on the resident's right heel from 6/2/18 to 6/27/18. The DON was unaware of the podiatrist's recommendations for a Collagen dressing to the resident's right heel pressure ulcer and stated she would clarify the order with the podiatrist. Interview with the Medical Director on 7/25/18 at 11:55 AM, after review of the Clinic Summary report dated 7/17/18, revealed that he was not informed by the facility of the Podiatrist's recommendations for Collagen dressings. 415.12(c)(2)

Plan of Correction: ApprovedAugust 24, 2018

F686 Treatment/services to prevent/heal pressure ulcer
The facility will ensure based on the comprehensive assessment of a resident. The facility must ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the clinical condition demonstrates that they were unavoidable. The facility will also ensure the resident receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new areas of skin impairment.
Resident #92 remains at Safire South. His medical records was reviewed with no further deficient practice noted.
All residents of Safire South who have existing ulcers (decubitus/venous/arterial/diabetic) have the potential to be affected by the same deficient practice.
The ADON was educated on the importance of timely communication of consultant recommendation with residents Primary Care Physician.
The RN Manager previously on unit no longer works at the facility.
All licensed nursing staff will be educated on the importance of continuity of care regarding communication of consultant recommendation to resident Primary Care Physician to ensure recommendation/new orders etc. are communicated as appropriate.
a 100% medical record and care plan review will be conducted for residents who currently have decubitus ulcers, venous/arterial ulcers, diabetic ulcers to ensure weekly assessments are conducted by a Registered Nurse or other medical provider to identify any further deficient practice.
The DON/ADON will audit all residents with ulceration weekly to ensure that weekly assessments are conducted as appropriate, documentation is complete and any consults that may have occurred have appropriate follow thru. Any identified deficient practice will be corrected immediately.
Weekly wound tracking will be given to the DON every Monday.
The DON will analyze and trend data.
Audit results will be brought to the QA&A monthly.

Person responsible for compliance: Director of Nursing (DON)

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING REHABILITATION

REGULATION: Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: * Requirements of Chapter 18 and 19 * Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code Survey completed on 7/26/18, an area of the building that was under renovation was not properly maintained. Issues included the corridor walls that separated areas under renovation from resident and staff use areas were not designed to resist the passage of smoke. This affected one (Second Floor) of two resident use floors. The finding is: 1. Observation on the Second Floor, on 7/18/18 at approximately 9:53 AM, revealed a temporary wall and door were constructed in the corridor near the resident lounge, separating the Second Floor from the therapy suite that was under construction. Further observation at this time revealed an approximate eight-foot long by one-half-inch wide, an approximate eight-foot long by one-quarter-inch wide, and at least ten one-quarter-inch circular penetrations through this temporary wall. Observations above the corridor ceiling tiles, at this time, revealed the temporary wall terminated at the ceiling assembly resulting in an approximate eight-foot long by 12-inch wide penetration between the ceiling assembly and the roof deck. Observations also revealed ceiling tiles had been removed from an approximate 12-foot long by eight-foot wide area of the ceiling on the construction side of the temporary wall. During an interview, at the time of these observations, the Chief Regional Engineer and the Maintenance Director stated, the temporary wall was installed by the outside contractor that was remodeling the therapy suite. During an interview on 7/24/18 at 3:05 PM, the Construction Project Manager for the company that was remodeling the therapy suite stated, the temporary wall was moved/ installed to its current location approximately four months ago. Per the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code: construction shall not make the building less conforming with other sections of this Code, or with any previous approved alternative arrangements, than it was before the renovation was undertaken. Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted. Corridor walls shall have a minimum one half-hour fire resistance rating and corridor walls shall form a barrier to limit the transfer of smoke. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.2.1, 19.3.6.2.3, 43.5.1.1, 43.4, 43.4.1.3, 43.5, 43.5.1.1, 43.5.1.3

Plan of Correction: ApprovedSeptember 7, 2018

K 111
The correction action that will be accomplished for the deficient practice for the NFPA 101 Building Rehabilitation will be:
All Penetrations in the temporary partition in the corridor near the Resident Lounge, separating the second floor from the Therapy Suite that was under construction, will be filled and the drop ceiling will be replaced.

All of the he Residents are affected by the same deficient practice per the 2012 Edition of the NFPA 101 Life Safety Code.
A full facility audit of the building will be conducted of the corridor walls under renovation to ensure the resistance of smoke from residents and staff .
Corridor walls shall be continued from the floor to the underside of the floor. Corridor walls must have a one half-hour fire resistance rating.
The measures that will put into place to ensure this deficient practice will not recur:
Corridor walls will be conducted on a weekly schedule - ongoing. Any fire rating issue will be immediately addressed.
All results will be reviewed at the monthly QA&A meeting.All results will be reviewed of the audits of the corridor walls .
Person Responsible : Administrator.

K307 NFPA 101:COOKING FACILITIES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 7/26/18, the kitchen hood's extinguishment system was not properly tested and maintained. Issues included the kitchen hood's extinguishment system was not inspected at least every six months and a nozzle for the kitchen hood's extinguishment system was not positioned as designed. This affected one (First Floor) of two resident use floors. The findings are: 1. Observation in the First Floor Kitchen, on 7/17/18 at 2:35 PM, revealed the kitchen's ventilation hood was equipped with an extinguishment system. Record review of kitchen hood system reports revealed approximately seven months passed between the kitchen hood's extinguishment system inspections on 12/14/16 and 7/10/17. During an interview on 7/20/18 at 7:53 AM the Regional Chief Engineer and the Maintenance Director stated, the kitchen hood's extinguishment system had not been inspected every six months. 2. Observation in the First Floor Kitchen, on 7/17/18 at 2:36 PM, revealed two nozzles from the kitchen hood extinguishment system were located above the six-burner gas range. Further observation at this time revealed one of the nozzles (the left-hand nozzle as one looked at the range top) was angled so it was pointing at the wall behind the range top instead of straight down at the range top's burners as it was designed. During an interview at the time of the observation the Food Service Director stated, she was not aware the nozzle had been moved and one of the dietary staff must have hit the nozzle with a pot when they moved it from the top of the oven to the range top. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.2.3 20 NFPA 96: 10.2.7.3, 11.2.1

Plan of Correction: ApprovedSeptember 4, 2018

K324- NFPA 101 Cooking Facility

The corrective action for the deficient practice.
1) All required Inspections by outside vendors are reviewed currently to ensure that these inspections occur timely.
The kitchen hood was inspected .
2) The left hand nozzle was adjusted on site to point in a down ward position on the range top burners. This was corrected immediately.
A 100 % audit of all required cooking facility inspections will be completed to ensure this deficient practice does not recur. The staff will be inserviced on the inspection requirement for the kitchen hood and the position of the nozzle.Monthly the Kitchen(NAME)and nozzle will be inspected . This report will be reviewed at the QA and A committee .
A 6 month preventative maintenance program will be initiated to monitor the inspections required of the cooking facilities to ensure timely compliance.
The corrective action will be monitored thru the monthly QA and A meeting for Data Analysis.
Responsible party : Maintenance Director

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, corridor doors were not properly maintained. Issues included corridor doors that would not resist the passage of smoke; could not be latched into their frames; and were held open/ obstructed from closing by devices that did not release when the door was pushed or pulled. This affected two (First and Second Floors) of two resident use floors. The findings are: 1. Observation of the First Floor on 7/17/18 at approximately 10:14 AM revealed there was an approximate six-foot long by one-quarter-inch wide gap between the dining room corridor doors when the doors were completely closed. 2. Observation of the First Floor on 7/19/18 at approximately 11:53 AM revealed the corridor door to the Activities office would not latch into its frame. a) Observation of the Yellow Unit, located on the First Floor, on 7/19/18 at approximately 12:24 PM revealed the corridor door to resident room #55 on(NAME)Drive would not latch into its frame. b) Observation of the Green Unit, located on the Second Floor, on 7/19/18 at approximately 12:46 PM revealed the corridor door to resident room #203 on(NAME)Lane would not latch into its frame. Further observation at this time revealed the door was hung up on its frame. 3) Observation of the Blue Unit, located on the First Floor, on 7/19/18 at approximately 11:54 AM revealed the corridor door to Resident Room #3 on Eckert Lane was obstructed from closing by a trash receptacle. a) Observation of the Blue Unit on 7/19/18 at approximately 12:00 PM revealed the corridor door to resident room #4 on Eckert Lane was obstructed from closing by an over-bed table. b) Observation of the Yellow Unit, on 7/19/18 at approximately 12:19 PM, revealed the corridor door to Resident Room #47 on(NAME)Drive was obstructed from closing by an over-bed table. During an interview on 7/24/18 at approximately 2:21 PM, the Maintenance Director stated he had logs for the audits of the building's corridor doors but he could not find them. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.6.3, 19.3.6.3.5, 19.3.6.3.10

Plan of Correction: ApprovedAugust 24, 2018

K 363- NFPA Corridor- Doors
The corrective action for the deficient practice is:
1) A ¾ inch metal strip has been installed to close the gap on the dining room door.
2) The door to activities office has been adjusted and now latches into its frame.
a) The door to room #55 has been adjusted and now latches into its frame.
b) The door to room # 203 has been adjusted and now latches into its frame.
3) The trash can that was obstructing the door to room # 3 was removed immediately.
a) The over- bed table that was obstructing the door to room # 4 was removed immediately.
b) The over- bed table that was obstructing the door to room # 47 was removed immediately.
A 100 % audit of all corridor doors and potential obstructing areas to identify any further deficient practice will be completed.
A random audit of 10 doors per week x 3 months and every 6 months thereafter will be completed to identify any potential issues, i.e. Latches, obstructing, flammable areas.
The results of the audits will be reviewed at the QA & A meeting, for continued compliance.

Responsible Person: Director of Maintenance

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/23/18, extension cords, power strips, and an electrical adapter were not properly maintained. Issues included, in-use extension cords, extension cords and power strips were plugged together (daisy chained) and an electrical adapter was being used to supply power to various equipment. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The findings are: 1. a) Observation on the First Floor, on 7/17/18 at 11:58 AM, revealed an extension cord was supplying power to a vending machine located in the staff lounge. Further observation at this time revealed a second extension cord was supplying power to a microwave oven located in the lounge. During an interview at the time of the observation the Maintenance Director stated he was not aware the extension cords were being used in the lounge. 2. Observation in the Basement, on 7/17/18 at 12:19 PM, revealed a three-outlet electrical adapter was supplying power to two fans that were on and running in the elevator equipment room. During an interview at the time of the observation the Regional Chief Engineer stated, the adapter should not have been used to supply power to the fans. 3. a) Observation in the Basement, on 7/17/18 at 12:38 PM, revealed a power strip that was daisy chained to an extension cord was supplying power to a candle wax/ oil warmer, a fan, and a phone charger in the Director of Housekeeping office. During an interview at the time of the observation the Regional Chief Engineer and the Maintenance Director stated, they were not aware the candle wax/oil warmer was in the building or that the power strip was plugged into the extension cord. b) Observation in the Basement on 7/17/18 at approximately 1:13 PM, revealed a power strip that was daisy chained to a second power strip was supplying power to the building's telephone and computer systems located in Electrical Equipment room. During an interview at the time of the observation the Regional Chief Engineer and the Maintenance Director stated the power strips were supplying power to building's telephone and computer systems. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 2.1, 2.2, 10.2.3.6, 10.2.4, 10.2.4.2 2011 NFPA 70: 110.3(A)(1), 110.3(A)(7), 110.3(A)(8), 400.3, 400.8(1), 590.3(B)

Plan of Correction: ApprovedSeptember 7, 2018

The facility completed the following:
An extension cord that was supplying power to a vending machine and microwave oven located in the staff lounge was removed .
A three - outlet electrical adapter supplying power to the two fans that were on and running in the elevator equipment room was removed.
A power strip that was in the Director of housekeeping,s office , connected to a candle/wax burner, phone charger and fan was removed immediately.
A power strip that was daisy chained to a second power strip supplying power to the buildings telephone and computer systems located in the Electrical Equipment room was removed so there is only power strip.
All residents have the potential to be affected by the same deficient practice.
A 100% audit of all rooms in the facility will be completed to ensure that the power strips are being either utilized appropriately or not at all . This audit will be done by the maintenance dept. A random audit of areas that may have extension cords and power strips will be completed monthly times three months and every three months thereafter.
The results of the audit will be brought to the monthly QA and A meeting for Data analysis.

Responsible person: Maintenance Director

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 7/26/18, electrical systems were not properly maintained. Issues included the ground prongs (a metal prong that is designed to divert electrical current into the ground instead of back into a piece of equipment in case of a short circuit) were missing from the plugs on electrical equipment, and electrical junction boxes were missing covers. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The findings are: 1. a) Observation on the First Floor Yellow Unit, on 7/17/18 at 10:26 AM revealed an approximate five-foot tall by three-foot wide metal pedestal fan was on, running and located in the(NAME)Drive corridor near Resident room [ROOM NUMBER]. Further observation at this time revealed the ground prong was missing from the plug on the fan's power cord. b) Observation on the First Floor Yellow Unit, on 7/17/18 at 10:43 AM, revealed an approximate five-foot tall by three-foot wide metal pedestal fan was on, running and located in the Shamrock Lane corridor near Resident room [ROOM NUMBER]. Further observation at this time revealed the ground prong was missing from the plug on the fan's power cord. During an interview at the time of the observation the Maintenance Director stated, the fans were in the corridors year-round and were audited every three months. During an interview on 7/24/18 at approximately 2:21 PM the Maintenance Director stated, he had audits for the building's fans but he could not find them. c) Observation on the First Floor Blue Unit, on 7/17/18 at a 11:29 AM, revealed an approximate four-foot tall by two-foot wide metal pedestal fan was on, running and located in the Eckert Lane corridor near Resident room [ROOM NUMBER]. Further observation at this time revealed the ground prong was missing from the plug on the fan's power cord. d) Observation on the First Floor Blue Unit, on 7/17/18 at 11:42 AM, revealed an approximate four-foot tall by two-foot wide metal pedestal fan was on, running and located in the Lake Drive corridor near Resident room [ROOM NUMBER]. Further observation at this time revealed the ground prong was missing from the plug on the fan's power cord. 2. a) Observation above the ceiling tiles, on the Second Floor, on 7/18/18 at 9:53 AM revealed the cover was missing from an electrical junction box located near the temporary door, in the temporary wall that separated the Therapy suite from the Second Floor corridor, closest to the resident lounge. b) Observation above the ceiling tiles, on the Second Floor, on 7/18/18 at 10:00 AM revealed the cover was missing from an electrical junction box located near the(NAME)Drive corridor smoke barrier doors. Further observation at this time revealed the junction box was located on the Nurse's station side of the doors. c) Observation above the ceiling tiles, on the First Floor, on 7/18/18 at 11:16 AM revealed the cover was missing from an electrical junction box located near the atrium door located by the show case. During an interview at the time of the observation the Maintenance Director stated, an outside contractor had installed new light fixtures in the building approximately eight months ago and the contractor must not have installed the junction box cover after running the wiring for the lights. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.1, 6.1.1, 1.3, 1.3.2.1, 6.3.2, 6.3.2.1, 2011 NFPA 70: 110.3(A)(1)(8), 400.24, 250.138(A), 314.25, 314.72(C)

Plan of Correction: ApprovedSeptember 11, 2018

K 911 NFPA 101 Electrical Systems - Other
The corrective action that was accomplished for the deficient practice.
1.a) The fan on yellow unit by room # 54, The ground was replaced, And on Shamrock Lane.
b) The ground plug was addressed and replaced.
c) The fan on Eckert Lane near room # 15, The ground was replaced.
d) The fan on Lake Drive near room # 29 , The ground was replaced.
2.a)The electrical junction box that was located near the temporary door that separated the Therapy Suite from the Second Floor was replaced with the new cover.
b)The electrical junction box that was located near Nicoles Drive corridor smoke barrier doors was replaced with the new cover.
A 100 % audit of all electrical/ outlet/ prongs ect. will be conducted.
Also a 100 % audit of the ceiling tiles will be conducted.A 100% audit of junction boxes located above the ceiling tiles will be conducted.
A preventative maintenance program will be implemented for every 6 months inspection and/ or repair and replacement.
Results will be reviewed at the monthly QA & A meeting.

Responsible Person: Director of Maintenance

ESTABLISHMENT OF THE EMERGENCY PROGRAM (EP)

REGULATION: The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on interview and record review during the emergency preparedness plan review, in conjunction with the Life Safety Code survey completed on 7/26/18, it was determined the facility did not comply with emergency preparedness requirements. Specifically, the written emergency preparedness plan was incomplete and the facility did not have documentation that verified: the facility had established and maintained a comprehensive Emergency Preparedness program, the emergency preparedness plan had been reviewed and updated annually, and the emergency preparedness plan's policies and procedures had been developed and implemented based on facility-based and community based risk assessment, utilizing an all hazards approach. This had the potential to affect all residents, staff, and visitors in the facility, in the event of a disaster. The finding is: 1. During an interview on 7/19/18 at 2:28 PM the Administrator stated the facility's emergency preparedness plan was not completed until 3/27/18 because she was not aware of the new emergency preparedness plan requirements and the corporation that owned the facility had not informed her of the new requirements until (MONTH) of (YEAR). The Administrator further stated, a facility-based and community based risk assessment, utilizing an all hazards approach had not been conducted for the facility. During an interview on 7/20/18 at 9:34 AM the Administrator stated the facility had no documentation the emergency preparedness plan had been reviewed or updated during (YEAR) and she had started working at the facility in (MONTH) of (YEAR). A review of the facility's Emergency Preparedness Plan revealed it contained no documentation the plan had been reviewed or updated in (YEAR). Further review of the plan revealed it contained no documentation that a facility-based and community based risk assessment, utilizing an all hazards approach had been conducted for the facility and it contained no documentation that verified the emergency preparedness plan's policies and procedures had been developed and implemented based on facility-based and community based risk assessment, utilizing an all hazards approach. 42 CFR 483.73-Emergency Preparedness 42 CFR 483.73(a)(1)(2) 42 CFR 483.73(b)

Plan of Correction: ApprovedAugust 28, 2018

E 001
The corrective action that will be accomplished for those residents found to have been affected by the deficient practice:
The Community Based Assessment was completed at the time of the LTC Survey.A hazards approach template was utilized for completion. The emergency plan will be reviewed and revised at a minimum of once per year. The facility hazard approach will be reviewed monthly as often as needed based on any internal or external environmental factors.Policies and procedures will be reviewed and/ or revised to ensure proper documentation for the community based assessment .
All staff will be inserviced on the facility,s community wide assessment ,hazard assessment and the emergency preparedness plan.This will be inserviced at a minimum of yearly.
All residents have the potential to be affected by the same deficient practice as they reside in the facility in the community
Measures to be put into place to ensure the deficient practice does not recur will include:
Training and In-service on the Facility Assessment as a whole to elicit most training on the Community Based Risk Assessment.
Policies/procedures will be reviewed/revised to ensure proper documentation for the community based assessment which will include but not be limited ,to hazards in the surrounding environmental areas.
The corrective action will be monitored monthly at the QA&A meeting to address any/all concerns relating to the Community Assessment,Hazard Assessment and Environmental Areas.
Person responsible : Administrator.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, a heat detector and a smoke detector were not properly maintained. Issues included a heat detector was covered with a plastic bag and sensitivity testing was not conducted on a smoke detector. This affected one (Second Floor) of two resident use floors and one of one Basement. The findings are: 1. Observation on the Second Floor Green Unit shower/ bath room, on 7/17/18 at 9:08 AM, revealed the heat detector installed from the ceiling of the clean utility room was completely covered by a plastic bag that was wrapped around the detector. During an interview at the time of the observation the Maintenance Director stated on outside contractor had been working in the shower/ bath room at the beginning of the previous week and he was not aware the plastic bag had been placed over the heat detector. During an interview on 7/17/18 at 10:32 AM the Construction Project Manager for the outside contractor that was working in the building stated he was not sure why the heat detector located in the clean utility room was covered with a plastic bag. 2. Observation in the Basement, on 7/17/18 at 12:19 PM, revealed a smoke detector was installed from the Basement's ceiling near the elevator. Review of a Fire Alarm Inspection and Testing report revealed sensitivity testing had been conducted on the building's smoke detectors on 2/3/17. Further review of the report revealed it contained no documentation for the sensitivity testing results of the smoke detector located in the Basement near the elevator. During an interview on 7/24/18 at approximately 3:53 PM the Regional Chief Engineer and the Maintenance Director stated, the facility had no documentation for the sensitivity testing results of the smoke detector located in the Basement near the elevator. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.4.1, 9.6, 9.6.1.3, 9.6.1.4 2010 NFPA 72: Table 14.4.5 14.4.5.3.1, 14.4.5.3.2, 14.3.1, 14.5.1

Plan of Correction: ApprovedSeptember 11, 2018

K 345- NFPA 101 Fire Alarms SYSTEM TESTING AND MAINTENANCE
The corrective action for the deficient practice:
The plastic bag covering the heat detector located in the clean utility room was immediately removed.
The fire inspection/ testing report did not identify the results for the smoke detector located in the basement near the elevator.
A file inspection/ sensitivity testing will be scheduled no later than 9/24/18.
A 100 % audit will be conducted to ensure all heat detectors have had sensitivity testing.
A 100 % audit of all heat sensors and smoke detectors was completed to ensure compliance and make sure they were not covered by plastic bags.
A preventative maintenance program for every 6 months will be started to ensure accurate and appropriate testing/ completion.
Daily inspections of construction areas will be completed after each work day and be documented.
All staff will be inserviced on the importance of not covering heat and smoke detectors with plastic bags.
The results of the audits/ findings reports will be reviewed at the QA & A monthly meetings.

Responsible Person: Director of Maintenance

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, oxygen cylinders were not properly stored. Issues included an oxygen cylinder was stored free standing and unsecured, a room containing oxygen did not have signage stating oxygen was being stored within the room, and combustible materials were stored less than five feet away from oxygen cylinders. This affected one of one Basement. The findings are: 1) Observation in the Basement, on 7/19/18 at 2:42 PM, revealed one C-size oxygen cylinder was stored free standing and unsecured on the floor in the Maintenance Director's office located in the Maintenance Shop. Further observation at this time revealed a cardboard box full of paper was stored approximately eight inches away from the oxygen cylinder. Continued observation at this time revealed the door to the Maintenance Director's office and corridor door to the maintenance shop did not have signage stating oxygen was being stored within the room. During an interview at the time of these observations the Maintenance Director stated, he did not know who put the oxygen cylinder in his office. 2) Observation in the Basement oxygen storage room, on 7/23/18 at 7:45 AM, revealed two wooden crutches were stored in the oxygen storage rack, against three E-size oxygen cylinders. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 11.3.2, 11.3.2.3(2), 11.3.2.6, 11.6.2.3(11), 11.3.4.1, 11.3.4.2

Plan of Correction: ApprovedSeptember 7, 2018

The facility has completed the following:
The one C sized O2 Cylinder was found to be free standing and unsecured in the maintenance office in the basement.The facility immediately placed the cylinder in its proper stand and was removed from the maintenance office.
The two wooden crutches that were being stored in the Oxygen Storage Room along side three E size tanks were removed immediately.
All residents have the potential to be affected by the same deficient practice.
The facility will conduct a 100% audit of all O2 and storage areas where there may be storage of O2. A random audit of all potential o2 supplies and tanks will be completed monthly times three months and every three months thereafter.

The audit results will be brought to the Monthly QA and A meeting for data analysis

Responsible person : Maintenance Director

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, hazardous area doors were not properly maintained. Issues included hazardous area doors were not equipped with self-closing devices and were not designed to self-close and latch into their door frames. This affected two (First and Second Floors) of two resident use floors and one of one Basement. The findings are: 1. a) Observation on the Second Floor, on 7/17/18 at 9:08 AM, revealed the door to the clean utility room was in a fully opened position, the door would not self-close and latch into its door frame, and the door was not equipped with a self-closing device. Further observation at this time revealed the clean utility room was greater than 50 square feet in size and being used to store an approximate seven-foot tall by four-foot long by two-foot wide three-tiered rack containing boxes of: vinyl gloves, plastic urinals, and plastic cups. Continued observation at this time revealed the clean utility room was located within the Green Unit shower/ bath room. During an interview at the time of the observation, the Maintenance Director stated he was not aware the clean utility room door was not self-closing and latching into its door frame. b) Observation on the First Floor, on 7/17/18 at 10:05 AM, revealed the door to the showcase room would not self-close and latch into its frame and the door was not equipped with a self-closing device. Further observation at this time revealed the room was greater than 50 square feet in size and was being used to store: 26 cardboard boxes of fish tank gravel, two cardboard boxes of coral and drift wood, one cardboard box full of tubes of caulk, one 60-pound bag of peat moss, and five pieces of wood. During an interview at the time of the observation the Maintenance Director stated, the items stored in the show case were for the atrium's fish tank project. c) Observation in the Basement, on 7/17/18 at 1:11 PM, revealed the corridor door to the clean linen storage room would not self-close and latch into its frame. Further observation at this time revealed the room was greater than 50 square feet in size and was being used to store: bed sheets, blankets, pillows, mop heads, rolls of paper towels, boxes of face masks, and one-gallon bottles of deodorizer and window cleaner. During an interview on 7/24/18 at approximately 2:21 PM the Maintenance Director stated, he had logs for the audits of the building's hazardous area doors but he could not find them. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.1

Plan of Correction: ApprovedSeptember 7, 2018

K 321 ?
The corrective action will that will be accomplished for those residents found to have been affected by the deficient practice:
1a.) The clean utility door has been adjusted and now catches into it frame.
1b.) A self closing devise was added to the show case door post construction this space will not be used for storage.
1c.) The corridor door to the clean linen storage has been adjusted and now latches into the frame.
A 100% audit of all the hazardous area doors and self closing doors with latching was performed to ensure proper closure by the maintenance staff.
Adjustments were made as needed.All staff will be inserviced on the hazardous area doors and the proper latching.
The measures that will be put into place to ensure the deficient practice does not recur.
All hazardous area doors will be placed on an every 6 month preventative maintenance program.
The monthly action will be monitored thru the QA&A committee for compliance.All audits of the self closing doors and latches will be reviewed at this time . Any changes and /or revisions will be recommended at this time

Responsible Person: Director of Maintenance

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, ventilation ducts were not properly maintained. Issues included ventilation ducts were installed above ceiling tiles instead of below them as designed, ventilation ducts were unsealed, and ventilation ducts were improperly installed. This affected two (First and second Floors) of two resident use floors. The findings are: 1) Observation above the ceiling tile, on the Second Floor, on 7/18/18 at 10:22 AM revealed an approximate eight-inch square ventilation duct was on top of the ceiling tiles in the Beauty Shop. During an interview at the time of the observation, the Regional Chief Engineer and the Maintenance Director stated, the ventilation duct was designed to be installed to vent the area below the ceiling tiles in the Beauty Shop, not above them. The Regional Chief Engineer and the Maintenance Director further stated, the ventilation duct was installed by an outside contractor that was working on the therapy suite project. 2) Observation above the ceiling tile, on the First Floor, on 7/18/18 at 10:22 AM revealed two approximate 20-foot long by four-inch wide circular lengths of flexible aluminum-foil ducts were connected to the building's ventilation system on one end and opened on the other end. Further observation at this time revealed the unconnected ventilation ducts were located in the center core of the building by the atrium. During the observation the Regional Chief Engineer and the Maintenance Director further stated, the ventilation ducts were installed by an outside contractor that was working on the atrium fish tank project. 3) Observation above the ceiling tiles on the First Floor Yellow Unit, on 7/24/18 at 8:44 AM, revealed an approximate 12-foot log by three-inch wide flexible aluminum-foil duct was connected to a two-inch circular plastic vent pipe for a shower in the shower/ bath room. During an interview, at the time of the observation, the Construction Project Manager for the outside contractor stated, the flexible duct was installed into the shower vent approximately one month ago as part of the atrium fish tank project. The Construction Project Manager further stated, the flexible aluminum-foil duct would be removed and replaced by a rigid duct. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.5.2.1, 9.2, 9.2.1 2012 NFPA 90A: 4.1.2, 4.3.1.5

Plan of Correction: ApprovedAugust 24, 2018

The facility completed the following:
The vent in the second floor beauty shop , has been re: installed in the ceiling .
The flexible metal duct has been removed from the first floor atrium area.
The flexible metal duct above the ceiling tiles on the yellow station has been removed and the penetrations have been sealed or capped .
All residents have the potential to be affected by the same deficient practice

A 100% audit of all ceiling tiles / ventilation ducts in the facility will be completed by the maintenance dept.
The audit results will be brought to the monthly QA and A meeting for data analysis .

Responsible person : Maintenance Director

K307 NFPA 101:INTERIOR WALL AND CEILING FINISH

REGULATION: Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: October 22, 2018

Citation Details

Based on observation, interview, and record review during a Life Safety Code survey completed on 7/26/18, non-fired rated interior wood wall finishes had been installed in the facility's atrium. This affected one (First Floor) of two resident use floors. The finding is: 1. Observation on the First Floor, on 7/17/18 at 11:30 AM, revealed non-fire rated sheets of plywood, sections of two-inch thick by four-inch wide boards, and sections of two-inch thick by six-inch wide boards were located above the fish tanks located in the atrium. During an interview on 7/19/18 at 1:12 PM the Construction Project Manager for the outside contractor that installed the fish tanks in the atrium stated, the non-fire rated wood was installed to support the cabinets and electrical work around the fish tanks in the atrium. The Construction Project Manager further stated, the atrium construction project started on 9/16/17 and the cabinet work in the atrium was completed on 4/20/18. During an interview on 7/23/18 at 12:35 PM the Construction Project Manager stated, the non-fire rated wood was installed in the atrium in two stages. The Construction Project Manager further stated, the first stage of installation was approximately three months ago and the second stage of installation was approximately one month ago. Review of documentation for the atrium construction project, provided by the Construction Project Manager, revealed 192 square-feet of plywood, 12 square-feet of two-inch thick by four-inch wide boards, 12 square-feet of two- inch thick by six-inch wide boards, and more than four square-feet of wood blocks of non-fire rated wood were installed in the atrium. Further review of this documentation revealed the project started on 9/16/17 and the cabinet work in the atrium was completed on 4/20/18. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.3.2, 10.2.3.2

Plan of Correction: ApprovedSeptember 24, 2018

The Non - fire rated sheets of plywood , sections of two inch thick by four inch wide boards and sections of two inch thick by six inch wide boards that are located above the fish tanks located in the atrium , will be treated with an approved intumescent coating. The coating to be applied will meet or exceed the requirements of a class A material.
All facility residents have the potential to be affected by the same deficient practice.
The facility will monitor any /all potential non - fire treated wood that could enter the facility during the construction.This will be ongoing
A 100% audit will be completed in the construction areas to ensure that there is no other non - fire treated wood on premises .
The results of the audit will be brought to the monthly QA and A meeting to monitor for construction compliance/non - fire treated wood.
The facility will be hiring a third party to verify installation specifications have been met to verify accuracy of applications .
Responsible Person : Administrator

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, an electrical room was not protected by the automatic sprinkler system. Issues included, an electrical room did not meet all code requirements to not be protected by an automatic sprinkler system. This affected one of one Basement. The finding is: 1. Observation in the Basement, on 7/17/18 at 1:13 PM, revealed the Electrical Equipment room contained the facility's emergency generator, the emergency generator's transfer switch, and the room was not protected by a supervised automatic sprinkler system. Further observation at this time revealed an approximate one-half-inch long by one-half-inch wide penetration above a bundle of electrical wires that were installed through the wall that separated the room from the Basement corridor. Continued observation at this time revealed an approximate two-foot long by one-foot wide wooden shelf with two, one-foot long by four-inch wide wooden supports was installed on one of the room's walls. The observation also revealed combustible materials including a cardboard box containing equipment and paper manuals for the building's telephone system was stored in the room. During an interview at the time of the observation the Regional Chief Engineer and the Maintenance Director stated, the room was not protected by a supervised automatic sprinkler system. Per the 2010 edition of National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems: Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5.1, 9.7, 9.7.1.1(1) 2010 NFPA 13: 8.15.10.3

Plan of Correction: ApprovedSeptember 7, 2018

The facility completed the following for the deficient practice:
The half - inch by half - inch penetration has been sealed with fire rated caulk.
The cardboard box containing equipment and paper has been removed.
All residents have the potential to be affected by the same deficient practice.
A 100 % audit of all combustible spaces will be completed .Any / all findings will repaired .A random audit of all combustible spaces will be completed monthly times three months and six months therafter
The audit results will be brought to the QA and A meeting for Data analysis and trending
Responsible person : Administrator

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Life Safety Code survey completed on 7/26/18, sprinkler heads and sprinkler pipes were not properly maintained. Issues included sprinkler heads that were missing escutcheons; sprinkler heads were obstructed, and sprinkler pipes were exposed to external loads. This affected two (First and Second Floors) of two resident use floors and the Basement. The findings are: 1. a) Observation of the Green Unit, located on the Second Floor, on 7/17/18 at approximately 9:21 AM revealed the escutcheon was missing from the sprinkler head located in the corridor near the stairway exit door by resident room [ROOM NUMBER]. During an interview at the time of the observation, the Maintenance Director stated the escutcheon must have been removed by the outside contractor who installed the new lay-in style ceiling assembly in the building approximately eight months ago. b) Observation of the Green Unit, on 7/17/18 at approximately 9:23 AM, revealed the escutcheon was missing from the sprinkler head located in the janitor's closet near resident room [ROOM NUMBER]. 2. a) Observation of the Yellow Unit, located on the First Floor, on 7/17/18 at approximately 10:21 AM revealed a sprinkler head located near the corridor smoke barrier doors by resident room [ROOM NUMBER] was obstructed by an illuminated exit sign. b) Observation of the Blue Unit, located on the First Floor, on 7/17/18 at approximately 11:48 AM revealed a sprinkler head located near the corridor smoke barrier doors by resident room [ROOM NUMBER] was obstructed by an illuminated exit sign. During an interview at the time of the observation, the Maintenance Director stated the exit signs must have been moved by the outside contractor who installed the new lay-in style ceiling assembly in the building approximately eight months ago. c) Observation of the Basement on 7/17/18 at approximately 1:43 PM revealed metal pipes and conduits were obstructing a sprinkler head located in the corridor near the Maintenance shop. 3. a) Observation of the Boiler room, located in the Basement, on 7/17/18 at approximately 1:06 PM revealed a ventilation duct for one of the boilers was hung from a sprinkler pipe by a metal cable. During an interview at the time of the observation, the Maintenance Director stated the boiler was installed in the building in (MONTH) of (YEAR). b) Observation above the ceiling tile on the First Floor on the Blue Unit, on 7/18/18 at approximately 12:00 PM, revealed an insulated pipe was hung from a sprinkler pipe by a metal wire near resident room [ROOM NUMBER] on Lake Drive. c) Observation above the ceiling tile on the First Floor on the Blue Unit, on 7/18/18 at approximately 12:02 PM, revealed five electrical wires were attached to a sprinkler pipe with tape and plastic ties in four areas near resident room [ROOM NUMBER] on Lake Drive. d) Observation above the ceiling tile on the First Floor on the Blue Unit, on 7/18/18 at approximately 12:19 PM, revealed five electrical wires were attached to a sprinkler pipe with tape in five areas near resident room [ROOM NUMBER] on Eckert Lane. e) Observation above the ceiling tile on the First Floor on the Yellow Unit, on 7/18/18 at approximately 12:28 PM, revealed a metal electrical conduit and electrical wires were attached to a sprinkler pipe with metal wire in two locations near resident room [ROOM NUMBER] on Shamrock Lane. f) Observation above the ceiling tile on the First Floor on the Yellow Unit, on 7/18/18 at approximately 12:53 PM, revealed a metal electrical conduit was attached to a sprinkler pipe with metal wire near the(NAME)Drive Nurses' Station. Review of a sprinkler inspection report dated 6/12/18 revealed the following was marked as Yes on the report; Are sprinklers in good condition, not obstructed, and free of corrosion or loading? 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.2.1.1.4, 5.2.1.2, 5.2.2.2

Plan of Correction: ApprovedSeptember 11, 2018

K353- NFPA 101 Sprinkler System maintenance and Testing
The corrective action that has been accomplished for those residents that have been affected by the
Deficient practice.
Escutcheon(both) on green unit have been replaced by gable sprinkler.
The ventilation duct that was hung on the boiler was removed.
The pipe that was hung from a sprinkler pipe by a metal wire on blue unit was removed.
All electrical wires that were attached to the sprinkler pipe with Tape and plastic ties were removed on the blue unit - Lake.
All electrical wires that were attached to the sprinkler pipe with Tape and ties were removed on the blue unit - Eckert
A metal electrical conduit and electrical wire were removed from the sprinkler pipe in both locations on ye;;ow unit Shamrock Lane.

The sprinkler head located near the maintenance shop has been relocated to the appropriate height.
Wire was removed from the sprinkler room # 17.
The tape was removed from the sprinkler pipe near room # 15.
Exit signs have been relocated to no longer interfere with sprinkler.
Sprinkler last checked on 05/19/2018
Last system test was provided by Gable Sprinkler.
Water system supply source is City Of Buffalo.

A 100 % audit of the sprinkler system for the facility will be completed.
The measures that will be put into place to ensure this deficient practice does not recur will be placed on a every 3 month preventative maintenance program.
The corrective action will be monitored thru the QA & A committee monthly.

Responsible Person: Director of Maintenance

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 7/26/18, a ventilation duct was not properly installed through a smoke barrier. Issues included a ventilation duct installed through a smoke barrier wall that was not equipped with an electronically supervised smoke damper. This affected one (First Floor) of two resident use floors. The finding is: 1. Observation above the ceiling tile on the Yellow Unit, located on the First Floor, on 7/18/18 at approximately 12:47 PM revealed an approximate four-inch circular ventilation duct was installed through the charting room smoke barrier wall. Further observation at this time revealed the ventilation duct was not equipped with an electronically supervised smoke damper. During an interview at the time of the observation, the Regional Chief Engineer and the Maintenance Director stated they were not aware the ventilation duct had been installed through the smoke barrier wall. The ventilation duct had been installed through the smoke barrier wall by an outside contractor who was working on the building's atrium fish tank project. During an interview on 7/18/18 at approximately 12:53 PM, the Construction Project Manager for the outside contractor who installed the fish tanks in the atrium stated, the ventilation duct had been installed through the smoke barrier wall approximately two months ago as part of the ventilation system for the atrium's fish tanks. The duct was not equipped with a smoke damper. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.7.3(2), 8.5, 8.5.5.2, 8.5.5.3, 8.5.5.4, 8.5.5.4.1

Plan of Correction: ApprovedAugust 24, 2018

The facility removed the ventilation duct and the penetrations have been sealed above the ceiling tile on the yellow unit - first floor.This eliminates the need for an electronic supervised smoke damper.
All residents have the potential to be affected by the same deficient practice.
The facility will identify and complete a 100% audit on any/all construction areas that may be affected by this deficient practice .The facility is reviewing alternatives to the previous ventilation system. Moving forward any/ all ventilation ducts will be made of a rigid material.They will also have appropriate smoke dampers and/or the path will not impede a smoke barrier.
The audit results will be reviewed at the monthly QA and A committee for any/ all concerns /issues with this deficient practice.

Responsible person : Administrator

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 26, 2018
Corrected date: September 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 7/26/18, smoke barrier doors were not properly maintained. Issues included, smoke barrier doors that were not maintained to resist the passage of smoke. This affected two (First and Second Floors) of two resident use floors. The findings are: 1. a) Observation on the Second Floor Green Unit, on 7/17/18 at 8:58 AM, revealed when the smoke barrier doors to the(NAME)Drive Unit were completely closed, there was a three-foot long by greater than one-quarter-inch wide gap between the doors. b) Observation on the First Floor Yellow Unit, on 7/17/18 at 10:05 AM, revealed when the Shamrock Lane cross corridor smoke barrier doors were released from their magnetic hold open devices and the door located closest to Resident room [ROOM NUMBER] traveled approximately three inches before it became stuck on the corridor floor. Further observation at this time revealed an approximate six- foot long by three-foot wide gap between the doors. During an interview at the time of the observation the Maintenance Director stated, the corridor floor on Shamrock Lane had been installed by an outside contractor approximately one year ago. c) Observation on the First Floor Yellow Unit, on 7/17/18 at 10:21 AM, revealed when the smoke barrier doors to the(NAME)Drive Unit were completely closed, there was an approximate six-foot long by one-half-inch wide gap between the doors. During an interview at the time of this observation the Maintenance Director stated, the door's latch must not have been reset and it was stopping the door from closing. During an interview on 7/24/18 at 2:21 PM the Maintenance Director stated, he had logs for the audits of the building's smoke barrier doors, but he could not find them. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.7.8, 8.5.4.1

Plan of Correction: ApprovedAugust 24, 2018

The facility has completed the following :
The smoke barrier doors on(NAME)Drive have been adjusted and new latches applied.
The smoke barrier door on Shamrock Lane have been adjusted and the bottom of the door has bee shaved to facilitate the doors opening and closing freely.
The smoke barrier doors on(NAME)Drive was reset and now latches appropriately
All Residents have the potential to be affected by the same deficient practice.
A 100% audit of all fire doors and latching mechanisms will ensue .The log for inspection of the fire doors will be updated and maintained on an on going basis. A preventative maintenance program will be implemented , for every six months, to ensure the doors meet compliance standards .
The audits /findings will be brought to the monthly QA and A meeting for Data analysis and trending.

Responsible person : Administrator