The Grand Rehabilitation and Nursing at Mohawk
March 14, 2018 Certification/complaint Survey

Standard Health Citations

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: March 16, 2018
Corrected date: May 14, 2018

Citation Details

Based on observation, record review, and interview during the recertification survey, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 11 employees reviewed for influenza (flu) vaccinations. Specifically, one employee who did not receive the flu vaccine was observed not wearing a mask correctly during the designated flu season. Additionally, the facility did not establish and maintain a risk assessment on the facility's potable water system, specifically the facility did not complete a risk assessment for Legionella (a bacterium found in building water systems). Findings include: FLU MASKS The facility's Influenza protocol for staff (undated) documented the following: - In (MONTH) 2013, a rule was passed requiring all unvaccinated health care personnel to wear a mask during the time when the Commissioner determines flu is prevalent. The New York State Department of Health Commissioner declared Influenza prevalent in the state on 12/13/2017. The facility's medical mask policy and procedure (undated) documented masks are to be worn wherever an unvaccinated health care worker might expose residents to the flu. The medical mask policy and procedure in-service roster documented certified nurse aide (CNA) #8 completed the mask training on 10/9/2017. Certified nurse aide (CNA) #8 was observed at the following times: - On 3/13/2018 at 10:42 AM in the third-floor hallway with her flu mask not covering her nose. - On 3/13/2018 at 12:19 PM in the dining room with her flu mask beneath her nose. - On 3/13/18 at 12:26 PM and 12:30 PM feeding a resident with her flu mask beneath her nose. - On 3/13/2018 at 12:40 PM she touched her exposed nose and then pulled the mask up over her nose. - On 3/13/2018 at 12:47 PM exiting the dining room with her mask beneath her nose. - On 3/15/2018 at 8:47 AM and 8:52 AM feeding residents with her flu mask beneath her nose. During an interview with Infection Control registered nurse (RN) #9 on 3/15/2018 at 11:25 AM, she stated she was responsible for educating staff regarding the flu, flu shot, and mask application. If a staff member declined the flu shot, he/she was required to read the policy and do a return demonstration of the correct way to apply the mask. The training included applying the mask in the right direction, applying the loops around the ears, and ensuring the mask was below the chin and pinched at the nose. Masks were to be changed when soiled or moist and unvaccinated staff were to wear a mask any time they were on a resident unit. Masks were to be worn when unvaccinated staff entered the facility and went past the lobby. Peers, unit managers, administration, and supervisors were responsible for monitoring and ensuring unvaccinated staff were wearing the mask correctly while in the resident areas. During an interview with CNA #8 on 3/15/2018 at 1:30 PM, she stated she had not had the flu shot and had training regarding mask application and its use; and the mask was difficult to keep on. LEGIONELLA Review of the facility's risk assessment on 3/14/2018 revealed there was no documented evidence a risk assessment was completed for Legionella. The undated Guidelines for the prevention of Legionella policy did not include acceptable pathogen levels for potable water system. When interviewed on 03/13/18 at 4:00 PM, the Plant Operations Manager stated he was unsure if there was a risk assessment performed for Legionella. During an interview with the Administrator on 3/14/18 at 12:45 PM he stated the facility did not have a risk assessment done for Legionella. 10NYCRR 415.19(a)(1-3)

Plan of Correction: ApprovedApril 12, 2018

F 880
1. The employee found not to wearing her flu mask appropriately has been educated and has demonstrated the appropriate way to wear a flu mask. The facility has created and completed a risk assessment for Legionella.
2. The Director of Education has a list of all staff members that did not receive the flu shot and this list has been provided to all department managers and nursing supervisors. Staff that did not receive the flu shot are identified by not having a sticker placed on his/her badge. Those staff members that did not receive the flu shot will meet with the Director of Education to demonstrate how to wear the flu mask and that the staff member is wearing the mask appropriately. The facility policy and procedure for testing for legionella has been reviewed and revised to include acceptable pathogen levels for portable water systems.
3. The policy and procedure for wearing of a flu mask has been reviewed and revised as well as the policy and procedure for Legionella testing. The Director of Education will in-service all staff that wear a flu mask on the proper way of wearing a mask. All maintenance staff will be educated on completion of the facility risk assessment for Legionella as well as acceptable pathogen levels for portable water systems.
The facility will develop an audit to be completed weekly (until flu season is closed) on all staff that are wearing a flu mask, ensuring that masks are being worn correctly. The facility will complete the risk assessment for Legionella testing semi-annually and will continue to complete the Legionella testing per regulations. Information obtained from the audits of staff wearing flu masks as well as the Legionella water testing results will be reviewed at the monthly QAPI meeting. This will be completed monthly for twelve months. Facility compliance goal is 100%
4. Director of Maintenance and Education
5. May 14, (YEAR)

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: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review conducted during the recertification survey, it was determined for 1 of 3 residents (Resident #12) reviewed for abuse/neglect and mistreatment, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were investigated or reported to the New York State Department of Health (NYSDOH) as required. Specifically, Resident #12 had a skin tear of unknown origin and an investigation to rule out abuse, neglect, or mistreatment was not initiated. Findings include: The facility's undated policy on incidents requiring I&As (incident and accident reports) listed Injuries (skin tears, abrasions, ecchymosis, burns, etc.) as incidents requiring an I&A. Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 12/2/17 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of two staff for all activities of daily living (ADLs), had one unhealed pressure ulcer, and no skin tears. The resident nursing instructions updated 1/21/2018, documented the resident required extensive assistance with ADLs, transferred with two persons and hand-held assistance, and was to have white Geri-sleeves (or derma sleeves, fabric covers for skin protection) on at all times, with removal for care. The comprehensive care plan (CCP) updated 2/26/2018 documented the resident was at risk for skin tears related to fragility and impaired cognition. Interventions included derma sleeves on at all times, remove in morning and bedtime for hygiene and care. The CCP update note on 2/26/2018 documented the resident had no current skin tears and continued to remain at high risk. The resident was observed on 3/13/2018 at 1:45 PM in her room, with a gauze bandage wrapped around her left forearm, secured with medical tape, and no date was marked on the tape. The resident's family member stated during an interview on 3/13/2018 at 1:45 PM, the resident had very fragile skin, had multiple skin tears in the past, and she was not notified of any recent skin tears. She stated she did not know the reason for the bandage on the resident's left forearm. On 3/15/18 12:30 PM, the resident was observed in the dining room. She had an undated gauze bandage wrapped around her left forearm. The resident's family member stated she inquired about the bandage and was told it was a skin tear. She was not advised of when or how it occurred. On 3/15/18 at 1:55 PM, during an interview, licensed practical nurse (LPN) #6 stated the resident had a small skin tear from the other day and she didn't have Geri-sleeves on when the aides transferred her to the bathroom. On 3/15/2018 at 3:48 PM, nursing progress notes from 3/1/2018-3/15/2018, physician's orders [REDACTED]. There was no documentation found regarding a skin tear to the resident's left forearm, an assessment, or a treatment ordered for the area. All incident reports related to the resident from 12/2017 to 3/15/2018 were requested on 3/15/2018. There was no documented evidence an incident report was initiated related to the resident's skin tear to the left forearm. During an interview on 3/16/2018 at 1:45 PM, certified nurse aide (CNA) #1 stated the resident required the assistance of 2 staff, transferred by standing/pivoting, was brought to the bathroom for toileting needs, and wore Geri-sleeves on both arms. She was unaware of an injury or bandage to the resident's left arm. CNA #2 stated during an interview on 3/16/18 at 2:00 PM, the last time she cared for the resident on 3/11/2018, she did not have a bandage on her left forearm. She currently had a bandage on the arm and did not know what happened. She stated the resident should have Geri-sleeves on at all times and her skin was very frail. During an interview with Registered Nurse (RN) Unit manager #3 on 3/16/2018 at 2:30 PM, she stated she was not made aware of the skin tear on the resident's left forearm. She was unaware of any skin treatment the resident was receiving. She stated any skin tear should be reported to an RN for assessment, an incident report needed to be done, family was to be notified, and medical notified to order a treatment. An LPN should not determine or initiate treatment for [REDACTED]. If an injury/skin tear occurred during care and the resident did not have her Geri-sleeves on, it would be a care plan violation and an investigation needed to be completed to rule out abuse and ensure safety of the resident. During an interview on 3/16/2018 at 3:20 PM, LPN #6 stated the resident sustained [REDACTED]. The resident had no Geri-sleeves on, had a small skin tear, she applied 2 steri-strips and bandaged the area. She was unable to recall the details of when the incident occurred and who was caring for the resident. The LPN stated she reported the incident to the supervising RN, and could not recall who that was. She did not initiate an incident report as the RN would have done so. The (incomplete) incident report dated 3/16/2018 at 3:30 PM documented the resident had a skin tear to the left forearm. A witness statement by a CNA documented the occurrence was on 3/13/2018 at approximately 9:30 AM. The resident was brought to the bathroom after breakfast, a skin tear was found, and no Geri-sleeves were on the resident when the skin tear was discovered. The witness documented she reported it to LPN #6, who immediately put on steri strips and wrapped it. During a follow up interview with RN Unit Manager #3 on 3/16/18 3:53 PM, she stated according to LPN #6, the skin tear occurred 3/12 or 3/13/2018, it was reported to RN supervisor #7, who worked overnights, and no incident report was initiated. She stated an investigation should have been initiated, with statements from all staff who worked that day. The purpose was to find the cause of the injury, rule out abuse or neglect, and identify ways to prevent recurrence. The RN unit manager stated LPN #6 should not have initiated treatment to the injury without the supervisor providing the order, the area needed to be assessed, the family should have been notified, and the injury and treatment should have been documented in nursing notes. On 3/19/2018 at 12:03 PM, RN #7 stated she was not notified of a skin tear early the week prior (3/11-3/13/2018). She had not been called to assess any skin tears for the resident and did not initiate a treatment. When interviewed on 3/19/18 at 11:42 AM, the Director of Nursing (DON) stated the protocol when injuries were discovered was CNAs were to report to the LPN, who should then call an RN for assessment, notify medical for order, and the LPN or RN was to begin an incident report immediately. She stated it could be potential abuse if the care plan was not followed and staff may be removed until an investigation was completed. The DON was made aware of the skin tear and stated an investigation was initiated 3/16/2018. 10NYCRR 415.4(b)(3)

Plan of Correction: ApprovedApril 11, 2018

F 610
1. The skin tear obtained by resident #12 was assessed by a RN and a treatment was ordered. The skin tear has since healed. The investigation for the incident involving resident # 12 was initiated upon notification by the DOH surveyor by the facility. The incident was further investigated, and it appears that the skin tear was caused by the dining room table. The resident?s plan of care was not followed as she was to be wearing geri-sleeves and she was not. The aide that provided care to resident # 12 was disciplined for failure to follow plan of care which resulted in an injury. The incident has been reported retrospectively to the NYSDOH. The nurse that did not report or document the incident has received education regarding the importance of reporting incidents timely, and medication/treatment administration. The LPN has also been disciplined for not following facility policy.
2. Accident and Incident reports for the previous 60 days will be reviewed for completion and accuracy and also to identify any incidents that were not thoroughly investigated. Any incident found to not have been investigated thoroughly will have an investigation completed. Any incident that meets the reporting requirements by the DOH will be reported by the Administrator or designee.
3. To prevent any re-occurrence, the facility policy and procedure for accident/incident reporting has been reviewed and revised. The Education Director will be responsible for in-servicing all staff regarding the facility Accident/Incident policy and procedure. The facility will continue to review all Accident/Incident reports every morning after morning report. The facility will also complete a monthly audit to track all Accident/Incident reports by the type of incident, to ensure that all accident/incident forms are completed accurately, that investigations are initiated timely, and that incidents that meet the New York State DOH reporting criteria are done so. The results from this audit will be reviewed during the monthly QAPI meeting. The audit will be completed monthly for six months at which time it will be referred to the QAPI committee for guidance. The facility compliance goal is 95% or higher.
4. Director of Nursing
5. May 14, (YEAR)

FF11 483.25:QUALITY OF CARE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, it was determined for 2 of 4 residents (Residents #7 and 12) reviewed for non-pressure related skin concerns, the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #7's skin treatment was not administered as ordered and unqualified staff were observed applying a prescription cream; the label on the prescription cream indicated the cream belonged to another resident, and the prescription cream was kept in an unlocked area in Resident #7's room. Additionally, oral medications were left on Resident #7's overbed table and there was no order for the resident to self-administer his medications. Resident #12 sustained a skin tear, it was not assessed timely, and a treatment was started without a physician's orders [REDACTED]. Findings include: 1) Resident #7 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive to total assistance with most of his activities of daily living (ADLs), he was at risk of developing pressure ulcers, and had moisture associated skin damage (MASD). Treatment Administration: The comprehensive care plan (CCP) dated 3/5/2018 documented the resident was at risk for skin breakdown. Interventions included certified nurse aide (CNA) to monitor the resident's skin during daily care and report any skin problems to the nurse. The nurse practitioner (NP) progress note dated 3/6/2018 documented the resident was being seen for chronic excoriation of his buttocks related to MASD (moisture associated skin damage) and continued to have loose stools. The plan was to continue with water cleansing and apply [MEDICATION NAME] (topical antimicrobial medication) and monitor for further breakdown. The 3/2018 electronic treatment administration record (eTAR) documented the resident received the following treatment to his buttocks every day during the 6 AM to 2 PM, and as needed (prn). - Cleanse buttocks with warm soapy water, pat dry, and apply a thin layer of [MEDICATION NAME] 1% topical cream daily (qd) and as needed (prn). On 3/14/2018 at 3:00 PM, CNA #5 was observed spraying the resident's excoriated buttocks with Soothe and Cool Cleanser (a type of spray-on cleanser) and patting the buttocks dry. The CNA then went into the bathroom and obtained a jar of [MEDICATION NAME] cream with another resident's name on the label. He then applied the [MEDICATION NAME] cream to the resident's buttocks and applied ABD (a type of bandage) pads to the area. On 3/14/2018, the eTAR was initialed indicating the treatment was completed by licensed practical nurse (LPN) #6. When interviewed on 3/15/18 at 11:05 AM, CNA #4 stated she took care of the resident today, washed him with soap and water, applied [MEDICATION NAME] to his entire backside and about 4 inches down back of legs and applied ABD pads on the sore areas. She knew how to care for the resident based on the Kiosks located throughout the unit (where computerized resident care card is found) or nurse instructions. She stated she believed the [MEDICATION NAME] was on the resident's care card, but the resident tells the CNAs exactly what to do, so she does what he says. The [MEDICATION NAME] was also applied with incontinence care, she was unaware of specific instructions for its use. She stated the [MEDICATION NAME] was kept in the nightstand drawer in the resident's room. She was unaware if another resident's name was on the jar. On 3/15/18 at 11:45 AM, the surveyor observed a jar of [MEDICATION NAME] 1% in the resident's nightstand drawer. The jar had a prescription label belonging to another resident on the unit. A second jar of [MEDICATION NAME] 1% was also in the resident's nightstand drawer, with the resident's name on the prescription label, unopened, with the seal intact around the lid of the jar. During an interview with LPN #6 on 03/15/18 at 1:45 PM, she stated the resident received [MEDICATION NAME] to his buttocks, the CNAs do it, they were not supposed to, it had been that way since she began working there. The resident did not want to wait for a nurse to do it, so he wanted the CNAs to apply the cream. She signed the eTAR without administrating the treatment, the medication should be kept in the treatment cart, it was kept in the resident's room. She stated nurses were supposed to complete treatments. She had not addressed the issue of the resident's wishes to have the CNAs apply the cream and not reported that she had not administered the treatment. The LPN accompanied the surveyor into the resident's room, she confirmed the open jar was prescribed to another resident and stated it should not be used for this resident. She confirmed the jar of [MEDICATION NAME] for Resident #7 was in the resident's drawer and unopened, with the seal intact. CNA #1 was interviewed on 3/16/18 at 1:45 PM and stated the resident refused this CNA to care for her because she had refused to do his nurses treatment to his butt. It had been about a month and a half since she last cared for him. His treatment was a prescription cream and ABD pads. When she provided his care before, she got the nurse when he was ready and the nurse did the treatment. He did not refuse the nurse. On 3/16/18 at 1:55 PM, CNA #2 stated during an interview she often provided the resident's care, he asked her to do the skin treatment, she knew it was a prescription treatment and CNAs were not supposed to do the treatment. The prescription cream was kept in his room, it was used with each incontinence episode, and the nurses were aware of the CNAs doing the treatment. She was unaware of any specific instructions regarding the treatment, only that she cleaned him and applied the cream to the affected areas on his backside and upper thighs. When interviewed on 3/16/18 at 2:30 PM, Registered Nurse (RN) Unit Manager #3 stated she was just made aware on 3/15/2018 the CNAs were doing Resident #7's treatment. She stated CNAs should not be doing skin treatments, any prescription cream should be kept in the treatment cart. Any treatment on the eTAR should be administered by the LPN even if resident wanted a CNA to do it, as CNAs were not trained on how to apply the treatment. It was not appropriate for a CNA to follow resident instructions regarding a skin treatment. The RN Unit Manager had not observed the resident's skin/buttock area and the nurse who was to have administered the treatment each day should also be viewing the area for worsening. If the LPN signed the eTAR, she expected it was the LPN who administered the treatment. If the resident refused the treatment from the LPN, she expected it to be documented on the eTAR and in progress notes. It had not been reported to her that the resident refused LPN treatment for [REDACTED]. The old [MEDICATION NAME] was previously used for a resident who no longer needed the treatment and she did not know why Resident #7 had the wrong [MEDICATION NAME] with the other resident's name on it. The other resident's prescription should have been discarded, not used on Resident #7, as it was an infection control issue to use another resident's skin treatment. Medication Administration: The facility's medication administration policy and procedure (reviewed 5/2016) documented the following: - Remain with the resident until medication has been taken and the resident does not aspirate. - Medications must be administered one hour before or one hour after the scheduled administration time. - Record each dose of medication as soon as it is taken. Clicking medication administered will place the nurse's initials on the eMAR (electronic medication administration record) indicating the medication was given and taken by the resident. The 3/2018 Medication Administration Record [REDACTED] - Sodium Chloride (salt, medication to treat low sodium) 1000 milligrams (mg), 2 tablets; - [MEDICATION NAME] (medication for muscle spasms) 20 mg, 1 tablet; and - [MEDICATION NAME] (medication to treat nerve pain) 100 mg, 1 capsule. On 3/14/2018 at 3:00 PM a medication cup with four oral medications was observed on the resident's overbed table. The resident asked CNA #5 what was in the medication cup, the CNA stated he did not know. The resident stated he did not know what the pills were, he did not normally take his medications alone, and said he probably should take them. On 3/14/2018 the eMAR was initialed at 1:00 PM by LPN #6 indicating the Sodium Chloride, [MEDICATION NAME], and [MEDICATION NAME] had been administered to the resident. LPN #6 was interviewed on 3/15/18 at 01:45 PM. She stated the resident was unable to self-administer medications and she is with him while he takes them. She administered medications on 3/14/18 mid-day and did not recall leaving the resident's medications on the table. She would not normally do that and should not do that. RN #3 Unit Manager was interviewed on 3/16/19 at 2:30 PM. She stated the resident is not care planned to self administer medications and would be unsafe to do so. The medication nurse should not leave medications on the over bed table and was not aware the LPN had done that. 10NYCRR 415.12

Plan of Correction: ApprovedApril 11, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 684
1. Resident #12 skin tear was assessed by an RN and medical was made aware. A treatment was ordered, and the area has now healed. Resident # 7 had a full body skin assessment completed and he was found to have areas of concern. Medical was notified and treatments were ordered and resident # 7 is being followed by the skin team. [MEDICATION NAME] cream that belonged to another resident that was found in resident #7 room has been discarded. There are no other treatments kept in resident #7 room. LPN #6 has been disciplined for not following facility policy and will be educated on Medication and Treatment Administration, proper documentation of administering medications and/or treatments.
2. The facility respectfully recognizes that all residents have the potential to be affected by the deficient practice. The facility completed a full house head to toe skin assessments on all residents. Medical was notified of all new skin areas of concern and treatments were ordered accordingly. Residents identified with new areas were added to be followed by the skin team until the areas resolve. All resident rooms were also checked to ensure that there were no medications or treatments left in resident rooms. Any medications or treatments that were found were disposed of accordingly.
3. In order to prevent reoccurrence, the policy and procedure for Medication and Treatment administration has been reviewed and revised. The Director of Education will be responsible to educate all nursing staff regarding the Medication/Treatment Administration policy.
4. The facility will develop an audit tool that will be completed weekly to ensure that treatments are being completed by qualified staff, no treatments are being left in resident rooms, medications are not being left at bedside (unless resident is care planned for self-medication), and that all treatments being administered have a physician?s order. The audit will be completed for twelve weeks and then monthly for three months at which time it may be referred to the Quality Assurance Committee for guidance. The Director of Nursing will report the findings at the monthly QAPI meeting, facility compliance goal is 100%.
5. Director of Nursing
6. May 14, (YEAR)

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the recertification survey, it was determined for 2 of 2 residents (Residents #14 and 96) observed for dignity, the facility did not ensure all residents had the right to a dignified existence. Specifically, Resident #14 was observed with long facial hair and Resident #96 was observed with facial hair growth for multiple days of survey. Findings include: 1) Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/7/2018 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of one person for dressing and hygiene, and had upper extremity impairment on both sides. The comprehensive care plan (CCP) updated 1/17/2018 documented the resident required extensive assistance with activities of daily living (ADLs) and was to have skin check and nail care on Mondays (6 AM-2 PM shift). There was no documentation regarding the resident's shaving preference. The resident nursing instructions updated 1/31/2018 documented the resident required extensive assistance for bathing, hygiene, and grooming and was to receive a shower on Mondays during the 6 AM to 2 PM shift. The resident CNA (certified nurse aide) documentation record for 3/2018 documented the resident received a shower on 3/5/2018 and 3/12/2018 and assistance with personal hygiene daily from 3/1/2018-3/16/2018. There were no care refusals documented. The resident was observed with long facial hair on her chin and sides of her face: - On 3/13/2018 at 12:30 PM while eating lunch in the dining room, and at 1:45 PM in her room; - On 3/14/2018 at 9:30 AM in the hall near, at 10:34 AM, near the nursing station, and at 2:57 PM near the nursing station; - On 3/15/2018 at 9:25 AM, near the nursing station; and - On 3/16/2018 at 11:09 AM, near the nursing station. During an interview on 3/16/2018 1:45 PM, CNA #1 stated shaving residents was part of ADL care, was not specified on care instructions, and was part of the grooming/hygiene routine. The resident preferred to be shaved, was agreeable to having care provided, was not known to resist care, and needed extensive assistance. The CNA had not provided her care recently, she stated she has observed the resident's facial hair to be very long, and would have shaved her by now if the resident was on her assignment. When interviewed on 3/16/2018 at 2:00 PM, CNA #2 stated the resident was agreeable to being shaved, preferred to be shaved, and asked the CNA to shave her today. The CNA stated she was assigned to her that evening, and the last time she cared for her was 6 days ago, and she was shaved then. She stated she observed the long facial hair, it was a dignity issue, and would shave the resident later. During an interview with Registered Nurse (RN) Unit Manager #3 on 3/16/2018 at 2:30 PM, she stated her expectation was residents be shaved regularly, as needed, and as part of daily hygiene and grooming. She stated the resident's facial hair was long and she should have been shaved as part of her routine grooming. 2) Resident #96 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The 2/17/2018 Minimum Data Set (MDS) assessment documented the resident had intact cognition, was totally dependent for all activities of daily living (ADLs), and had upper extremity impairment on both sides. The comprehensive care plan (CCP) updated 1/21/2018 documented the resident was totally dependent for all care. Goals included the resident will be maintained at optimal hygienic cleanliness, tidiness, and neatness of facial hair and nails routinely. Interventions included a weekly shower per schedule and dependence on staff for personal hygiene. The resident nursing instructions updated 3/14/2018 documented the resident was totally dependent on staff assistance for all ADLs and was to receive a shower on Mondays during the 6 AM to 2 PM shift. The resident CNA (certified nurse aide) documentation record for 3/2018 documented the resident received a shower on 3/5/2018 and 3/12/2018, and assistance with personal hygiene daily from 3/1/2018-3/16/2018. There were no care refusals documented. The resident was observed with pronounced stubble/facial hair growth on his face: - On 3/13/2018 at 10:58 AM, while in bed; and at 12:40 PM in the dining room; - On 3/14/2018 at 9:54 AM in his room; and - On 3/15/2018 at 9:05 AM, in the hall near the nursing station, and at 5:45 PM, in the dining room. On 3/16/2018 1:45 PM, CNA #1 stated shaving residents was part of ADL care. It was not specified on care instructions and was part of the grooming and hygiene routine. The resident loved to be shaved, could not do it himself, and had an electric razor. She stated the resident told her today I'm furry. She was not assigned to the resident this week, shaved him when she cared for him, and he never refused shaving. When interviewed on 3/16/2018 at 2:00 PM, CNA #2 stated she had cared for the resident and shaving was routine for him. He preferred to be shaved and she did not know why he was not shaved on the days observed. During an interview with Registered Nurse (RN) Unit Manager #3 on 3/16/2018 at 2:30 PM, she stated her expectation was residents be shaved regularly, as needed, and as part of daily hygiene and grooming. She stated she had noticed the resident was not shaved, she believed he was shaved today. She stated he should have been shaved sooner in the week. 10NYCRR 415.5(a)

Plan of Correction: ApprovedApril 12, 2018

F 550
1. Both resident #14 and resident #96 have both shaved. An electric razor will be purchased for resident #96 at his request. Both residents will be shaved on their shower days or as needed. The unit manager(s) will be responsible to follow up for both residents on his/her shower day, as well as all others to ensure the resident(s) are shaved accordingly his/her care plan. The care cards for residents 14 and 96 have been updated to ensure that shaving is addressed on his/her shower day.
2. The facility respectfully recognizes all residents as having potential to be affected by the deficient practice and the facility has determined that there have been no negative outcomes as a result of the deficient practice. A full house review of all residents will be completed to identify all residents in need of being shaved. All residents that are found in need of a shave, will be shaved and those residents that refuse, will have it documented, and will be care planned accordingly.
3. To prevent any re-occurrence, the facility has reviewed and revised the policy on resident rights and dignity. The Education Director will be responsible for in-servicing all staff on residents rights and dignity. The facility created a dignity audit tool, and the audits will be completed weekly on 10 % of the facilities resident population. The audit tool will ensure that residents are receiving care (shaving) in a dignified matter. Issues that are identified during the audit are to be addressed immediately will be and the information obtained from these audits will be reviewed at the monthly QAPI meeting for review and follow up. The facility compliance goal is 100%.
4. Director of Nursing
5. May 14, (YEAR)

FF11 483.10(f)(5)(i)-(iv)(6)(7):RESIDENT/FAMILY GROUP AND RESPONSE

REGULATION: §483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility. (i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. (ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation. (iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. §483.10(f)(6) The resident has a right to participate in family groups. §483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 16, 2018
Corrected date: May 14, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification survey, the facility did not consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 8 residents present at the Resident Council meeting, with potential to affect all residents in the facility. Additionally, the facility was not able to demonstrate their responses and rationale for such response. Specifically, the Resident Council did not receive responses to topics or concerns addressed in prior meetings and was not involved in decisions regarding use of resident group funds. The facility's undated Resident Rights and Responsibilities policy documented the following: - Residents have the right to give an oral or written complaint or recommendation concerning the facility to the resident council liaison. A member of the facility administration will respond to your concern within 21 days except under extraordinary circumstances such as health or administrative emergencies. Resident Council meeting minutes documented the following: - 10/2017 (day not noted), new concerns regarding more activities, an outing request, and assisting residents with holiday cards; - 11/21/2017, old business was seeking volunteers to read to residents who were unable, had been brought up at a previous meeting; a new activity suggestion for evening bingo. There was no documentation about the topics noted the prior month including having more activities and outing requests and assisting with holiday cards. - 12/16/2017, no old business noted; new concerns raised regarding lack of attendance for a bowling activity, no explanation regarding no bowling or bingo the previous week, staff not asking all residents/entering rooms to invite to activities, asked about having activities announced on the intercom, staffing concerns, and lack of communication between residents and staff. Council president requested a format for residents' concerns to be addressed. There was no documentation about the topics noted the prior month. - 1/15/2018, no old business noted; new concerns regarding size of activities calendar and locations of activities, lack of communication between resident and staff, resident behavior on one unit upsetting many residents, and the council president requested a format for residents' concerns to be addressed. There was no documentation about the topics noted the prior month. - 2/28/2018, no old business noted, no new comments or concerns addressed. There was no documentation about the topics noted the prior month. A resident fund statement of activity documented the following transactions: - Deduction 10/1/2017, $130.94 for a haunted boy, - Deduction 10/26/2017, $52.79 for Halloween expenses, - Deduction 11/21/2017, $100.00 for raffle baskets, - Deduction 11/28/2017, $22.57 for tree [MEDICATION NAME], - Deduction 12/6/2017, $12.99 for tissue paper, - Deduction 12/8/2017, $485.29 for Christmas gifts (noted money given to an individual the Resident Council President did not recognize, from the fund). - Deduction 12/15/2017, $517.12 for a discount retail store and $100.00 for raffles, - Deduction 12/20/2017, $76.11 for a Santa suit, and - Addition, undated of $280.00 for a cowboy raffle (money added from raffle sales). During the resident group meeting on 3/13/18 at 2:30 PM, eight anonymous residents in attendance stated they were not involved in choices or decisions about meeting topics including availability of activities and dietary suggestions. They stated they did not receive any feedback from the facility about concerns regarding staffing shortages, communication with staff, or canceled activities. During an interview with the Resident Council President on 3/15/2018 at 5:15 PM, when reviewing the resident fund report with him, he stated the transactions were not addressed at any meetings, and he was unaware of the circumstances or reasons for the expenses. He did not know who the individual who received the $485.29 for Christmas gifts was and was unaware of the recipients of such gifts. The money may have been given to a staff member to purchase gifts for residents. He stated he would not consider holiday decorations and supplies to be something for resident purposes and would have questioned the expenses as shown on the resident fund report. He stated the Resident Council did not receive information regarding topics addressed at prior meetings and if it was not documented on the meeting minutes, then there would be no way for the Council to follow up on unresolved issues. He stated the facility was working with him to develop a form to track concerns within the facility. The resident stated topics addressed at the meetings do not need to be considered complaints or grievances, as he wanted to refrain from negativity, he just expected a means to address various topics raised and have acknowledgment and follow-up from the facility. There was no documented evidence the Resident Council or representatives received responses from the facility to questions, suggestions, or concerns raised at the Resident Council meetings. There was no documented evidence the Resident Council was addressed regarding the balance, expenditures, or fund raising activities for the resident fund. During an interview with the Activities Director on 3/16/18 at 11:48 AM, she stated she acted as the liaison between the facility and the Resident Council, was responsible for recording the meeting minutes, and following up on topics or concerns addressed at meetings. She stated she addressed any concerns or ideas directly at the meeting and such responses should have been included on that month's meeting minutes. If questions, concerns, or suggestions were with another department or Administration, she used to put them on a concern/grievance form, but residents did not want to submit forms with their names and did not want to file a formal complaint. She stated concerns addressed at meetings were not necessarily formal grievances and she did not have to utilize the grievance form. She did not utilize any other format to address resident concerns and she and the Council President were working on a new form to exclude names and identifying information. She stated, old business should be addressed at each new meeting, with a follow-up from the appropriate department, she did so verbally at meetings, or by going directly to the individual resident. There was no documentation regarding old issues on subsequent meeting minutes and attendees would not know the outcome if it was not reviewed. The Activities Director stated there was no resident fund and the Resident Council was not involved in any decisions about fund allocation or fundraising. She had not asked the residents for input regarding the funds and the Activities and Human Resource (HR) departments made the decisions regarding expenditures and fundraising. During an interview with the Administrator on 3/16/18 at 12:45 PM, he stated there was a Resident Council fund, the HR Director maintained the money box, and there was no official oversight of the funds and transactions. He stated the Resident Council was formerly involved in decisions regarding fundraising and allocation of funds and have not been involved for several months, since the prior Activities Director left the position. The Administrator stated resident funds should be discussed at Resident Council meetings, with an accounting of fund activity, resident input, and documented on each month's meeting minutes. He stated he expected the liaison to record meeting minutes, address any topics or concerns with the appropriate department in the facility, and follow up with the Resident Council the following meeting as to how the topic was addressed, with whom, the status of the issue, or how it was resolved. The follow-up should be documented on the meeting minutes. When interviewed on 3/16/2018 at 2:23 PM, the HR Director stated she maintained the locked money box for resident funds. She was given the box to manage last year, after the former Activities Director left her position. She stated the current Activities Director obtained funds from her (the HR Director) for resident purposes. She had not received any specific direction regarding disbursement of the funds, had not addressed anyone on the Resident Council, and had not been asked to provide any information about the account activity for Resident Council. She believed the residents should have input on what happens with the funds and be advised of the balance. 10NYCRR 415.5(c)(6)

Plan of Correction: ApprovedApril 11, 2018

F565
1. The treasury report will be reviewed at the upcoming Resident Council meeting in (MONTH) (YEAR). Residents will also be educated on how the facility will follow up on issues/concerns that arise at the resident council meeting.
2. The facility respectfully recognizes that all residents have potential to be affected by the deficient practice and the facility has determined that there have been no negative outcomes because of the deficient practice.
3. To prevent re-occurrence, the Treasury Report as well as discussion of use of the council monies will be added to the monthly agenda of the resident council meeting to ensure that it is discussed at each meeting. The facility has reviewed and revised the policy and procedure on resident council. Changes to the policy includes; addressing and providing follow up on issues/grievances from the previous meetings. Resident Council will be educated on the new process of following up on issues/grievances and also all department managers will be educated on changes to policy to ensure that follow up is being provided to residents regarding issues/grievances that arise at the resident council meetings. Minutes from the resident council meeting will be reviewed monthly at the facility QAPI meeting. Minutes will be reviewed to ensure that the treasury report was reviewed with residents and there is discussion of what to use the monies for. Minutes will also be reviewed to ensure that issues/grievances are addressed and follow up has been provided to the residents timely. The facility compliance goal is 100%.
4. Director of Activities
5. May 14, (YEAR)

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview conducted during the recertification survey, the facility did not ensure the emergency generator remote annunciator was properly installed for the generator. Specifically, the emergency generator did not have an alarm annunciator remotely installed in an area that had 24-hour staff coverage. Findings include: During an interview on 3/14/2018 at 11:16 AM, the Plant Operations Manager stated that when the generator was installed in 2013, a remote annunciator panel located in an area with 24 hour staff coverage was not installed. 2012 NFPA 99: 6.4.1.1.17 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 8, 2018

K916
1. The annunciator panel has been properly installed for the generator.
2. To prevent any re-occurrence, the annunciator panel will be audited twice a month to ensure that it is functioning properly, and the results will be reviewed during the monthly QAPI meeting. This audit will be re-evaluated at that time to determine frequency and duration.
3. Education will be provided to all Maintenance Personnel.
4. Director of Environmental Services-5/7/18

K307 NFPA 101:ELEVATORS

REGULATION: Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview conducted during the recertification survey, the facility did not ensure all elevators were inspected and tested as specified in ASME A17.1, Safety Code for Elevators. Specifically, the elevators were not inspected and tested as per ASME A17.1. Findings include: During an interview on 3/14/2018 at 3:00 PM, the Plant Operations Manager stated the elevator vendor told him the facility elevators were not inspected and tested as per ASME A17.1. The inspection documentation did not indicate that the facility elevators were inspected per ASME A17.1. 2012 NFPA 101: 19.5.4, 9.4.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 8, 2018

K 531
1. The elevators will be inspected and tested as specified in ASME A17.1, safety code for elevators.
2. Elevator inspections will be completed semi-annually
3. To prevent re-occurrence, the facility will review elevator inspection results upon completion at the monthly QAPI meeting. Any issues that are derived from the inspections will be reviewed along with the corrective action that was done.
4. Education provided to all Maintenance Personnel.
5. Director of Environmental Services-5/7/18

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not ensure that fire drills were completed quarterly for 2 of 3 shifts (night shift, evening shift) in (YEAR), as required. Specifically, the night shift fire drill was not completed for the first quarter of (YEAR), and the evening shift fire drill was not completed for the fourth quarter of (YEAR). Findings include: During review on 3/14/2018 at 12:54 PM of fire drill reports, a surveyor identified the night shift fire drill was not completed for the first quarter of (YEAR), and the evening shift fire drill was not completed for the fourth quarter of (YEAR). When interviewed on 3/14/18 at 1:15 PM, the Plant Operations Manager stated: - he thought the night fire drill done on 12/29/2017 would cover the first quarter of (YEAR); - the day shift drill done on 10/25/2017 at 1:21 PM was intended to be a evening shift fire drill and should have been completed after 2:00 PM. 2012 NFPA 101: 19.7.1 10 NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedApril 8, 2018

K 712
1. Fire drills will be held quarterly on each shift.
2. The Fire/ Code Red Policy and procedure has been reviewed and revised. To ensure that the facility fire drills are held quarterly on each shift, the facility has created a fire drill schedule to ensure that drills are assigned to each shift accordingly. The facility has also reviewed and revised the fire drill audit sheet.
3. To prevent re-occurrence, the fire drill schedule along with the fire drill audit sheet will be reviewed and the monthly QAPI meeting. This audit will be re-evaluated at that time to determine frequency and duration.
4. Education to be provided to all Maintenance and Nursing staff
5. Director of Environmental Services 5/7/18

K307 NFPA 101:GAS EQUIPMENT - TRANSFILLING CYLINDERS

REGULATION: Gas Equipment - Transfilling Cylinders Transfilling of oxygen from one cylinder to another is in accordance with CGA P-2.5, Transfilling of High Pressure Gaseous Oxygen Used for Respiration. Transfilling of any gas from one cylinder to another is prohibited in patient care rooms. Transfilling to liquid oxygen containers or to portable containers over 50 psi comply with conditions under 11.5.2.3.1 (NFPA 99). Transfilling to liquid oxygen containers or to portable containers under 50 psi comply with conditions under 11.5.2.3.2 (NFPA 99). 11.5.2.2 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on interview conducted during the recertification survey, the facility did not ensure the transfilling of oxygen from one cylinder to another was done in accordance with National Fire Protection Association (NFPA) 99. Specifically, the transfilling of oxygen was being done in rooms with non-rated fire doors and door frames, and flooring that was not concrete or ceramic, as required. In addition, the appropriate oxygen signage was missing. On 3/13/2018 between, 1:15 PM and 2:34 PM, a surveyor observed the following rooms were not transfilling oxygen in accordance with NFPA 99: - inside the fourth floor oxygen room there were two Companion 41 liquid oxygen reservoirs, and 5 liquid oxygen totes. The room flooring material was vinyl, and the door and door frame was not 45 minute fire rated. - inside the third floor oxygen room there were two Companion 41 liquid oxygen reservoirs, and 3 liquid oxygen totes. The room flooring material was vinyl, and the door and door frame was not 45 minute fire rated. - inside the second floor oxygen room there were two Companion 41 liquid oxygen reservoirs, and 1 liquid oxygen tote. The room flooring material was vinyl, and the door and door frame was not 45 minute fire rated. and - inside the first floor physical therapy room there was one Companion 41 liquid oxygen reservoir, and 1 liquid oxygen totes in a curtained off section of the room. Both of the physical therapy doors and door frames were not 45 minute fire rated, and the appropriate oxygen signage was missing. During an interview on 3/14/2018, between 1:30 PM and 2:00 PM, the Plant Operations Manager stated he was not aware liquid oxygen transfilling can only be done inside a one hour fire rated room with a 45 minute fire rated door. During an interview on 3/14/2018 at 4:26 PM, the Administrator stated the vendor had not made him aware of the room requirements for liquid oxygen transfilling. 2012 NFPA 99: 9.3.7.4 2010 NFPA 55: 6.2.1, 6.4.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 8, 2018

K927
1. The doors to the rooms in which the transfilling of oxygen is being done will be fire rated to ensure that it meets the 45-minute fire rating. The vinyl flooring will be removed and replaced with ceramic tiles and the facility will add the appropriate signage. Only the oxygen filling stations will be stored in theses rooms, portable units will no longer be stored in the room.
2. All oxygen transfilling rooms will remain at risk for the deficient practice. All rooms have been checked to ensure that the rooms only contain the transfilling stations, and that proper signage is in place.
3. To prevent re-occurrence, the facility will complete environmental walking rounds twice a month to audit the oxygen transfilling rooms have the proper signage and that no other units except the filling units are stored in the rooms. The results from these audits will be reviewed during the monthly QAPI meeting. The audit will be re-evaluated at that time to determine frequency and duration.
4. Education to be provided to all Maintenance and Nursing staff
5. Director of Environmental Services 5/7/18

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness (EP) survey, the operator did not comply with Emergency Preparedness requirements. Specifically, there was no method for sharing information from the EP plan with residents and their families or representatives. Findings include: During review of the EP plan dated (MONTH) (YEAR) there was no documented evidence that information from the EP plan was being shared with residents and their families or representatives. When interviewed on 3/14/2018 at 10:15 AM, the Administrator stated they had never shared information from the EP plan with anyone. He further stated they will incorporate it moving forward. 10 NYCRR 42 CFR:483.73(c)(8)

Plan of Correction: ApprovedApril 8, 2018

E035
1. The facility will add to the admission packet an informational sheet that informs residents as well as families that the facility has in place an Emergency Preparedness plan. This sheet will inform residents and families of the location of the Emergency Plan is located for their review and a contact person if they have any questions regarding the Emergency Preparedness Plan.
2. A brief review of the Emergency Preparedness Plan will be provided to residents at the resident council meeting in (MONTH) (YEAR).
3. To prevent re-occurrence, the facility will review the admission packet annually to ensure that information pertaining to the Emergency Preparedness Plan remains in the packet and the facility will also review the Emergency Disaster Plan at least annually at Resident Council.
4. Revised manuals will be provided for all department heads to review with staff, and staff will be educated on where to direct residents and staff to review the Emergency Preparedness Plan, if they choose.
5. Administrator - 5/7/2018

K307 NFPA 101:MULTIPLE OCCUPANCIES - CONSTRUCTION TYPE

REGULATION: Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the 1-1/2 hour fire rated occupancy separation barrier doors were maintained for 3 of 4 separation barriers (Adult Day Care office area, Adult Day Care activity room, and first floor Nursing Home/Hospital separation wall). Specifically, there was a large gap under the Adult Day Care office area door and the door/door frame was not rated, the Adult Day Care activity room doors/door frames were not rated, and one of the first floor Nursing Home/Hospital separation wall doors had an unsealed hole in it. Findings include: 1) Gap Under Separation Barrier Door On 3/13/2018 at 12:50 PM, a surveyor observed there was a 1 inch gap under the Adult Day Care office area door. A fire rated door can not have a gap greater than 3/4 inch under the door, per regulation. During an interview on 3/13/2018 at 12:50 PM, the Plant Operations Manager stated he was not aware the gap under the Adult Day Care office area door was too large. 2) Unrated Separation Barrier Doors/Door Frames On 3/13/2018 at 1:00 PM, a surveyor observed both the Adult Day Care office area door/door frame, and the Adult Day Care activity room doors/door frames were not 1-1/2 hour fire rated as required for a 2 hour fire barrier. During an interview on 3/14/2018 at 5:06 PM, the Plant Operations Manager stated he was not aware the doors within the Adult Day Care separation walls were required to be fire rated. He was not aware the doors fire rated labels were missing. 3) Separation Barrier Unsealed Holes On 3/13/2018 at 2:15 PM, a surveyor observed one of the first floor Nursing Home/Hospital separation wall doors had a 1/4 inch unsealed hole in it. During an interview on 3/14/2018 at 5:06 PM, the Plant Operations Manager stated he was not aware one of the first floor Nursing Home/Hospital separation wall doors had an unsealed hole in it. 2012 NFPA 101 19.1.3.5 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 8, 2018

K133
1. The gap under the separation barrier door has been corrected so that the gap is not greater than ¾ inch under the door. The doors to the Adult Day Care area will be checked and labeled accordingly that the doors meet the 1 ½ hour fire rating as required. The inch unsealed hole in the door that leads from the first floor to the to the hospital has been sealed.
2. All doors will be inspected to ensure that all doors meet the requirements under NFPA 101 Multiple Occupancies-Construction Type. Any door identified not to be in compliance will be repaired accordingly.
3. To prevent any re-occurrence. A follow up audit will be conducted monthly on a random selection of doors to ensure that doors meet the requirements of NFPA 101 Multiple Occupancies-Construction Type, and the results will be reviewed during the monthly QAPI meetings. This audit will be re-evaluated at the time to determine frequency and duration.
4. Education provided to all maintenance personnel.
5. Director of Environmental Services-5/7/18

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on record review and interview conducted during an Emergency Preparedness (EP) survey, the operator did not comply with Emergency Preparedness requirements. Specifically, there was no policy and procedure for the use of volunteers listed within the EP plan. Findings include: During review of the EP plan dated (MONTH) (YEAR) there was no documented evidence of a policy and procedure for the use of volunteers. When interviewed on 3/14/2018 at 10:15 AM, the Administrator stated they have no policy in place for the use of volunteers. He further stated they will have to implement one moving forward. 10 NYCRR 42 CFR:483.73(b)(6)

Plan of Correction: ApprovedApril 8, 2018

E 024
1. A policy and procedure for the use of volunteers in an emergency/disaster situation will be written and added to the Emergency Preparedness Plan.
2. The Emergency Preparedness Plan will be reviewed to ensure that all policies and procedures required to be in the Emergency Preparedness Plan are included in the plan and have been updated.
3. To prevent re-occurrence, the facility will review its Emergency Preparedness plan annually to ensure that all policies and procedures have been reviewed and revised annually, and that the Emergency Preparedness plan complies with Federal, State, and local laws.
4. Revised manuals will be provided to all department heads to review with staff.
5. Administrator - 5/7/2018

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: March 14, 2018
Corrected date: May 7, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 2 isolated areas (main lobby, and laundry room), in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2. Section 8.3.3.2 states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, the main lobby and the laundry room contained both quick response sprinkler heads and standard response sprinkler heads. Findings include: On 3/13/2018 at 10:10 AM, a surveyor in the main lobby observed 10 quick response sprinkler heads and 6 standard response sprinkler heads. On 3/13/2018 at 3:30 PM, a surveyor in the laundry room observed 9 quick response sprinkler heads and 6 standard response sprinkler heads. During an interview on 3/13/2018 at 3:30 PM, the Plant Operations Manager stated he was not aware of the requirement that sprinkler heads in a smoke zone had to be the same type of sprinkler head, and did not know the main lobby and the laundry room had mixed types of sprinkler heads in them. He thought all the sprinkler heads were the same because they were the same color. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedApril 8, 2018

K0351
1. The sprinkler heads in the main lobby and the laundry room will be changed out so that now all sprinkler heads are quick response sprinkler heads.
2. All sprinklers within a compartment are at risk of this deficient practice. All other sprinklered compartments will be audited to ensure that all sprinkler heads in that area are the same type of sprinkler heads. Any sprinklers found to be replaced
3. To prevent any re-occurrence, a follow up audit will be conducted any time a sprinkler head is replaced to ensure the correct type sprinkler head has been replaced. This audit will be conducted monthly for 6 months and reviewed during QAPI. The audit will be re-evaluated at that time to determine frequency and duration.
4. Education provided to all maintenance personnel.
5. Director of Environmental Services-5/7/18