Capstone Center for Rehabilitation and Nursing
December 20, 2016 Certification/complaint Survey

Standard Health Citations

FF09 483.75(b):COMPLY WITH FEDERAL/STATE/LOCAL LAWS/PROF STD

REGULATION: The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not operate and provide services with accepted standards and principles that apply to professionals providing services in the facility on one of three units during the recertification survey and abbrieviated survey (Case #NY 556). Specifically: the facility allowed a Licensed Practical Nurse (LPN) to provide services to the resident's of the facility while aware the LPN was not currently registered by the Office of the Professions. This is evidenced by: Finding #1: During the recertification survey LPN #1 s registration status was reviewed. The facility provided documentation, obtained on [DATE], from the Office of the Professions that documented LPN # 1 was not registered. The date of her licensure documented [DATE]. The facility provided a copy of a letter, dated [DATE], sent to LPN #1 from the State Education Department. This letter documented the registration period as ,[DATE]-,[DATE]. This letter documented that the State Education Department received a Delayed Registration Application (from LPN #1) to reactivate her registration in New York. The letter documented that LPN #1 should answer the question(s) with a box around it, resign, date and return along with a check or money order for the amount requested. There was no further documented evidence that the LPN received her registration. Time card documentation revealed that the LPN performed the duties of an LPN on the following dates: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], [DATE]. On [DATE] LPN #1 was removed from the schedule. On [DATE], the LPN returned to work as a Resident Assistant with no nursing or direct care responsibilities. During interview on [DATE] at 11:20 am, the Human Resources Director (HRD) stated she noticed on [DATE] that LPN #1s registration had expired. She took action. (She provided a written statement that the employee was immediately taken off the schedule; received a 3 day suspension for non compliance and the phone number for the office of the professions was provided; on [DATE] the administrator and Director of Nurses were notified LPN #1 was suspended due to expired license; on ,[DATE] LPN # 1 supplied confirmation she was getting delayed registration taken care of and on [DATE], the LPN's status was reduced to Resident Assistant. The HRD stated that she looks at license expirations on a monthly basis, she looks at Certified Nurse Assistants and nurses. She stated she has to know about the CNA's because the facility pays for their certifications. The HRD stated that LPN #1 continued to work as an LPN after the facility found out she was not licensed. She provided time sheets documenting the LPN did perform the duties of an LPN. During an interview on [DATE] at 9:07 am, the Administrator was asked about the LPN. She stated they thought she brought paperwork in that she renewed her license, but she didn't. She stated they had done a full house audit after that. She stated that now they have to have a monthly system to monitor licenses. She said the HRD has a system, but there was no backup system. She stated no one was auditing licenses of nurses to make sure they had current licenses. 10NYCRR400.2

Plan of Correction: ApprovedJanuary 27, 2017

What corrective action will be implemented for those residents found affected by the deficient practice
LPN# 1 is no longer employed at the facility.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All resident have the potential to be effected by the deficient practice. A full house audit of licensed staff was completed on 12/21/16. No other employees were out of compliance.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur.
The facility reviewed and revised the current license check policy to include monthly license checks. The HR Director and Administrator were educated on the policy.
How the corrective action will be monitored to ensure the deficient will not reoccur: i.e.: QA program put in place.
The facility will complete monthly Office of Professions checks on all licensed staff. Audits to be presented at monthly QA. The QA committee will determine when the frequency of this QA can be decreased.

5. The date for the correction and the title of person responsible for correction of each deficiency.
Date of correction 02/01/17. The HR Director is responsible for this corrective action.

FF09 483.20(d), 483.20(k)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe 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 §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview it was determined during the recertification survey and abbreviated survey (Case #NY 668) the facility did not develop a Comprehensive Care Plan (CCP) for each resident to meet the resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #'s 16, 45, 53 and 120) of 24 residents reviewed. Specifically for Resident #16 there was no CCP for the resident's expressed ideations of suicide; For Resident #45, there was no CCP for pain when the resident received physician ordered pain medication; For Resident #53, there was no documented evidence of a care plan for the resident's use of [MEDICAL CONDITION] medication; and for Resident #120, there was no written care plan for infection control when the resident developed [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) to a wound on her back and no documented evidence of written care plan for an open blister on the resident's back thast had foul smelling drainage. This was evidenced by: The facility's Policy and Procedure for Care Planning documented that care plans must include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Care plans are to be updated at the time of any change in the resident's status, needs, goals and/or interventions. Resident #16: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident understands, was understood and had a Brief Interview of Mental Status of 15/15 or no cognitive impairment. A Social Work Progress Note dated 8/24/16, documented that the resident expressed to staff that she wanted to commit suicide. This writer spoke with the resident and she stated I'm not going to live with this hanging over my head, I should just kill myself so my husband can get the care he needs. When this writer asked her if she had a plan she stated no, I didnt't really mean it. You guys need to relax. My husband used to say that he was going to burn down the house and kill us all and didn't mean it. The resident was told that statements like that are taken seriously and completed a suicide risk assessment. The resident has no suicidal plan wihch is followed by reasons not to kill herself such as I'm young, my husband needs me. The resident has no history of trying to (kill ) herself. She will be seen by the doctor on Friday as requested by the resident. A review of the following Social Work Progress Note dated 8/24/16 at 2:57pm, documented the Suidice Risk Assessment was completed. The resident was at low risk for commiting suicide. She had no plan and promised that she wound not harm herself and that she wasn't serious. We proceeded with low risk goals and interventions. A review of the resident's CCP did not include a CCP for suicidal ideation. Additionally, there was no documented evidence of this resident's expressed Suicidal ideation documented an other CCP's. During interview on 12/20/16 at 10:25 am, the Registered Nurse Unit Manager (RNUM) stated that when a resident voices suicidal ideation Social Work (SW) does a suicide evaluation and agreed that was something the facility does not take lightly. She stated a CCP would be initiated by SW. She stated she was not aware of the suicide statement, if she had been she would have added it to a CCP. During interview on 12/20/16 at 11:50 am, the SW who wrote the 8/24/16 note stated she went to talk with the resident and she said the resident did not mean it. The SW got a suicide Risk Assessment form and completed it and gave it to the Administrator. She stated the resident was low risk according to the assessment. The resident was seen by the psychiatrist. The SW stated there was nothing put in a CCP about suicide ideation, the resident said it was just a joke. The SW stated she did not consider a CCP for the suicide ideation, she was new, there only a month. She stated she had talked with the Administrator and her Supervisor and they never mentioned care planning, just assessment, a progress note and the psychiatric evaluation. During interview on 12/20/16 at 12:06 pm, the Director of Social Work stated that they generally put suicide ideation in a mood CCP. She stated she did not recall if she told the SW to put the suicide ideation in a CCP. She said you have to take it seriously if a resident says something about suicide. Resident #45: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14. The resident sometimes had difficulty understanding others or difficulty making others understand. The Pain Management section under Health Conditions in the MDS documented that the resident had received scheduled pain medication in the last 5 days and that a pain assessment interview should be conducted. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The Pain Evaluation forms dated 12/01/16 to 12/20/16, documented that the resident was consistently evaluated as not being in pain. During an interview on 12/19/16 at 1:30 pm, the Registered Nurse Unit Manager stated that there was no CCP for pain and that a CCP for pain should have been in place. Resident #120: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, was usually able to make herself understood and was usually able to understand others. The Comprehensive Care Plan (CCP) for At Risk for Impairment of Skin Integrity dated 8/05/16, documented a goal: the resident will be free of skin impairment/breakdown as evidenced by intact skin. A revision to the careplan dated 8/11/16, documented the resident had an open blister to her right middle back. A Skin Care Alert dated 8/11/16, documented the resident had a broken blister 6 centimeters (cm) x 3 cm. An At Risk for Impairment of Skin Integrity assessment dated [DATE], documented the resident had an open blister on her right mid back. A Skin Condition Evaluation dated 8/23/16, documented the resident had a blister to her right mid back 6.0 x 3.3 cm. Wound bed was abnormal with sloughing and 40% moist yellow or gray necrotic tissue. A Wound Culture dated 8/23/16, documented the wound was positive for [MEDICAL CONDITION] (MRSA). A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an interview on 12/19/16 at 10:59 am, the Registered Nurse Manager (RNM) #3 reviewed the resident's careplans and stated the resident had a a Risk for Skin Integrity Impairment Careplan. She stated since the blister had opened, was draining and infected, a new care plan for Actual Impaired Skin Integrity should have been initiated. RNM #3 stated the wound physician examined the wound to resident's back and ordered a culture obtained. This culture came back positive [MEDICAL CONDITION]. The RNM stated she also did not see a careplan for Infection Control related [MEDICAL CONDITION] infection to the resident's wound on her back. The resident had been placed on precautions and this would have been included in the careplan. RNM #3 stated that both of these careplans should have been initiated. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedJanuary 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
Resident #16 care plan was updated to include her previous history of [MEDICAL CONDITION].
Resident #45 care plan was updated to include her history of pain and routine pain medication.
Resident #53 care plan was updated to include her [MEDICAL CONDITION] medication.
Resident #120 was discharged from the facility.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house audit of resident care plans to be completed by 02/01/17. To ensure all residents care plans are in place to ensure residents attain or maintain their highest practicable physical, mental and psychosocial well-being. Any care plans found out of compliance will be corrected.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility reviewed the facility Care Plan policy. All Unit Managers, Nursing supervisors, and all other members of the interdisciplinary team will be educated on the facility care plan policy by 02/01/17.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
The facility will complete monthly care plan audits for 10% of residents, audits will include care plan content related to residents, medications, diagnosis, recent behaviors and MDS CAAs to ensure resident care plans are comphrehensive. Audits will be presented at QA. Audits will be completed monthly until the QA determines the frequency can be decreased.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of correction 02/01/17. The Assistant Director of Nursing will be responsible for this corrective action.

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not utilize standard food safety practices. 10 NYCRR Chapter 1 State Sanitary Code Subpart 14-1.32 defines that a hermetically sealed container is designed to be secure against the entry of microorganisms. Specifically, the hermetic seals of canned foods found in the main kitchen were compromised. This is evidenced as follows: The main kitchen was inspected on 12/15/2016 at 8:45 am. The hermetic seal of one #10 can of mixed fruit, found on the speed rack with the common stock in the dry storage area, was compromised with a V shaped dent in the top seam of the can. The Food Service Director stated in an interview conducted on 12/15/2016 at 8:45 am, that cans placed on the speed rack is ready for use and that she had not discussed what to look for on dented cans with the stock person. 10 NYCRR 415.14(h); 10 NYCRR Chapter 1, Subpart 14-1.32

Plan of Correction: ApprovedJanuary 27, 2017

What corrective action will be implemented for those residents found affected by the deficient practice
The can #10 was removed from ready to use stock and discarded on 12/15/16.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken.
All ready to use kitchen stock was checked to ensure no other cans were dented, any items found to be out of compliance were removed and discarded.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur.
The facility will re-educated all kitchen staff by 02/01/17 on sanitary conditions in the kitchen and the need to removed dented cans from ready to use stock. The facility implemented a ready to use stock check list that includes the identification of dented cans for removal of the ready to use stock.
How the corrective action will be monitored to ensure the deficient will not reoccur: i.e. Quality assurance program will be put in place.
The facility will audit sanitary conditions in the kitchen including ready to use stock to ensure there are no dented cans weekly following food deliveries. To be reported in QA monthly until the QA committee determines the frequency can be decreased.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of correction 02/01/17. To be completed by the Food Service Director.

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not provide necessary housekeeping and maintenance services. 10 NYCRR 483.10(i)(2) requires that the facility provide for a clean environment. Specifically, the floors were not clean on 3 of 3 resident units. This is evidenced as follows: The environment on the 2nd floor residential unit, 3rd floor residential unit and 4th floor residential unit corridor floors were not clean behind the smoke barrier doors, in corners and at the base of door frames. Further the floors were not clean in corners and behind doors in resident rooms 279, 356, 454, 476, 485 and 487. The Director of Plant Operations stated in an interview conducted on 12/19/2016 at 2:50 pm, that some floor cleaning equipment including a corner-cleaning tool, was not in good repair and that staff have not yet begun to strip the floors in resident rooms. 10 NYCRR 483.10(i)(2)

Plan of Correction: ApprovedJanuary 27, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be effected by the deficient practice.
Rooms 279, 356, 454, 476, 485 and 487 floors and corners of the floors were cleaned. 4th floor unit corridors and corners behind the smoke barriers were cleaned.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house check of resident rooms, halls, common areas, medication rooms and clean utility rooms will be completed by 02/01/17.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Housekeeping staff and maintenance department will be educated on floor cleaning by 02/01/17.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
Housekeeping audits of the will be completed monthly, the audits will include the cleanliness of the floors and corners of the floors.
Monthly audit of 10% of areas to include resident rooms, halls and common areas will be completed and presented during monthly QA until the facility has reached an acceptable level of compliance, the QA committee will then determine the frequency of the audits.
The date for the correction and the title of the person responsible for correction of each deficiency.
To be completed by 02/01/17. The Director of Maintenance is responsible for corrective action of this deficiency.
will be completed and presented during monthly QA.
The date for the correction and the title of the person responsible for correction of each deficiency.
To be completed by 02/01/17. The Director of Maintenance is responsible for corrective action of this deficiency.

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification 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: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and Administrative Policy review during the recertification survey, it was determined that the facility did not conduct the minimum required background checks prior to hiring employees. 10 NYCRR 483.12(a)(3) requires that facilities may not employ individuals with a finding entered into the State nurse aide registry (NAR) concerning abuse, neglect, mistreatment of [REDACTED]. Specifically, the State nurse aid registry check and a New York State Department of Education Office of the Professions (OP) check was not conducted for 1 of 1 licensed new employees reviewed. This is evidenced as follows: The personnel file for Registered Nurse #1 (RN), rehired on 07/18/2016, was reviewed on 12/15/2016. This record review revealed that the facility had not conducted either a NAR check and an OP check for this employee before rehiring. The Director of Human Resources stated in an interview conducted on 12/15/2016 at 4:00 pm, that she did not think a NAR and OP check would be required since the RN left employment on 07/15/2016 and was rehired per diem on 07/18/2016. The facility policy Employee Prescreen/License/Credentialing was reviewed on 12/15/2016. This policy states that licensed applicants will be processed and prescreened through the Prometric Nurse Aide Registry Verification and the New York State Office of the Professions license verification. 10 NYCRR 483.12(a)(3)

Plan of Correction: ApprovedJanuary 27, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be effected by this deficient practice. RN #1 is no longer employed at the facility.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house audit of background checks will be completed by 02/01/17 to ensure all facility employees or contracted employees have all pre-hire checks completed.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility background check and pre hire check policy was reviewed on 01/09/17.
The Human Resources Director, all Department Managers who are responsible for hiring staff and facility Administrator will be re-educated on the policy by 02/01/17.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit of all new hires pre-hire checklist will be audited and presented to the QA committee monthly and will be ongoing until the QA committee determines the frequency can be decreased.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of correction 02/01/17. The HR Director is responsible for the correction of this deficiency.

FF09 483.25(i):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that each resident maintained acceptable parameters of nutritional status, such as body weight for one ( Resident #5) of two residents reviewed for weight loss during the recertification survey. Specifically: a significant weight loss was not assessed in a timely manner. This is evidenced by: Resident #5: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident understands, was understood and had a Brief Interview of Mental Status of 15/15 or no cognitive impairment. It also documented the resident weighed 194 lbs and had a significant weight loss, not prescribed by a physician. The MDS of 7/27/16, also documented the resident was 205 lbs and had a significant weight loss, not physician prescribed. The facilities computerized weight record documented: 5/4/16=224.6 lbs., 6/15/16=226.8 lbs., 6/30/16=224 lbs., 7/12/16=201.2, then approximately 39 minutes later weight = 204.6 lbs (significant loss of 8.6%), 7/20/16=205.8 lbs, 8/3/16=207.8 lbs, 8/17/16= refused, 8/24/16= refused. The Comprehensive Care Plan, updated 11/29/16, documented goals that included adequate food and fluid intake to maintain weight and good hydration. Approaches included: hour of sleep snack as desired; provide diet as ordered; monitor meal intake sheets/flow sheets, encourage fluids; adhere to resident's food preferences; on 9/20/16 added Two Cal 90 milliliters three times a day. A Nutrition Quarterly Assessment done on 4/21/16 documented the resident's weight as 222 lbs with an 8 lb gain in 3 months. Average food intake was 77-100% at meals. The next nutrition progress note or Assessment was on 7/28/16 or 16 days after the significant weight loss. This assessment documented the resident weighed 206 lbs and the weight was down 14 lbs in 30 days and 16 lbs in 90 days. The resident was currently being tested for [MEDICAL CONDITION] and Ca (calcium) status per unit manager. The resident lost weight in the past month after gaining weight gradually from Nov. to June. Current weight remains well above healthy range, but the sudden decrease is undesirable. Fluid intake is very good but solid food intake has decreased since last review, resident is refusing meals fairly often. Meal plan is set up per resident preferences and resident still makes her needs and preferences known. Evening snack is provided along with between meal snacks being offered from the unit. There was to be no change in diet plan at the time. Monitoring of weight, labs, intake acute change, tolerance to diet order, bowels and skin integrity were to continue. During interview on 12/20/16 at 11:15 am, the Registered Nurse Unit Manager (RNUM) stated that on 7/12/16 she notified the MD of the 20 lb weight loss and there were no new orders. She stated that she did talk to the Dietitian (RD) about the weight loss around that date, but did not know when specifically. The RNUM stated they talked about endocrinology and oncology appointments, and possible return of [MEDICAL CONDITION]. The RNUM stated that Oncology said the resident was stable and nothing came up from any testing. During interview on 12/20/16 at 12:39 pm, the RD stated the resident weights change quickly, it is not realistic that it is nutrition. She stated they had never done a calorie count on the resident. The RD stated that her experience was that you get missing information from them. The RD stated that she had trouble believing the 7/12 weight was real. She looked at the resident's weights in the computer and said that a second weight was done that day and it was close to the first weight. She stated the assessment of the weight loss was not done until 7/28/16 and at that point the resident was being tested for [MEDICAL CONDITION] and getting an oncology consult. The RD stated there have been dramatic fluctuations for this resident's weight since she was admitted . She said she did not add anything (on the 28th) because the resident was still eating. The RD said that 16 days later was not a timely assessment of the weight loss, she tries to catch weight loss sooner than that. 10NYCRR415.12(i)(1)

Plan of Correction: ApprovedJanuary 27, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
Resident # 5 was seen by the physician on 01/11/17 related to her previous weight loss and the dietician will review and see the resident by 01/20/17.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents were reviewed for weight loss to ensure all residents with significant weight loss were identified and interventions were put in place to maintain their nutritional status unless unavoidable. Any residents identified during the full house audit that have not had timely interventions will be corrected and the dietician and MD will be notified for follow up.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility weight loss policy will be reviewed. Unit managers, diet tech and dietician re-educated on the facility weight loss policy.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
Weekly audits of all residents who trigger for a significant weight loss based on the electronic medical record weight loss report will be completed to ensure residents who had a significant weight loss have appropriate interventions in place timely. Audits to be reported at QA monthly until the QA determines their frequency can be decreased.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of correction 02/01/17. Person responsible is the facility Registered Dietician.

FF09 483.10(b)(11):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

REGULATION: A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in §483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in §483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during a recertification survey and an abbreviated survey (Complaint # NY 8493), the facility did not notify the resident's family when there was a significant change in the residents' physical status for one (1) (Resident #119) of fourteen (14) residents reviewed. Specifically, Resident #119's family was not notified that the resident's second toe on the left foot became necrotic and that the resident's left foot became grossly [MEDICAL CONDITION] (swollen). Resident #119: The resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was able to understand others and was able to be understood. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The Nursing Progress Note dated 6/22/16, documented on admission skin check, the left top portion of the resident's foot had an open area; the outer part of the left foot had an open blister and the second toe had an old scabbed area to the back side of the toe. The Nursing Progress Note dated 8/20/16, documented the resident's second toe on his left foot had a fluid filled intact blister to the top aspect of the foot just below the toe. The toe was bluish/black in color with a superficial abrasion on top of the toe. The second toe and foot itself was grossly [MEDICAL CONDITION] and red. The Nursing Progress Note dated 8/21/16, documented the blister to top of the resident's left foot just below the toes had opened with drainage observed. The foot remained very red and [MEDICAL CONDITION]. The Nursing Progress Note dated 8/22/16 at 10:47 am, documented the resident was assessed by an Registered Nurse as staff verbalized that he had been hearing voices. The resident was also confused and pale. The resident realized he had been hallucinating. The blister on the second toe had opened, with serosanguinous (containing both blood and liquid part of the blood) drainage. His left toes remained bluish/black in color and skin was sloughing off to the top and bottom of the foot. The physician was notified and ordered the resident transferred to the emergency room to be evaluated by a surgeon. The Nursing Progress Note dated 8/22/16 at 10:55 am, documented the resident's son had been notified that the resident was being sent to the hospital for evaluation of his left foot. The Nursing Progress Note dated 8/22/16 at 4:43 pm, documented the resident was admitted to the hospital with [REDACTED]. During an interview on 12/16/16 at 10:15 am, the Registered Nurse Manager (RNM) #1 stated the resident had multiple wounds when admitted which included a wound to the dorsal (back) aspect of his left foot which was diagnosed by the wound doctor as a diabetic ulcer. On admission, there were no wounds to his toes on the left foot. RNM #1 stated that skin sheets documented skin assessments which had been sent to all disciplines. The resident would sit on his bed dangling his feet. He was educated to keep his feet up due to his poor circulation. RNM #1 stated the resident was non-compliant with keeping his feet up. On 8/20/16, the left foot had a fluid filled blister with the second toe being blue/black in color. There was an abrasion to the foot and the top of the toe was [MEDICAL CONDITION] and red. RNM #1 stated she spoke with the physician on 8/22 about of the condition of the resident's left foot. She attempted to call the resident's sister and did call his son to notify him that the resident was being sent to the hospital. RNM #1 reviewed the progress notes and stated there was no documentation in the progress notes to indicate that the family had been notified of the condition of the resident's left foot. During an interview on 12/16/16 at 11:58 am, RNM #2 stated she was the supervisor the day the resident was sent to the hospital. She assessed the resident's left foot to have a fluid filled blister on top with the toe being bluish/black in color. The foot and second toe were [MEDICAL CONDITION]. The doctor was made aware. RNM #2 stated that typically the supervisor or RNM would call the family to tell them about a change in a resident's condition. She did not call the family as the LPN stated she would call. She did not check back with the LPN to find out if the family had been called. During a telephone call on 12/20/16 at 9:30 am, the LPN stated she had no recollection of the resident. 10NYCRR415.3(e)(2)(ii)(b)

Plan of Correction: ApprovedJanuary 27, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
Resident number #119 is no longer at the facility.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house audit of nurses notes from the last 30 days will be completed to ensure no other residents were impacted by this deficient practice.
Any residents with issues identified will have their family members contacted.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
An education with all licensed nursing staff will be completed by 02/01/17 on family notification.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
The facility implemented a weekly audit of all resident's nurses notes to identify any resident issues that require updates to their family member. Audits to be reported in monthly QA x3 month until the facility has reached an acceptable level of compliance, the QA committee will then determine the frequency of the audits.
The date for the correction and the title of the person responsible for correction of each deficiency.
The Director of Nursing will be responsible for monitoring this corrective action to be completed by 02/01/17

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that it maintained clinical records that were accurately documented for one ( Resident #30) of 14 residents reviewed during phase one of the recertification survey. Specifically: For Resident #30, nursing staff did not accurately document the effect of an as needed medication. This is evidenced by: Resident #30: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident usually understands, was usually understood and had a Brief Interview of Mental Status of 10/15 or moderately impaired cognitive ability. A physician order [REDACTED]. The Comprehensive Care Plan (CCP) for the use of [MEDICAL CONDITION] drugs, dated 10/28/16, documented approaches which included: medications per MD order; administer medications as ordered and observe for effectiveness. The resident's CCP for behavior dated 9/26/16, documented approaches of : medication as ordered; monitor effectiveness of medications. The Medication Administration Record [REDACTED]. The outcome of medication administration was documented 5 times as improved. There was no further clarification of how the resident was improved or what the resident was doing after the medication administration The MAR for (MONTH) (YEAR), documented the PRN [MEDICATION NAME] was given 8 times on 10/1, 10/2, 10/3, 10/5, 10/6, 10/10, 10/20 and 10/22/16. The outcome of medication administration was documented 5 times as improved. There was no further clarification of how the resident was improved or what the resident was doing after the medication administration On 10/6/16, there was a nursing note that documented the PRN [MEDICATION NAME] was given for behaviors with no change, the resident continued to call out and be combative with cares. The MAR for (MONTH) (YEAR), documented the PRN [MEDICATION NAME] given 1 time on 11/30/16. The outcome of medication administration was documented as improved. There was no further clarification of how the resident was improved or what the resident was doing after the medication administration The MAR for (MONTH) (YEAR), documented the PRN [MEDICATION NAME] given 3 times on 12/2, 12/13 and 12/16/16. The outcome of medication administration was documented two times as improved. There was no further clarification of how the resident was improved or what the resident was doing after the medication administration During an interview on 12/20/16 at 9:34 am, the Registered Nurse Manager looked at the MARs for this resident and saw the PRN [MEDICATION NAME]. She stated there were interventions given prior to administration of the PRN [MEDICATION NAME]. She was asked about the effectiveness. She saw the documentation of improved. She was asked what that meant to her. She stated the behavior was better, but some still there. She said the effectiveness should have a note to to say specifically what the resident was now doing, i.e calm, cooperative, etc. She looked back through (MONTH) (YEAR) and stated there was nothing to further clarify the evaluation of effectiveness of the PRN medication. During an interview on 12/20/16 at 1:43 pm, a Licensed Practical Nurse (LPN), who has given the resident her PRN medication, explained there were two ways to give the PRN. You can put it under [MEDICAL CONDITION] medication or put it under other. If the medication is put under other a drop down box comes up that says either effective or not effective. If the medication is put in under the [MEDICAL CONDITION] medication then a drop down box comes up that says effective, not effective, improved, worsened or stayed the same. She stated when giving the PRN she would write a nurses note stating the symptoms for giving, then go back and write a note about the effect. She said that improved would mean no longer aggressive, etc. She was asked if what she meant by effective or improved would be the same as someone else and she said not necessarily. 10NYCRR415.22(a)(1-4)

Plan of Correction: ApprovedJanuary 27, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
Resident # 30 was seen by the psychiatric nurse practitioner on 01/06/17 to review her current medications and prn use to ensure they continue to be effective for this resident.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house audit will be completed by 01/20/17 of all residents on prn [MEDICAL CONDITION] to identify whch residents have the potential to be effected by this deficient practice. All residents utilizing prn [MEDICAL CONDITION] will have referral for psych NP follow up or MD follow for review of effectiveness of the prn [MEDICAL CONDITION] medication.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility will re-educate licensed nursing staff adding comments to their prn post [MEDICAL CONDITION] use and the importance of accurate documentation.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
Post prn [MEDICAL CONDITION] use will be audited weekly, audit will consist of 10% of residents on prn [MEDICAL CONDITION] to ensure there is accurate documentation and presented at monthly QA. The QA committee will determine when the frequency can be decreased.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date certain 02/01/17. The person responsible is the Director of Nursing Services.

FF09 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that services provided met professional standards of quality during the recertification survey and abbrieviated survey (Case # 556) for one of three units. Specifically: a Licensed Practical Nurse (LPN) was performing the duties of an LPN without a current registration from the Office of the professions for approximately 10 months. This is evidenced by: Finding #1: During the recertification survey LPN #1's registration status was reviewed. The facility provided documentation, obtained on [DATE], from the Office of the Professions that documented LPN #1 was not registered. The date of her licensure documented [DATE]. The facility provided a copy of a letter sent to LPN #1 from the State Education Department dated [DATE]. This letter documented the registration period as ,[DATE]-,[DATE]. This letter documented that the State Education Department received a Delayed Registration Application (from LPN # 1) to reactivate her registration in New York. The letter documented that LPN #1 should answer the question(s) with a box around it, resign, date and return along with a check or money order for the amount requested. There was no further documented evidence that this LPN received her registration. A review of the facility's Time card documentation documented that LPN #1 performed LPN duties on the following dates: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and on [DATE]. On [DATE], LPN #1 was removed from the schedule. On [DATE], LPN #1 returned to work as a Resident Assistant with no nursing or direct care responsibilities. During interview on [DATE] at 11:20 am, the Human Resources Director (HRD) stated she noticed on [DATE] that LPN #1's registration had expired. She took action. (She provided a written statement that the employee was immediately taken off the schedule; received a 3 day suspension for non compliance and the phone number for the Office of the Professions was provided; On [DATE], the Administrator and Director of Nurses were notified that LPN #1 was suspended due to an expired license; on [DATE], LPN #1 supplied confirmation she was getting the delayed registration taken care of and on [DATE], LPN #1's status was reduced to Resident Assistant. The HRD stated that she looks at license expirations on a monthly basis, she looks at Certified Nurse Assistants and nurses. She stated she has to know about the CNAs because the facility pays for their certifications. The HRD stated that LPN #1 continued to work as an LPN after the facility found out she was not licensed. She provided time sheets that documented LPN #1 worked in the capacity of LPN. 10NYCRR415.11(c)(3)(i)

Plan of Correction: ApprovedJanuary 27, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be effected by this deficient practice. LPN# 1 is no longer employed at the facility.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All resident have the potential to be effected by the deficient practice. A full house audit of licensed staff was completed on 12/21/16. No other employees were out of compliance.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility revised the current license check policy to include monthly license checks. The HR Director and Administrator were re-educated on this policy.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
The facility will complete monthly audits of employee profession/license checks to be presented at monthly QA. The QA committee will determine when the frequency can be decreased.
The date for the correction and the title of the person responsible for correction of each deficiency.
02/01/17 the HR Director will be responsible for this corrective action.

Standard Life Safety Code Citations

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review during the recertification survey, it was determined that the facility did not protect all cooking facilities in accordance with adopted regulations. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Section 11.1.4 requires that instructions for manually operating the kitchen fire-extinguishing system shall be reviewed with employees by the management. NFPA 17A Standard for Wet Chemical Extinguishing Systems 2009 edition section 7.3.3 requires that at least semiannual maintenance to be conducted on kitchen fire-extinguishing systems in accordance with the manufacturer's listed installation and maintenance manual. Specifically, 2 of 2 kitchen staff interviewed did not know how to manually activate the kitchen fire-extinguishing system and the facility management had not reviewed the procedure with the employees. Additionally, the kitchen fire extinguishing system was not tested semi-annually. This is evidenced as follows. When interviewed on 12/15/2016 at 9:45 am, the Food Service Director did not know how to manually operate the kitchen fire-extinguishing system. When interviewed on 12/15/2016 at 9:55 am, Dietary Aide #1 stated that he had not received instruction on how to manually operate and did not know how to manually operate the kitchen fire-extinguishing system. The kitchen fire extinguishing system test reports were reviewed on 12/20/2016. The documentation provided revealed that the kitchen fire extinguishing system was tested on [DATE] only during (YEAR). The Director of Plant Operations stated in an interview conducted on 12/20/2016 at 1:30 pm, that the kitchen fire extinguishing system was not tested prior to 07/12/2016 during (YEAR). 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.2.3; 2011 NFPA 96 11.1.4; 2009 NFPA 17A 7.3.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.2.6; 1998 NFPA 96; 1998 NFPA 17A 5-3.1.1(e)

Plan of Correction: ApprovedJanuary 13, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All resident have the potential to be effected by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All resident have the potential to be effected by this deficient practice. The kitchen fire extinguishing system is scheduled to be tested on [DATE].
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility will re-educate all dietary staff on how to use the kitchen fire extinguishing system. The facility the current life safety checklist to ensure Kitchen Fire Extinguishing system tests were a part of the list and re-educated the Director of Environmental Services on the schedule for Kitchen Fire Extinguishing test requirements.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
The facility will complete monthly audits of dietary staffs understanding of how to active the kitchen fire extinguishing system utilizing a staff interview to include 10% of kitchen staff monthly to be reported at monthly QA. Audits will continue monthly until the QA committee determines the frequency can be decreased.
The kitchen fire extinguishing system test date will be reviewed monthly at QA to ensure the QA committee is aware of when the next semiannual test is due. This reviewed monthly for 12 months then the QA committee will determine the frequency of this audit.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of correction 02/01/17. The Maintenance Director is responsible for the correction of this deficiency.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

Based on observation and employee interview during the recertification survey, it was determined that the facility did not develop maintenance policies for and provide records of all testing and repairs of all patient-care electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.5.2.1 requires that facilities shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment. Section 10.5.6 requires that records and a log shall be maintained of the tests and associated repairs or modifications of all patient-care electrical equipment. Specifically, the facility did not develop maintenance policies and record all testing and repairs of all patient-care related electrical equipment. This is evidenced as follows. No associated maintenance policy was available for survey review and no associated testing and repair records and logs for patient care-related electrical equipment were available for survey review on 12/12/2016. The Director of Plant Operations stated in an interview conducted on 12/19/2016 at 9:00 am, that the facility does not have standardized maintenance policies and test records and logs for all patient-care related electrical equipment. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.5.2.1.1, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedJanuary 13, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be effected by this deficient practice.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be effected by this deficient practice. A full house audit of all patient care equipment will be completed to ensure all current patient care equipment has been checked and tested by 02/01/17. Any equipment not fit for use will be removed from use.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility will develop a policy and procedure for the testing and maintenance of a patient- care related equipment. The facility develop a log for all maintenance and testing of patient ? care equipment. The Maintenance Director and maintenance staff will be educated on this policy, procedure and log.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
The facility will audit the patient-care equipment log monthly to ensure current patient-care equipment has been maintenance and logged and any new equipment brought into the facility that month has been checked and logged.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of the correction 02/01/17. The Maintenance Director will be responsible for the correction of this deficient practice.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 20, 2016
Corrected date: February 1, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.6.2 requires that the walls to vertical openings, such as stairwells, have a 1-hour fire resistance rating and be continuous from floor to roof. Specifically, the walls of the west stairwell were not continuous from floor to the underside of the roof and did not maintain a 1-hour fire resistance rating. This is evidenced as follows: The 4th floor west stairwell was inspected on 12/19/2016 at 10:40 am. Two 5-inch holes for piping and one 2-inch hole for a conduit pipe were found. The Director of Plant Operations stated in an interview conducted on 12/19/2016 at 11:35 am, that the penetrations found were overlooked and the holes for the piping are probably new. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedJanuary 13, 2017

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be impacted by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be impacted by this deficient practice. The facility has an outside consultant that will complete a full house audit of all vertical openings for penetrations using the facility floor plans to identify areas that must be checked. All areas identified during the full house audit will be sealed and protected using the appropriate product.
The 4th floor west stairwell piping holes and conduit holes identified in the statement of deficencies were sealed and protected using the appropriate product.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
The facility obtained the services of a consultant, not employed by the facility, to develop and implement an acceptable plan of correction.
The consultant will educate Maintenance staff on vertical openings and the need for 1 hour fire resistance rating.
A QA committee met on 01/06/17 to complete an assessment of the causative factors that may have contributed to vertical openings not properly enclosed with a 1 hour fire rating. The assessment tools utilized was a fish-bone diagram to assist to identifying the root cause of this deficient practice.
The QA team included the outside consultant who assisted in identifying the specific steps/interventions to correct the causative factors identified during the assessment phase.
The QA team identified the triggers that will signal or alert staff of an evolving problem or deficient practice situation related to vertical openings and penetrations. The QA team identified a plan to complete internal permits and work plans with new contractors who complete any new work in the building. In addition contractors will be requested not to replace moved ceiling tiles until the Director of Environmental Services reviews the work done to ensure there are no penetrations that have not been sealed.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
The facility will complete semi-annual inspections of the buildings vertical opening penetrations. The first semi-annual inspection will be completed as the facility full house vertical opening penetration check completed by the outside consultant. The second semi-annual check will be completed by the Director of Environmental and the outside consultant.
Any new contractor work done or internal work done will be reported at monthly QA to ensure there are no vertical penetrations. Audits to be completed by the outside consultant for the Director of Environmental Services to present during monthly QA. QA to be completed for 12 months. After 12 months the QA committee will determine the frequency of continued audits.
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of correction 02/01/17. The person responsible is the outside consultant. Consultant resume sent separately.