Hornell Gardens, LLC
March 30, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(b)(2)(ii):COMPREHENSIVE ASSESSMENT AFTER SIGNIFCANT CHG

REGULATION: §483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2018
Corrected date: May 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #55) of 28 residents reviewed for accuracy and completion of the Minimum Data Set (MDS) Assessments, the facility did not ensure that a Significant Change MDS Assessment was completed. The issue involved a resident who had significant changes in two late loss Activities of Daily Living (ADLs) and urinary incontinence. This is evidenced by the following: The Resident Assessment Instrument 3.0 User's Manual Version 1.15 (MONTH) (YEAR), directed that a Significant Change Status Assessment is required to be performed when a resident has two or more areas of decline including, but not limited to, a change in the resident's incontinence pattern and any decline in at least one ADL physical functioning area where a resident is newly coded as extensive assistance, total dependence, or activity did not occur since the last assessment and the changes are not self-limiting and has not resolved within two weeks. Resident #55 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/10/18, revealed that the resident had moderately impaired cognition. Review of the Quarterly MDS Assessment, dated 11/25/17, revealed that the resident was occasionally incontinent of urine and bowels, and required supervision for bed mobility, transfer, and ambulation. Review of the Quarterly MDS Assessment, dated 2/10/18, revealed that the resident was frequently incontinent of urine and bowels, and required extensive assistance for bed mobility and limited assistance for transfer and ambulation. When interviewed on 3/28/18 at 9:58 a.m., the Certified Nursing Assistant (CNA) said that the resident's abilities have changed recently and he needs a lot more assistance with turning in bed, transferring, and walking. She said that he is always incontinent now and that she believes the nurses are aware of the changes in his abilities. On 3/28/18 at 10:08 a.m., the Licensed Practical Nurse (LPN) stated that the resident had declined in the last one and a half to two months in several areas. She said he has definitely declined in his ambulation and incontinence. The LPN said that she was sure the Registered Nurse (RN) Manager was aware. When interviewed on 3/29/18 at 8:33 a.m., the RN MDS Coordinator said that if the CNA documentation was correct, the resident has had a significant decline in his abilities and should have had a Significant Change MDS Assessment completed within two weeks of 2/10/18. She said if there was a decrease in two or more late loss ADLs, weight loss, or decrease in incontinence, the team has two weeks to evaluate the resident to see if the changes are self-limiting. The RN MDS Coordinator said that it was important to do a significant change MDS Assessment because it affects the resident's plan of care. She stated the Care Plan and CNA Care Guide need to be updated. On 3/29/18 at 8:47 a.m., the RN Manager (RNM) stated that when a resident declines, the interdisciplinary team discusses that in the morning meeting. She said Physical and Occupational Therapy, the Physician or Nurse Practitioner, and nursing staff would have evaluated the resident. The RNM said a Significant Change MDS Assessment would have been started and if necessary, changes in the Care Plan and CNA Care Guide would have been made. The RNM said she noticed a decline in the resident and was aware he needs more assistance. She said the Care Plan and the CNA Care Guide have not been updated to reflect the care he needs. She said it was important to do a Significant Change Assessment because it is more comprehensive and generates a Care Area Assessment Summary that helps identify care plan changes. (10 NYCRR 415.11(a)(3)(ii))

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
A significant change assessment for resident #55 has been scheduled for (MONTH) 25, (YEAR).
A review of Point Right MDS software by the Corporate MDS Coordinator shows that no other significant change assessments were missed.
The Corporate MDS Coordinator will reeducate the Interdisciplinary team on the significant change process and the new significant change worksheet.
A new full time MDS Coordinator has been hired. The MDS Coordinator will conduct weekly MDS meetings with the MDS team and, using an internal significant change worksheet as well as utilizing the Point Right software, will determine when a significant change assessment is needed.
The MDS Coordinator will perform monthly MDS completion audits to ensure that significant change MDS assessments are completed when necessary and timely. The results of these audits will be reported to the Quality Assurance Committee for their review and action as necessary.
The MDS Coordinator is responsible for the correction of this deficiency.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2018
Corrected date: May 4, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #81) of two residents reviewed for accidents, the facility did not ensure that the resident received adequate supervision to prevent accidents. The issue included a recliner chair that was torn, exposing sharp edges which may have been causing irritation and scratching the resident's back. This is evidenced by the following: Resident #81 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/6/18, revealed that the resident had moderately impaired cognition. When observed on 3/26/18 at 11:35 a.m., the resident was sitting in his recliner, in his room without a shirt on. The back of the recliner had a large area where the plastic had peeled away revealing the underlying cloth. On 3/28/18 at 2:25 p.m., the resident was in the hallway without a shirt on. The resident went into his room and sat in his recliner. The back of the recliner was ripped and not covered to protect the resident's back from injury. When interviewed on 3/29/18 at 9:03 a.m., the Registered Nurse Manager (RNM) said she was not aware of the condition of the resident's recliner. At that time, the RNM and the surveyor went together to observe the recliner. The back of the recliner had a torn area that measured 8 inches wide and 14 inches long. The edges were ripped away leaving sharp edges. The resident said it hurts his back and causes scratches. The RNM observed the resident's back and there were reddened areas to numerous to count, some of which had scabbed over. On 3/29/18 at 9:18 a.m., the Certified Nursing Assistant (CNA) said the recliner had been that way for months, and she thinks all the staff are aware of the condition of the recliner. She said she thinks the resident was tearing the recliner. The CNA said she was aware the resident had reddened areas on his back because she puts lotion on his back. When interviewed on 3/30/18 at 8:31 a.m., the Administrator stated that a peer review committee does an audit on resident rooms, including furniture every six months. He said the last one was done in (MONTH) (YEAR), and there was no report for the resident's room at that time. He said he was not aware of the condition of that chair but would expect housekeeping, CNAs, and nurses to report deterioration of furniture. (10 NYCRR 415.12(h)(1)&(2))

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The recliner in this resident's room has been removed and replaced.
The Housekeeping Supervisor will conduct an audit of all resident room chairs. Those found to be in disrepair will be repaired or replaced.
All housekeeping staff will be inserviced on reporting unsafe or damaged resident furniture to the Housekeeping Supervisor. These reports will be forwarded to the Administrator for follow up as needed.
The Housekeeping Supervisor will conduct monthly audits of all resident room chairs to ensure that they remain in good condition. The results of these audits will be provided to the Quality Assurance Committee for their review and action as necessary.
The Housekeeping Supervisor will be responsible for the correction of this deficiency.

FF11 483.25(c)(1)-(3):INCREASE/PREVENT DECREASE IN ROM/MOBILITY

REGULATION: §483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and §483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. §483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 873), the facility did not ensure that for one (Resident #7) of one resident reviewed for mobility/ambulation received the appropriate treatment and services to improve and/or maintain ambulation. Specifically, the resident was not being ambulated as recommended by therapy. This is evidenced by the following: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/16/17, revealed that the resident had severely impaired cognition and could ambulate in his room with the extensive assist of two staff members. Review of the Certified Nursing Assistant (CNA) Resident Care Plan, dated as reviewed on 1/3/18, revealed under ambulation that the resident could ambulate 0 to 15 feet with a rolling walker and assist of one staff member. A Physical Therapy Discharge Summary, dated 2/6/18, includes that the resident received skilled therapy for transfer and gait training and could ambulate 10 to 50 feet depending on motivation with the assist of one to two staff members. A Nurse Practitioner progress note, dated 3/16/18, includes that the resident has been fairly weak lately as it took three staff to assist the resident to the bathroom. Therefore, a Physical Therapy evaluation has been ordered. A Referral to Therapy form, dated 3/16/18, revealed that transfer was checked with a notation that it takes three people to stand the resident. Review of a CNA Tracking Form, dated (MONTH) (YEAR), revealed documentation that the resident had not ambulated for the past 12 days. When observed on 3/28/18, the resident was a stand-pivot-sit transfer from wheelchair to bed with the assist of two staff members for incontinence care. There was no attempt made to ambulate the resident. Interviews conducted on 3/27/18 included the following: a. At 12:01 p.m., a visiting family member stated that they do not see the resident walk anymore. The family member said that they thought Physical Therapy was supposed to see the resident but they had not heard back regarding that. b. At 1:00 p.m., CNA #1 (day shift) stated that the resident does not ambulate anymore. In an interview on 3/28/18 at 3:37 p.m., CNA #2 (evening shift) stated that the resident walks but on days only, not during the evening shift. When interviewed on 3/29/18 at 10:48 a.m., the Physical Therapist (PT) stated that they did receive a request for an evaluation on 3/16/18 and that the evaluation has not been done yet. The PT said that he did speak with staff members about the resident's transfer difficulties and told them to assist with two staff versus one staff for safety. The PT said he was not informed that the resident was no longer able to ambulate. The PT said that it was the expectation that the floor staff ambulate the residents as recommended. He said if residents are unable to ambulate consistently (as opposed to just having a bad day), staff need to inform therapy and not just give up and not attempt anymore. (10 NYCRR 415.12(e)(2))

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL Law.

Resident #7 was assessed by registered nurse and decline was noted in ambulation ability. Physical Therapy evaluation was completed on 4/9/18 with updated recommendations provided to nursing. Care plan was updated to reflect changes.
We have reviewed all resident?s ambulation goals and recommendations by PT. Any residents identified as not meeting ambulation goals were assessed by Registered Nurse. We have reviewed our policy ?functional Impairment ? Clinical Protocol?. A documentation tool ?Ambulation Documentation? has been developed to provide daily record of ambulation for residents indicated by therapy.
Our Staff Developer will educate CNAs, LPNs, RNs of their roles and responsibilities related to policies. All education will be completed by compliance date.
A quality assurance tool has been created to monitor compliance. Any issue identified during audit will be reported to Unit Manager and Staff educator for remediation. The results of the audits will be reported to the Quality Assurance Committee for review and appropriate actions as determined at that time. Audits will be done monthly for 3 months and regularly thereafter as directed by the Quality Assurance Committee. The DON is responsible for implementation of policies; the Unit Managers are responsible for ongoing compliance.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #7) of two residents reviewed for incontinence care, the facility did not provide care using appropriate infection control standards of practice. Specifically, staff did not change gloves after cleansing feces prior to touching other areas on the resident and multiple environmental surfaces, placed soiled linen on the floor without a barrier, and did not wash hands after removing soiled gloves. This is evidenced by the following: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/16/17, revealed the resident had severely impaired cognition, required extensive assist of one staff member for toileting and personal hygiene, and was occasionally incontinent of bowels. The current facility policy, Incontinence Care-Exposure to Feces and Urine, includes staff are to wash their hands after removing gloves following incontinence care. In an observation of care with two Certified Nursing Assistants (CNAs) on 3/28/18 at 9:33 a.m., the resident was incontinent of bladder and bowels. CNA #1 donned gloves and cleansed the resident's buttocks of stool and then cleansed the penis of urine. All soiled linens were placed on the bare floor. After cleansing the resident and still wearing the same gloves, the CNA applied a clean brief, touched the resident's arm, his linens, the siderail, the bed controls, the call bell, the resident's walker (hand bars), and the cleaning supplies. After discarding the soiled linens in a linen bag in the hallway, the CNA did not attempt to wash her hands. When interviewed at that time, the CNA stated that she guessed she should have changed her gloves after cleaning the resident's buttocks of stool and before touching everything. The CNA washed her hands after surveyor intervention. Interviews conducted on 3/29/18 included the following: a. At 11:11 a.m., the Registered Nurse Manager (RNM) stated that staff have been instructed many times to not place dirty linens on the floor but to place them on the bed or a chair on a barrier. The RNM said she would expect staff to change their gloves after cleansing feces and before touching anything and wash their hands when done. b. At 1:18 p.m., the Infection Preventionist/Employee Health stated that the expectation was for staff to clean a resident from front to back and to change their gloves when finished. He said that dirty linen does not go on the floor, gloves should be removed prior to touching environmental surfaces, and that hands should be washed. (10 NYCRR 415.19(b))

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
Resident # 7 was assessed for any s/s infection, irritation, etc. Staff member who provided care was offered and accepted remediation with Staff Development Coordinator to review Policy for ?Perineal Care Procedure? and ?Laundry and Bedding, Soiled?
Residents who receive care for bowel and bladder incontinence will be reviewed to assure care provides cleanliness and comfort and care to prevent infection and skin irritation.
Our policies ?Perineal Care Procedure?, ?Incontinence care? and ?Laundry and Bedding, Soiled? were reviewed and revised where necessary.
Our Staff Developer will educate CNAs, LPNs and RNs of their roles and responsibilities related to policies. All education will be completed by compliance date.
Two quality assurance tools have been created to monitor compliance of provision of perineal/incontinence care and handling of soiled bedding/linen. Any issue identified during audit will be reported to Unit Manager and Staff educator for remediation. The results of the audits will be reported to the Quality Assurance Committee for review and appropriate actions as determined at that time. Audits will be done monthly for 3 months and regularly thereafter as directed by the Quality Assurance Committee. The DON is responsible for implementation of policies; the Unit Managers are responsible for ongoing compliance.

FF11 483.55(b)(1)-(5):ROUTINE/EMERGENCY DENTAL SRVCS IN NFS

REGULATION: §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility- §483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #27) of two residents reviewed for dental services, the facility did not provide dental services to meet the resident's wishes. The issue involved lack of follow-up for denture fittings following multiple teeth extractions. This is evidenced by the following: Resident #27 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/21/17, includes that the resident was [AGE] years old, cognitively intact, and required supervision and set-up assist for eating. A Comprehensive MDS Assessment, dated 11/9/17, includes that the resident has obvious or likely cavities or broken natural teeth. The facility policy, Dental Services, dated (MONTH) (YEAR), includes that routine and dental services are available to meet the resident's oral needs in accordance with the Resident Assessment, Plan of Care, physician orders [REDACTED]. Review of Dental Consult notes, dated 9/25/17 and 10/16/17, included that the resident had multiple teeth and root tips extracted. In a Dental Progress Note titled, Annual Oral Examination, dated 1/22/18, the dentist documented that the resident has no natural teeth present in the maxillary (upper) or mandibular (lower) arch and that the resident does not wear upper or lower dentures. It includes that the soft tissues appear normal, that the condition of the upper ridge was good, and the lower ridge was atrophied. Under recommendations, the dentist documented that he would recommend no dental treatment. The patient has no complaints with his mouth, and he is able to eat and function without dentures. The Comprehensive Care Plan, dated as last reviewed on 1/3/18, includes that the resident has chewing and swallowing difficulty related to his stroke and that his teeth are in poor condition, altered dentition, missing teeth, and self-feeding difficulty. Interventions include to monitor and report problems eating that may be due to dental state. The Certified Nursing Assistant (CNA) Resident Care Plan, dated 11/15/17, includes under eating that the resident gets soft foods and to cut up in small pieces. A Speech Therapy evaluation, dated 3/25/18, included that the resident was being seen for an evaluation of swallow functioning due to coughing with meals. Precautions include, but were not limited to, recommended diet was regular with some puree. The evaluation includes that the resident was edentulous (no natural teeth), and the long-term goal was that the resident will tolerate a mechanical soft diet without signs of aspiration. In observations and interviews on 3/26/18 at 11:37 a.m., on 3/27/18 at 3:35 p.m., and again on 3/28/18 at 10:01 a.m., the resident stated that he had a few teeth (roots) in the way back and recently had the rest of his teeth removed. He said that he hopes to get dentures as he has some trouble chewing and was waiting to be fitted. The resident said he was not told he could not have dentures, just that he had to have his teeth out and he did. The resident said that he could eat ok but if he had dentures he could eat better and look better. Interviews conducted on 3/28/18 included the following: a. At 11:22 a.m., the CNA stated that the resident eats ok but does cough a lot. She said he has not mentioned dentures to her. b. At 12:47 p.m., the Speech Therapist stated that he did not know if the resident was going to get dentures or not. He said that the resident would like to get dentures so that he could eat anything he wants. He stated at least upper dentures would give the resident a better quality of life and eating which he enjoys. c. At 2:26 p.m., the Registered Nurse Manager stated that there are no dental appointments scheduled for the resident. She said she did not think there were any plans to fit the resident with dentures but she did not think there was any reason he could not have them. d. At 2:58 p.m., the Dentist stated that he never indicated to the resident that he would be fitting him for dentures. He said a lot of nursing home residents function better without dentures. The Dentist said it is a very involved process and difficult to get accustomed to wearing dentures. When informed that the resident was [AGE] years old, the Dentist stated that he would talk to the resident and see if it was possible. (10 NYCRR 415.17(c))

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
Dentist was contacted for need of further evaluation for resident #27 on 3/29/18. Dental evaluation was completed on 4/16/18 by Dentist.
All current edentulous residents have been reviewed by Registered Nurse for documentation related to need / appropriateness of dentures. Residents who experience dental extractions will be reviewed for documentation related to need/ appropriateness of dentures.
We have reviewed our policy ?Dental Services?
Our Staff Developer will educate licensed LPNs and RNs on their roles and responsibilities related to policies. All education will be completed by compliance date.
A quality assurance tool has been created to monitor compliance. Any issue identified during audit will be reported to Director of Nurses. The results of the audits will be reported to the Quality Assurance Committee for review and appropriate actions as determined at that time. Audits will be done monthly for 3 months and regularly thereafter as directed by the Quality Assurance Committee. The DON is responsible for implementation of policies; the Unit Managers are responsible for ongoing compliance.

FF11 483.90(i):SAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRON

REGULATION: §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 30, 2018
Corrected date: May 18, 2018

Citation Details

Based on observations and an interview conducted during the Recertification Survey, it was determined that the facility did not provide a functional environment for staff and the public. Specifically, public restrooms were out of order. This is evidenced by the following: Observations on 3/26/18 at 10:45 a.m. revealed the doors to the men's and women's restrooms, located on the first floor across from the Social Work Office, were marked with paper signs that read: Out of Order, please use the restroom in the activity room. Further observations in the first floor activity room revealed the bathroom was designed for resident use and was equipped with grab-bars and a call cord. When interviewed, the Director of Maintenance revealed the administrative wing bathrooms have been out of service since around 12/25/17. An interview with the Administrator revealed there was a break in the sewer line somewhere, and the bathrooms were taken out of service because there were sewer backups that affected the kitchen. The Administrator said that they have quotes for repairs and are considering their options. When interviewed on 3/28/18 at approximately 9:40 a.m., two Certified Nursing Assistants said that the two second floor bathrooms marked men's and women's are for resident use, and staff use the one at the nurses' station. There were no other restrooms designated for public use. (10 NYCRR 415.29)

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
Repair of the sewer line servicing the public restrooms is being coordinated with facility staff and a local plumber.
These are the only two designated public restrooms. A review of the other staff restrooms reveals no plumbing issues.
The maintenance staff will ensure that all sewer lines remain functional by periodic cleaning as necessary.
The Maintenance Supervisor shall provide the Quality Assurance Committee with a report of all sewer line malfunctions and repairs for their review and action as necessary.
The Administrator will be responsible for the correction of this deficiency.

Standard Life Safety Code Citations

DEVELOPMENT OF EP POLICIES AND PROCEDURES

REGULATION: (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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 These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 30, 2018
Corrected date: May 25, 2018

Citation Details

Based on an interview and record review conducted during the emergency preparedness review in conjunction with the Life Safety Code Survey completed on 3/28/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, emergency and disaster specific scenarios were not updated annually based on a Hazard Vulnerability Assessment (HVA). The findings are: On 3/27/18 at 9:20 a.m., the Administrator provided the surveyor with the facility Emergency Preparedness Plan (EPP) for review. Page two of the table of contents revealed that in Section E (Emergency Procedures for Specific Events) there are plans that included: Active Shooter/Person with a weapon, Bioterrorism/Terrorism, Carbon Monoxide Alarm Activation, Civil Disturbance/Demonstration, and Hazardous Materials Spill or Leak. A Review of Section E of the EPP revealed there were no emergency procedures for the aforementioned specific events, and the emergency procedures for specific disasters was last revised in (MONTH) of 2005. The EPP did not include an annual HVA to be used to develop emergency procedures for specific events. Further review of the EPP revealed Section B (Emergency Operations Plan, procedures applicable to all hazard responses) was blank. An interview with the Administrator revealed Section B has not been completed yet. (42 CFR 483.73(b) - Emergency Preparedness)

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The facility has procured a copy of Russell Phillips and Associates Emergency Preparedness Guidebook for Long Term Care and is in the process of using it, step by step, to revise the required Emergency Preparedness Plan updating or developing specific emergency and disaster scenarios based on the Hazard Vulnerability Assessment.
There is only one Emergency Preparedness Plan.
The Emergency preparedness Plan will be reviewed and revised by the Administrator and Managers annually or as necessary.
When completed, the Emergency Preparedness Plan will be presented to the Quality Assurance Committee for its review and comment.
The Administrator is responsible for the correction of this deficiency.

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 minimal harm
Citation date: March 30, 2018
Corrected date: N/A

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey completed on 3/28/18, it was determined that for one of one emergency generator the facility did not properly maintain the emergency power system. Specifically, there was no remote annunciator for the emergency power source (generator). The findings are: Observations on 3/26/18 at approximately 11:40 a.m. revealed an Onan brand natural gas emergency generator located in the basement boiler room. Further observations throughout the facility revealed there was no annunciator panel for the generator. When interviewed on 3/27/18 at 12:52 p.m., a mainatenance staff person said there was a light that comes on at the generator but nowhere else. He said they are aware of it and are getting quotes. The 1999 edition of NFPA 99, Health Care Facilities Code, requires a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 6.4.1.1.17, 6.5.1)

Plan of Correction: ApprovedApril 23, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The Facility is requesting a time limited waiver (6 months).
The Facility's Onan emergency generator is approximately [AGE] years old and we have been looking for a vendor who would be able to install a compliant annunciator for some time now without success. Just recently I was put contact with an electrician who believes he will be able to install a compliant annunciator, however, he must visit the facility, examine the generator and if he can do the installation offer a quote. Assuming he can successfully install an annunciator I can not be certain that the deficiency can be corrected within the mandated timeframe. Therefore, the Facility will be submitting, to the Bureau of Architecture and Engineering in Albany New York, a request for a time limited waiver of 6 months by (MONTH) 1,2018.
The Administrator is responsible for the correction of this deficiency.

NAMES AND CONTACT INFORMATION

REGULATION: [(c) The [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 every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 30, 2018
Corrected date: May 25, 2018

Citation Details

Based on an interview and record review conducted during the emergency preparedness review in conjunction with the Life Safety Code Survey completed on 3/28/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, there was no formal communications plan, or contact information for staff members and resident physicians listed in the facility Emergency Preparedness Plan. The findings are: On 3/27/18 at 9:20 a.m., the Administrator provided the surveyor with the facility Emergency Preparedness Plan (EPP) for review. Page A.5 of the EPP stated that the communications plan provides names and contact information for staff, resident physicians, entities providing services under arrangement, other health care facilities, volunteers, and that contacts are located in Section F: Emergency Resources and Lists. A review of Section F of the EPP revealed lists of facility names and sectors, but did not contain contact information for staff or resident physicians. An interview with the Administrator revealed that the contact information for staff was kept on the computer system, and the contacts for the two Nurse Practitioners and Medical Director can be found at the nurses' stations. (42 CFR 483.73 (c)(1) - Emergency Preparedness)

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The facility has procured a copy of Russell Phillips and Associates Emergency Preparedness Guidebook for Long Term Care and is in the process of using it, step by step, to revise the required Emergency Preparedness Plan including a comprehensive communications plan.
There is only one Emergency Preparedness Plan.
The Emergency Preparedness Plan will be reviewed and revised by the Administrator and Managers annually or as necessary.
When completed, the Emergency Preparedness Plan will be presented to the Quality Assurance Committee its review and comment.

PLAN BASED ON ALL HAZARDS RISK ASSESSMENT

REGULATION: [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 30, 2018
Corrected date: May 25, 2018

Citation Details

Based on an interview and record review conducted during the emergency preparedness review in conjunction with the Life Safety Code Survey completed on 3/28/18, it was determined that the facility did not comply with emergency preparedness requirements. Specifically, the facility did not complete a Hazard Vulnerability Assessment (HVA). The findings are: On 3/27/18 at 9:20 a.m., the Administrator provided the surveyor with the facility Emergency Preparedness Plan (EPP) for review. Section A of the policies and planning section calls for a HVA to be completed and it can be found in appendix A. The appendices section of the facility EPP only had a copy of the (YEAR)/2018 mutual aide plan. When interviewed, the Administrator revealed the facility has been using the Mutual Aide Plan in place of the HVA and he does not think one has been done. (42 CFR 483.73(a)(1) - Emergency Preparedness)

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
The facility has procured a copy of Russell Phillip and Associates Emergency Preparation Guidebook for Long Term Care and is in the process of using it, step by step, to revise the required Emergency Preparedness Plan including a HVA.
There is only one Emergency Preparedness Plan.
The Emergency Preparedness Plan will be reviewed and revised by the Administrator and Mangers annually or as necessary.
When completed, the Emergency Preparedness Plan will be presented to the Quality Assurance Committee for its review and comment.
The Administrator is responsible for the correction of this deficiency.

K307 NFPA 101:PORTABLE SPACE HEATERS

REGULATION: Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 30, 2018
Corrected date: April 20, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey completed on 3/28/18, it was determined that for one (first floor) of two resident use floors, the facility did not provide compliant heating units. Specifically, non-compliant portable space heaters were in staff offices. The findings are: Observations on 3/26/18 at approximately 11:20 a.m. revealed a Comfort Zone brand portable space heater in use under a desk in the first-floor Social Work Office. Further observations in the first-floor Business Office revealed a Holmes First Touch brand portable space heater plugged in (but not running). An interview with an employee in the Business Office revealed they do not use the space heater and did not know it was there. There was no documentation provided by the facility to show that the heating elements of the portable heaters did not exceed 212 degrees Fahrenheit. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.7.8)

Plan of Correction: ApprovedApril 19, 2018

THE PREPARATION AND EXECUTION OF THIS PLAN OF CORRECTION DOES NOT CONSTITUTE ADMISSION OR AGREEMENT WITH THE FACTS ALLEDGED OR CONCLUSIONS SET FORTH IN THIS STATEMENT OF DEFICIENCIES. THIS PLAN OF CORRECTION IS EXECUTED SOLELY BECAUSE IT IS REQUIRED BY PROVISION OF FEDERAL LAW.
Both of the cited portable space heaters have been removed from the facility.
The Housekeeping Supervisor has completed an inspection of all offices and resident rooms to ensure that no other portable space heaters are in use or present.
The Administrator has developed a policy prohibiting the use of all nonconforming portable space heaters. This policy was introduced to 100% of the Departmental Managers and Nurse Managers by the Administrator.
The House Keeping Supervisor will conduct monthly room and office audits to ensure that portable space heaters are not reintroduced into the facility. The results of these audits will be provided to the QUPI Committee for their review and action as is necessary.
The Administrator is responsible for the correction of this deficiency.