Bronx Center for Rehabilitation & Health Care
January 10, 2019 Certification Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey the facility did not ensure that a resident's plan of care was revised before the initiation of a [MEDICAL CONDITION] medication. Specifically, 1) There were no documented non-pharmacological interventions identified and incorporated into the resident's plan of care to address the resident's behavior prior to starting an [MEDICAL CONDITION] medication. In addition, 2) The facility did not ensure that a resident was afforded the opportunity to participate in formulating a plan of care. Specifically, there was no documentation of the residents involvement in the care plan meetings or discussions. This was evident for 2 of 38 sampled residents. (Resident #184 and # 39). The findings are: The facility policy titled, Care Plans, Comprehensive Person-Centered updated 8/2017 documents: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1) The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a Comprehensive, Person Centered Care Plan for each resident. The resident and or their representative is invited to participate in the Comprehensive Care Plan (CCP) meeting. 4) Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a) Participate in the planning process. c) Participate in establishing the expected goals and outcomes of care. h) See the care plan and sign it after significant changes are made. 7) The care planning process will: a) Facilitate resident and/or representative involvement. 10) Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of the interdisciplinary process. 13) Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 14) The Interdisciplinary Team must review and update the care plan: a) When there has been a significant change in the resident's condition. b) When the desired outcome is not met. 1) Resident # 184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/7/19 at 12:11 PM, the resident was observed sitting in a wheelchair in the dining room during lunch. The resident was neatly groomed and neatly dressed. The resident was wearing glasses. The resident had a plate containing chicken, white rice, mixed vegetables. A bowl of chicken noodle soup, a slice of white bread, a cup of tea and a container of Glucerna were also on the tray. The resident stated she was not hungry. The resident was quiet and in no distress. On 1/8/19 at 2:30 PM, the resident was observed propelling herself in wheelchair down the hallway past the nurses station. The resident was neatly groomed and neatly dressed. The resident was wearing glasses. The resident was calm and in no distress. On 1/9/19 at 10:01 AM, the resident was observed sitting in wheelchair in the day room at a table with 2 other residents. The resident was neatly groomed and neatly dressed. The resident was wearing glasses. This surveyor greeted the resident and asked how the resident felt. The resident responded I feel sleepy today. The resident was calm and in no distress. On 1/9/19 at 12:14 PM, the resident was observed sitting in her wheelchair and eating lunch in the day room. The resident was neatly groomed and neatly dressed. The resident was wearing glasses. The resident was eating beef stew, noodles and green beans. The tray also contained a cup of tea and a container of Glucerna. The resident was asked how the food tastes today and responded it will do. The resident was eating independently. The resident was calm and in no distress. On 1/10/19 at 9:19 AM, the resident was observed sitting in wheelchair in the day room. The resident was neatly groomed and neatly dressed. The resident was wearing glasses. The resident cleared her throat with a slight cough. The resident was asked how she was today and responded I feel okay but I am kind of sleepy. The resident was watching TV in the day room. The most recent Comprehensive Annual Assessment as documented in the Minimum Data Set (MDS) 3.0 dated 7/4/2018 documents the following: Hearing- minimal difficulty, no hearing aid. Clear speech. Understood. Understands. Vision- impaired, wears corrective lenses. Cognitive Patterns- Brief Interview for Mental Status (BIMS) score = 3. Cognitive patterns- N0- resident was able to complete interview. [MEDICAL CONDITION]- the following behaviors were NOT present - Inattention, Disorganized thinking and Altered level of consciousness. Mood- Total Mood Severity Score = 0. Behavior- No hallucinations. No delusions. Behavioral Symptoms- Presence and Frequency- Behavior not exhibited- Physical behavioral symptoms directed toward others, Verbal behavioral symptoms directed towards others. And other behavioral symptoms not directed toward others. Rejection of Care- Presence and Frequency- 0- Behavior not exhibited. Wandering- Presence and Frequency- 0, Behavior not exhibited. How does resident's current behavior status, care rejection or wandering compare to prior assessment? - same. Functional Status- Extensive assistance- bed mobility, transfer, walk in room, walk in corridor, dressing, eating, toilet use and personal hygiene- all one person assist. No Functional Limitation in range of Motion. Mobility devices- walker and wheelchair. Frequently incontinent of bladder and bowel. Medications received- none documented. The MDS Quarterly assessment dated ,[DATE] (YEAR) documents- same except for the following- Always incontinent of bladder and bowel. Diagnosis- [MEDICAL CONDITION] (other than [MEDICAL CONDITION]). Medications Received - Antipsychotic - 7 days. Antipsychotic medication review- Yes- Antipsychotics were received on a routine basis only. Has a gradual dose reduction been attempted- No. Physician documented GDR as clinically contraindicated - N0. Care Plan - [MEDICAL CONDITION] Drug Use - Evidenced by disruptive voice, behavior of inappropriate words to staff, negative behavior towards room -mate- family. Goals- demonstrate decreased need for psychoactive medication. Resident will have decreased incidents of mood or behavior. Interventions- Encourage verbalization of feelings. Establish appropriate [DIAGNOSES REDACTED]. Observe for any signs of decline in functional cognitive status. Obtain psychiatric consult or follow up as necessary. The Comprehensive Care Plan did not document a [MEDICAL CONDITION] or a [DIAGNOSES REDACTED]. The Comprehensive Care Plan did not document non- pharmacological interventions that were tried to address the residents behavior prior to the prescribing and administering of [MEDICATION NAME]. Care Plan - [MEDICAL CONDITION] - Cognitive loss- dementia. Related to impaired decision making, long and short- term memory loss, oriented to self but not to time or place. Judgement - insight- poor. Goals- Resident will demonstrate ability to make decisions in activities. Resident will selfcare within mental and physical limitations. Interventions- Evaluate medication regimen. Evaluate pain management. Promote activities that reduce frustration and support success. Use simple words or instructions. Physicians Monthly Orders dated 9/14/2018 thru 12/18/18 documents- [MEDICATION NAME] 0.5 mg- Give one tablet daily at bedtime. Diagnosis- restlessness and agitation. Physicians Monthly Orders dated 1/7/19 documents- [MEDICATION NAME] 0.5 mg - Give one tablet daily at bedtime. Diagnosis- other psych disorder not due to a sub or known physiol condition. Medication Administration Records dated 9/14/18 thru 1/6/2019 documents the resident received [MEDICATION NAME] 0.5 mg daily at bedtime. Physicians Progress Notes document the following- 9/28/18 - Diagnosis - Dementia with behavioral disturbances. Aggressive behavior towards others. [MEDICATION NAME] ordered. 10/23/18 - Diagnosis- [MEDICAL CONDITION] and behavioral disturbances. Tolerating [MEDICATION NAME]. 11/20/18 - Diagnosis - [MEDICAL CONDITION] On [MEDICATION NAME] 12/18/18 - Diagnosis- [MEDICAL CONDITION]- No new behavioral changed noted. On [MEDICATION NAME]. Psychiatric Consult dated 8/22/18 documents: Follow - up. Patient is a [AGE] year old female with history of Dementia, on no psyche meds. As per staff patient has been stable, no behavioral disturbances. Patient states she is doing okay. Patient did not provide details about history. Patient believes she has been here for one year. Patient denies depression, denies confusion, denies psychotic symptoms and denies memory deficits. No evidence of hopelessness, helplessness or suicidal ideation. No reported side effects of medication. No problems with sleep. Diagnosis- [MEDICAL CONDITION]. Assessment/Plan - no new behavioral issues since last contact. Meds- continue same management, no new recommendations. Psychiatric Consult dated 9/13/18 documents: Follow-up. Chief complaint- agitation, [MEDICAL CONDITION], belligerent behavior. As per staff patient has been agitated, belligerent and threatening towards other patients. Patient states she is doing okay. Patient did not provide details about history. Patient believes she has been here one year. Same as above. Diagnosis- [MEDICAL CONDITIONS]. Assessment/Plan -with agitation and [MEDICAL CONDITION]. Psychiatric Consult dated 9/27/18 documents - Reason for follow up, patient recently started on [MEDICATION NAME]. Chief complaint- agitation, [MEDICAL CONDITION] and belligerent behavior. As per staff has been calmer, she is doing okay. Same as above. Diagnosis -[MEDICAL CONDITION] and [MEDICAL CONDITION]. Assessment/Plan tolerating current psyche meds. No new behavioral issues. Meds- continue same meds. Psychiatric Consult dated 11/1/18 documents- Follow up. As per staff patient has been calmer. She is doing okay. Patient did not provide details about her history. Same as above. Diagnosis - [MEDICAL CONDITION] and [MEDICAL CONDITION]. Meds- continue same meds. No new recommendations. Psychiatric Consult dated 11/29/18 documents: Patient seen for follow up. Patient is a [AGE] year old female with history of dementia on psyche meds. As per staff patient has been calmer. She is doing okay. Patient did not provide details about history. Patient believes she has been her for years. Patient denies depression. No evidence of hopelessness or suicidal ideation. No reported side effects of meds. No problem with sleep. No new behavioral issues. Tolerating current psyche meds. Psyche med [MEDICATION NAME] 0.5 mg at bedtime. Mental Status Examination - Appearance- alert, awake, cooperative. Gait seated. Muscle tone- normal. Mood- good. Affect- reactive. Suicidal ideation - No. Homicidal ideation- No. speech - normal. Thought process - slowed. Thought content-delusions- No. Paranoid ideation - No. Hallucinations- No. Associations- No. Orientation- person- Yes. Place- No. Time- No. Attention and concentration - decreased. Memory short term- Poor. Memory long term - Poor. Language [MEDICAL CONDITION]- No. Fund of Knowledge- Poor. Insight and Judgement - limited. Abnormal movements- No. Diagnosis- [MEDICAL CONDITION] and [MEDICAL CONDITION]. Assessment/Plan- tolerating current psyche meds. No new behavioral issues. Meds- continue same meds. No new recommendations. Follow up 4 - 6 weeks and prn. High Risk Management Meeting dated 9/12/18 documents- Risk Area- behavior disruptive. Placed on High Risk ATCH List- Yes. Follow up steps- Non-pharmacological interventions - Re-direct and re-orient, family involvement, Rec on unit Rehab. Psyche consultation. Pharmacist Monthly Drug Regimen Review -Completed Monthly on 7/2/18, 8/9/18, 9/4/18/10/2/18 11/1/18, 12/2/18 and 1/2/19 - documented in the Sigma software system - No Irregularities Noted. The facility presented a copy of the Medication Regimen Review dated 1/2/19. It documents for this resident, Patient is a [AGE] year old with [DIAGNOSES REDACTED]. Please evaluate for Gradual Dose Reduction. Black Box Warning. Physician response is dated 1/8/19 Psych GDR. The FDA approved product labeling documents only three approved indications for the use of [MEDICATION NAME]. [MEDICATION NAME] is indicted for 1) treatment of [REDACTED]. A United States Food and Drug Administration Alert dated 6/16/2008 documents the following: FDA is notifying healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for [REDACTED]. Since issuing that notification, FDA has reviewed additional information that indicates the risk is also associated with conventional antipsychotics. Antipsychotics are NOT indicated for the treatment of [REDACTED]. The following BLACK BOX WARNING is included in the prescribing information product labeling in the package insert of the drug [MEDICATION NAME]: WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA -RELATED [MEDICAL CONDITION]. Elderly patients with dementia related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] is not approved for use in patients with dementia related [MEDICAL CONDITION]. On 1/7/19 at 12:34 PM, the covering Attending Physician was interviewed and stated, The resident is taking [MEDICATION NAME] 0.5 mg at bedtime. I am checking the Psychiatrist consult and it states the resident is taking [MEDICATION NAME] due to vascular [MEDICAL CONDITION]. This resident is [AGE] years old. I don't think this is an appropriate drug to give this resident. The dose of [MEDICATION NAME] 0.5 mg is a little too high. Maybe we need to lower the dose. I know elderly residents with dementia do not need antipsychotic medications. The Psychiatrist usually comes and evaluates the resident and recommends the medication. As the Attending Physician I review the medication. I just signed the renewal order today for this medication. The Black Box warning means we have to follow the resident's EKG. The patients have high risk for falls. I don't remember what else the Black Box warning covers. On 1/7/19 at 12:50 PM, the 4th floor Registered Nurse(RN) #3 Unit Manager was interviewed and stated, The resident was started on [MEDICATION NAME] 0.5 mg at bedtime on 9/14/18. The resident was started on this medication because she was aggressive towards staff. She was going into the other resident's space in her room, telling them that this is her room, she paid for it and the roommate should not be there. She was staying up late at night and using inappropriate language to the staff when they tried to redirect her. The resident did not want to go to bed. It was hard to get her compliant with care such as taking a shower and getting washed up in the evening for bed. She would go in and out of the dining room. She would eat a little then leave the dining room. We try to talk to her. We try to redirect her from the room. We take her to the dining room. We tried to get her involved in the recreation programs. We took her off the unit to participate in church programs and craft programs. She will tell staff after she is brought off the unit to the other programs, she does not want to be there. I told the Psychiatrist about her behavior. He recommended to redirect her but it was not working. After she was seen by the Psychiatrist we called her granddaughter to explain the behavior and the Psychiatrist recommendation. The resident has never hit any staff member to my knowledge. The resident has not hit any other resident. The resident never expressed any notions of suicidal tendencies by saying she wants to kill herself. Since the resident has been on the [MEDICATION NAME] she still has a mouth on her. She says what she wants to say if it is appropriate or not. She now speaks to the roommates family. All the nurses are responsible to write behavior notes on a resident. They should be documenting the behavior as it occurs. We do not have a separate section in the Sigma software computer system to document resident behaviors. We document all inappropriate behaviors in the Progress Notes. I only have Progress Notes written on 3 days. The first day is 9/11/18 prior to the [MEDICATION NAME] being prescribed. The second note is dated 9/14/18 on the day [MEDICATION NAME] was prescribed. The third note was written on 10/1/18 Where I wrote the resident was seen by the Psychiatrist on 9/26/18, she was recently started on [MEDICATION NAME], there has been a decrease in agitation and disruptive behaviors. The [MEDICATION NAME] was prescribed due to behaviors of being disruptive, loud, not going to bed and using inappropriate language. The nurses on the floor myself included are responsible to write progress notes. The resident should have been monitored by the nursing staff including myself and if need be behavior notes should have been written for behaviors exhibited by the resident after the [MEDICATION NAME] was prescribed. The medication was working. Her behavior issues decreased and there was less of it seen. I should have documented this, but I did not. I should have written behavior notes in between the visits of the Psychiatrist not just after his visit. Nurses are responsible to monitor residents for any side effects of medications. The nurses are supposed to monitor if the non-pharmacological interventions are working. If they are not working, we discuss and report it to the doctor. The Certified Nursing Assistants (CNA) do not document any issues with resident behavior in their Personal Digital Assistance(PDS) records. On 1/9/19 at 11:23 AM, the 4th floor RN #3 Unit Manager was interviewed and stated, I am the person that writes and updates the care plans as needed. After the Interdisciplinary Team (IDT) meeting, I tried to redirect her. I tried to get her involved in the recreation programs. She did not want to go off the unit to the programs. So on the unit she liked movies and musical singing activities. We tried to get her involved in yoga. She like to go to rehab. I did NOT update the care plan to reflect these non-pharmacological interventions that I just told you were done. I do not have any written notes or documentation to show you that these things were done. As far as her complaining about other people being in the room and she pays the rent for the room and nobody should be there but her. As far as I know I did not offer her a private room. I don't remember anybody offering her a private room. On 1/7/19 at 1:04 PM, the Licensed Practical Nurse (LPN) #3 was interviewed and stated, The resident is taking [MEDICATION NAME] 0.5 mg at bedtime. She takes this medication because she is angry and really mad. I saw her taking things such as pillows from her roommate. I saw her make the roommate cry. I saw her wheeling herself up and down the floor and complaining that nobody takes care of me. She will see other residents being given care by the staff and then will say nobody takes care of me. I see she sometimes gets mad and wants all the attention to her. She never hit me. She has never hit any other resident. She has yelled at me and said she will tell her daughter. She yells at other residents and says her roommate took her things. I will offer her something to drink or to eat when she acts up. I offer to get her another pillow. On 1/7/19 at 1:33 PM, the 4th Floor Certified Nursing Assistant CNA #2 was interviewed and stated, The resident is calm and nice when I come in to give her care in the morning. I say good morning and I take her to the bathroom. to wash her up. I will then get her dressed. I tell her I want to take her to the dining room for breakfast and she curses at me. She says I have to get another job. The resident has never hit me. She has raised her hands and shook her fingers at me. I have never seen her hit another resident. She does not like the other person in the room. She says she paid for the room and does not want another person in the room with her. In the day room she will yell and scream at other residents if they pass behind her and hit her chair by mistake. Some of the residents in the day room make noise and she will scream at them. Sometimes she wants to talk to other residents and they tell her leave me alone and she will yell at them. When she yells and screams I will leave her alone until she calms down. When I leave her alone and go back to her she is calm. I will ask her if she wants to go to the bathroom, if she wants to lie down or if she wants something to drink. I never saw her hit any other residents. When I see the issues with behavior I sometimes report it to the nurse. I don't report every time she has a behavior problem or outburst, because she has this behavior every day and it is her way. She gets upset about every little thing. I only report the behavior to the nurse if it gets out of control. If I can't get her to calm down or if I go away and then go back to her and she is still acting up I will report this to the nurse. I don't write anything concerning the resident's behavior in my accountability notes On 1/8/19 at 10:07 AM, the Psychiatrist was interviewed and stated, I prescribed [MEDICATION NAME] to this resident because she is agitated, paranoid and aggressive. She would not allow nursing care or people to interact with her. I have been working in the facility one year. My [DIAGNOSES REDACTED]. Before I started her on the [MEDICATION NAME] I recommended behavior management work with a specific staff member, to place her in a single room and redirection. The Food and Drug Administration approves [MEDICATION NAME] to treat [MEDICAL CONDITION]. This is the primary indication. It is also approved for [MEDICAL CONDITION]. It can be used to treat [MEDICAL CONDITION] with depression and [MEDICAL CONDITION] disorders. It can be used to treat hallucinations. The resident was paranoid which is a form of [MEDICAL CONDITION]. She says I was trying to hurt her and attacking her. I know what the Black Box Warning is. It says that patients on psyche drugs with dementia tend to have increased mortality when compared to patients not on antipsych medications. My understanding is the [MEDICAL CONDITION] is not solely attributed to her Dementia. The dosage forms of [MEDICATION NAME] are 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg and 4 mg. I started her on [MEDICATION NAME] 0.5 mg which allows once a day dosing. Most residents tolerate 0.5 mg. I have not seen a tremendous response on 0.25 mg. I have not read the Federal regulations concerning the use of antipsychotic medications in nursing homes. The plan was to do a Gradual Dose Reduction(GDR) and do a rapid GDR once her behavior came under control. The patient is aggressive to other patients. No one ever told me she hit anyone, either staff or any other resident. Your point is taken that a lower dose should have been prescribed or that probably more intensive behavior management should have been done before I recommended the start of the [MEDICATION NAME]. Based on this conversation I intend to do a rapid GDR to taper it down and then stop the medication. On 1/8/19 at 11:31 AM, the Attending Physician was interviewed and stated, I write the monthly orders for this resident. The resident is taking [MEDICATION NAME] 0.5 mg at bedtime. The resident has been with us a few years. The resident had behavioral changes and she was noted with a change in her quality of life. The behaviors were she was more agitated, issues with redirection, at times responding to stimuli. There was a question if she was paranoid. The initial plan was to redirect her with behavior management. When those measures failed we involved the Psychiatrist. We felt she would benefit from medication. The resident does not have [MEDICAL CONDITION] and does not have a [DIAGNOSES REDACTED]. The Psychiatrist recommended [MEDICATION NAME] as he felt the resident might benefit form a small dose of these antipsychotics. I have heard of the Black Box Warning. It says there are increased incidents of adverse events such as death, cardiac disorders, infections and pneumonia. The Psychiatrist wrote a [DIAGNOSES REDACTED]. I am aware of the Black Box Warning that [MEDICATION NAME] should not be used in patients with Dementia related [MEDICAL CONDITION]. The resident should be started on the lowest dose. She was prescribed [MEDICATION NAME] 0.5 mg at bedtime which is not the lowest dose. The lowest dose [MEDICATION NAME] 0.25 mg. The resident is not violent. She has not hit staff or any other residents. I would give this a second review. On 1/9/19 at 9:16 AM, the Psychiatrist was interviewed and stated, I felt the conversation we had was helpful as I come from the hospital setting. We frequently use psychiatric medication for off label uses. I started working here in (MONTH) (YEAR). This is the first nursing home where I am working as a Consultant Psychiatrist. The attending doctor wrote the clinical indication for prescribing the [MEDICATION NAME] which is restlessness and agitation. This is NOT a reason to prescribe [MEDICATION NAME]. On my Psyche consults I have been writing the [DIAGNOSES REDACTED]. On 9/13/18 I was called to the see the resident for a follow visit. Before I see the resident, I talk to the nursing staff. I was told that the resident had become increasingly agitated, belligerent, restless and not responsive to redirection. She has not had any aggressive interaction with another resident, but staff was concerned that it might happen. I did not look up the Federal regulations as pertains to Antipsychotic medications, but my understanding is that you try to minimize the dose, use the lowest dose for the shortest duration and the prescribing should be a last resort after all other options failed. For agitated residents, limit setting, redirection, modify the environment, placing the resident in a single room, having her work with the same staff consistently and trying to anticipate her needs. As far as I know these were tried. The resident was never placed in a single room. I did not start the resident on the lowest possible dose. I felt [MEDICATION NAME] 0.5 mg although not the lowest dose in an effective dose. If she would not do well on this dose we would reduce it. The FDA approves this medication for [MEDICAL CONDITIONS] disorder and autism. This resident does NOT have any of these 3 diagnoses. The Black Box Warning says there is an increased mortality associated in elderly patients that are being prescribed antipsychotic medications. It also says that [MEDICATION NAME] should NOT be prescribed in patients with Dementia, related [MEDICAL CONDITION]. After our conversation I would be very reluctant to prescribe these medications again to elderly residents with Dementia. I know what a GDR is. I do NOT know what the Federal regulations are for performing GDR's in nursing homes. I should know what the Federal regulations are. I know that if residents are on Antipsychotic medications you try to taper the dose every 3- 4 months. I have recommended to the Attending Physician and the nursing staff that the [MEDICATION NAME] 0.5 mg at bedtime be reduced to [MEDICATION NAME] 0.25 mg at bedtime. We will monitor her for the reemergence of psychotic symptoms. We will reinforce to the nursing staff that we continue to implement behavior management. I have learned a lot from this experience. On 1/8/19 at 11:10 AM, the Director of Nursing was interviewed and stated, The resident is taking [MEDICATION NAME] 0.5 mg at bedtime. The Psychiatrist recommended the medication for this resident and the Attending Physician prescribed it. He wrote a [DIAGNOSES REDACTED]. I know this resident displays disruptive behaviors. This is evidenced by verbal outbursts toward her roommate, secondary to her belief she owns the room. The resident has had verbal outbursts towards the staff. The resident has not hit any staff or any other residents. The resident has no history of physical aggression. The resident gets agitated easily when she perceives something does not go her way. An example is sharing her room, or she does not like her lunch or dinner. She seems to repeat that she pays the rent here and when she perceives something is not to her liking she gets upset. We should implement non-pharmacological interventions before a resident is given antipsychotic medications. We involved the family. The resident has a granddaughter that comes to visit her. We do reorientation and redirection. On 1/9/19 at 10:46 AM, the Director of Nursing was interviewed and stated, The non -pharmacological interventions that should be tried, include music therapy, pet therapy, if a person likes Bingo or the movies. I involved the family for input. We can provide 1:1 to calm the person down. We redirect and reorient the person. For this resident we reorient her. I know she participates on the unit in group activities. The resident has a semi -private 2 bedded room. To my knowledge the resid

Plan of Correction: ApprovedJanuary 31, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F657 The facility will ensure that plan of care is revised before any resident starts on [MEDICAL CONDITION] drugs by: 1) thorough and timely documentation of person-centered non-pharmacological interventions identified for specific residents and their effectiveness and 2) by involvement of residents (who are able to participate) and/or their representatives in the development of the care plan.
Resident #184 was assessed by RN, SW and MD to ensure that resident didn?t experience any adverse effects from the use of the medication. None noted. [MEDICATION NAME] dose was decreased.
Resident?s care plan was revised to include non-pharmacological interventions such as participation w/ recreational activities on the unit, music and pet therapy, yoga, movies, reading to resident and encourage simple discussions, and tactile activities/stimulation on the unit e.g. hand massage.
Resident # 184 granddaughter participated in the decision to start resident on [MEDICATION NAME] 0.5 mg at bedtime. She was also made aware of a change in the dose on 1/9/19
Resident # 39 had a quarterly care plan meeting on 1/24/19, resident was invited and participated in the meeting.
All residents with [DIAGNOSES REDACTED].
An audit of care plans of all residents with primary DX of dementia w/ behavioral issues will be conducted with an emphasis on care plan revision to include person-centered non-pharmacological interventions prior to the initiation of a psychoactive medication.
Going forward, the SW will send invitations to the care plan meetings to the residents and/or family members, and maintain evidence of such invitation.
The policy and procedures on Dementia care /Behavior Management, especially non-pharmacological interventions, were reviewed and revised.
All IDCP Team and other clinical staff will be educated on the facility?s revised policy on Dementia care paying special attention to non-pharmacological interventions.
Prior to the initiation of a psychoactive medication, Nurse Managers will revise care plans to include specific person-centered non-pharmacological interventions.
Nurse managers will write Psychoactive Medication Review notes on a monthly basis for all residents on [MEDICAL CONDITION] drugs
All residents (or their representative) before they start on a [MEDICAL CONDITION] drug will participate in the decision ? making process via signing the Informed Consent for Psychoactive medications use.
All residents and /or their repr
1251

DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: §483.45(c) Drug Regimen Review. §483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. §483.45(c)(2) This review must include a review of the resident's medical chart. §483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. §483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: 2019-01-10
Corrected date: 2019-03-19

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: 2019-01-10
Corrected date: 2019-03-19

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

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: January 10, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, (1) an oxygen tubing was observed touching the floor. This was evident for 1 of 38 residents reviewed in the investigation sample. (Resident # 35). (2) The facility policy and procedure for Antibiotic Stewardship and Infection Control Program were not reviewed within the last calendar year. The findings are. Resident #35 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident's cognitive level is moderately impaired and the resident requires total assistance of two persons with all Activities of Daily Living (ADLs). On 01/04/19 at 09:39 AM and at 11:33 AM, on 01/08/19 at 09:59 AM and 12:50 PM, and on 01/09/19 at 10:33 AM, the resident's oxygen tubing was observed touching the floor. On 01/09/19 at 10:01 AM, CNA # 1 stated that if a resident is on oxygen, she would check the resident oxygen level. She would ensure that the resident is breathing without difficulties and she ensure oxygen is flowing. CNA # 1 stated that the oxygen tubing should not be touching the floor. CNA # 1 further stated that the oxygen tubing should be placed in way that it does not touch the floor. CNA # 1 also stated that she received infection control training two months ago. On 01/09/19 at 10:52 AM, LPN # 1 stated that when a resident is on oxygen, he ensures that the head of the bed is elevated. He checks the flow rate of oxygen and ensure the resident is breathing. LPN #1 stated that he ensure oxygen tubing is dated and is clean. LPN # 1 further stated that the oxygen tubing should be placed very close to the resident and the tubing should never be touching the floor. On 01/09/19 at 10:56 AM, RN Manager # 1 stated that when a resident is on oxygen, she ensures the head of bed is elevated and the nasal cannula is properly placed. RN Manager also stated that she ensures oxygen tubing is not touching the floor. RN Manager # 1 stated that she make rounds several times throughout her shift. RN Manager # 1 stated that moving forward, she would ensure the oxygen tubing is placed in a way so that if the resident moves, the tubing does not touch the floor. RN Manager # 1 also stated that she will in-service the CNAs again to ensure that they check on residents who are on oxygen often throughout the shift and also ensure oxygen tubing is not touching the floor.
The findings are: During review of the facility's Infection Prevention and Control Program (IPCP) the policies titled Antibiotic Stewardship and Infection Control Program were observed with an initiation date of 10/2017. The date revised fields for both of these policies was blank. There was no documented evidence that the policies were reviewed and/or updated annually. An interview was conducted on 01/10/19 at 12:27 PM, with the Assistant Director of Nursing (ADON) who stated that she was unaware that the IPCP policies regarding the Infection Control Program and Antibiotic Stewardship were not updated within the last year. The ADON further stated that she unaware that an annual update of the IPCP policies was required. 415.19 (a) (1-4)

Plan of Correction: ApprovedJanuary 31, 2019

Resident #35 was evaluated by the RN and MD to ensure resident was stable and didn?t suffer any adverse effects related to the oxygen tubing touching the floor ? none was evident.
CNA # 1 and LPN #1 were reeducated on infection control and prevention with a focus on oxygen therapy.
ADNS was educated on the requirement of updating the Infection Control and Stewardship policy annually
All residents who are on supplemental oxygen have the potential to be affected by the same deficiency.
Nurse Managers, Supervisors will conduct environmental rounds observing all residents who receive oxygen with a special focus on oxygen tubing placement, positioning, bagging and labeling.
The policy and procedures on Infection Control and prevention were reviewed and revised.
All staff will be educated on the revised policy and procedure on infection control and prevention, with a special focus on care of residents who receive supplemental oxygen.
The ADON/designee will conduct audits, observation and monitor the practice of infection control and prevention program on each unit weekly x 4 weeks then monthly x 4 months.
Results of audits with corrective actions will be presented at the monthly QA Committee meetings.
Responsible Party: Assistant Director of Nursing/ Designee

MENUS MEET RESIDENT NDS/PREP IN ADV/FOLLOWED

REGULATION: §483.60(c) Menus and nutritional adequacy. Menus must- §483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: 2019-01-10
Corrected date: 2019-03-19

Citation Details

Details not available

Plan of Correction: N/A

Plan of correction not approved or not required

E3BP 402.9(b)(2):RESPONSIBILITIES OF PROVIDERS; REQUIRED NOTIF

REGULATION: Section 402.9 Responsibilities of Providers; Required Notifications. ...... (b) Notifications. A provider must immediately, but within no later than 30 calendar days after the event, notify the Department, and document such notification occurred, when: ...... (2) any employee who was subject to, and underwent, a criminal history record check in accordance with this Part is no longer employed by the provider.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: March 19, 2019

Citation Details

Based on record review and interview, the facility did not submit the termination form within the required calendar 30 days of being permanently reassigned from direct care. This was evident for 1 of 2 employees reviewed for compliance with the Criminal History Record Check program. The finding is: Employee #2 was hired as a Dietary Aide. A Pending Denial letter was issued on 7/19/18. There was no documented evidence that Termination Form 105 was submitted for the employee within the required 30 day time frame. On 01/10/19 the Assistant Director of Nursing (ADON) was interviewed. She stated that the Dietary Aide (DA) was hired on 2/16/18 as a Per Diem staff (person who works on day by day basis) and worked in the facility until 8/9/18. The Pending denial letter came on 7/19/18 which she reviewed. On 7/19/18 she stated that she had a meeting with the Administrator, the Director of Nursing (DON) and the DA. During the meeting the DA was told he could write a letter about the circumstances explaining what happened and submit it to her before 8/30/18. She stated that he agreed to write the letter but never returned with a letter. He did not formally resign and was still on the roster as a Per Diem staff. The ADON further stated that she goes into the system and checks on new hires daily. She took him out of the system on 10/31/18 when she was checking the system and realized he was not working here any longer. She stated that she realizes she missed the 30 day timeframe. 01/10/19 the DON was interviewed and stated that prior to 7/19/18 the employee was a dietary aide serving meals on the units. When the Pending Denial letter was received on 7/19/18 he was reassigned to work in the kitchen only. On the last day that he worked, 8/9/18, he worked in the kitchen. He never came back to work in the facility. The Dietary department did not notify her that they were not taking him back. She lastly stated that she did not communicate with Dietary department regarding if he was still working in the kitchen.

Plan of Correction: ApprovedJanuary 31, 2019

No residents were affected.
Employee #2 was hired as a dietary aide on a per diem basis. The pending denial letter came on 7/19/18 which was reviewed by ADON, administrator and DON. The aide was reassigned to the kitchen area only, and didn?t go to the units. Last day of work was 8/9/2018. ADON was not aware of his termination.
Director of Food Service educated that going forward she must inform Nursing Administration of any employee that has been terminated from the department.
All residents have the potential to be affected by this deficiency.
Review of all new hires is ongoing to ensure that all documents are completed, signed, information submitted to the CHRC, and final report placed in the employees? files.
The policy and procedures on CHRC were reviewed and revised.
? All department heads will be in-serviced on the policy and procedure regarding CHRC procedures.
? All Department heads must inform the ADON of all terminations immediately.
? The ADON will submit the termination notices to New York State?s CHRC system within 30 days.
ADON will provide in-service to all departments heads to ensure timely communication regarding their employees? employment / termination status.
The DNS/Designee will audit the HR files of all newly terminated employees weekly x 4, then monthly x 6 to ensure termination notices are submitted to New York State within 30 days.
The DNS/Designee will submit the results of the audit with corrective action to the QA Committee monthly.

Responsible Party: Director of Nursing/Designee

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

Based on observation, staff interview and record review, it was determined that the facility did not ensure that electrical equipment used for resident care was maintained and tested in accordance with NFPA 99. Reference is made to the lack of documentation to show that the resident use electric beds; commercial type hair dryers; electrical mattress pumps; oxygen concentrators, and feeding pumps were maintained and tested for safety as per policies and protocols established by the facility or the contracted agency. The findings include: On (MONTH) 7 and (MONTH) 8, 2019 between the hours of 10:00 AM to 3:00 PM, during the annual recertification survey of the facility, it was observed that the facility had provided a number of resident care electrical equipment in the resident rooms or in other areas of the facility for resident use, as needed. An interview with the facility's Assistant Director of Maintenance and a review of facility's maintenance records revealed that the facility lacked appropriate documentation to show that all resident care electrical equipment , including but not limited to the following, were maintained and tested in accordance with established policies and protocol. 1. In a number of resident rooms, the residents' electric beds had no tags/inspection stickers affixed to the beds, as per facility policy, examples were : resident room #'s 606, 607, 609, 610, 611, 613, 509, 506,518 and 519. The power cords connected to the beds were bent and had casing broken at the base of the connecting terminal. The facility did not retained any maintenance and care manuals by the manufacturer of the beds. Also, the facility had not established any policies and protocol for the maintenance, the type of tests and intervals of testing for the safety of resident electric beds. 2. In the barber shop, the two commercial type hair dryers had no inspection tags affixed to the hair dryers. The facility had not established any inspection/testing intervals for the electric hair dryers. 3. The electrical mattress pumps located in a number of resident rooms lacked inspection tags/stickers affixed to the pumps or an written records for the testing and maintenance of the pumps, examples were : resident room #'s 404, 413 and 304. 4. The electric feeding pumps located in resident room #'s 409 had no inspection tags or written records for the testing and maintenance of the pumps. 5. The oxygen concentrators provided in resident room #'s 404, 403, 218 and in the rehabilitation area had no inspection tag/sticker affixed to the equipment , nor the facility had any written records for the testing and maintenance of the concentrators. On (MONTH) 8, 2019, at approximately 12:30 PM, the facility's Director of Maintenance stated that the manufacturers of the the resident electric beds; in the resident rooms and all other electrical resident care equipment will be contacted to obtain care manuals for the beds and other electrical equipment. The Assistant Director further stated that the policy and protocols for the maintenance and testing of the beds and other equipment based on manufacturer's recommendations will be established and followed and records maintained as per NFPA 99 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedFebruary 8, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Director of Building/ Designee ordered electric bed tags/inspection stickers and new power cords.
On 1/9/19, the Director of Building located the care and maintenance manual by the manufacturer of beds.
On 1/9/19, the Director of Building inspected the hair dryers in the barber shop and placed the inspection tags.
On 1/9/19 the Assistant Director of Building inspected the electric feeding pumps in room [ROOM NUMBER] and oxygen concentrators in rehab area, and the inspection tags were placed.
The Director of Building/Designee will conduct bi-annual visual inspection of all fixed or portable electrical equipment for any defects; if any noted, the equipment will be removed from service until repaired.
Appropriate documentation will be maintained to show that all resident care electrical equipment is maintained and tested in accordance with established policies and protocol.
The Director of Building developed policy and protocol for the maintenance, the type of tests and intervals of testing for the safety of resident electric equipment.
The Director of Building/Designee will provide in-service to maintenance staff on a new policy.
The Director of Building / Designee will keep updated inspection logs to provide documentation that electrical equipment is being maintained and tested on bi-annually basis.

The Director of Building will report to the QA Committee quarterly about any negative findings and corrective actions.
Responsible party: Director of Building

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

This standard is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that empty oxygen cylinders were not marked and separated from the full cylinders, as per NFPA99. Reference is made to the empty K size oxygen cylinders that were not identified and were stored along with the full cylinders, in oxygen storage room on at least fourth floor and second floor. The findings include: On (MONTH) 7and (MONTH) 8, 2019 at 10:00 AM to 3:00 PM, it was observed that the facility was storing oxygen cylinders in oxygen storage rooms on the resident floors. The empty oxygen cylinders stored in oxygen storage room on at least fourth floor and second floor were mingled with the full oxygen cylinders and were also not marked with suitable signs. The empty oxygen cylinders must be identified and stored separately from the full oxygen tanks to avoid confusion. On (MONTH) 8, 2019, at approximately 12:45 AM, the facility's assistant director of maintenance stated that nursing staff will be advised to mark the empty cylinders and keep separated from the full cylinders. 711.2 (a)(1)

Plan of Correction: ApprovedFebruary 8, 2019

?Empty? and ?Full? signs are ordered.
No residents were affected by this deficient practice.
The Director of Building/Designee will install ?Empty? and ?Full? signs in all oxygen storage rooms on each unit.
Policy and Procedures for Gas Equipment- Cylinder and Contained Storage were reviewed and revised.
The Director of Building/ Designee will in-service nursing staff on a new policy.
The Director of Building / Designee will provide weekly visual inspection of storage rooms to ensure that practice meets the requirements, and keep the record of each inspection.
The Director of Building will report to the QA Committee quarterly about any negative findings and corrective actions.
Responsible party: Director of Building

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that hazardous areas equipped with automatic extinguishing system were enclosed with at least the smoke resistance rated construction. Reference is made to the storage areas that were not separated with at least smoke resisting walls/doors, examples were : storage rooms off the vestibule at the facility entrance, storage closet adjacent to the business office ; the food storage room, off the 1st floor corridor and the kitchen storage room, off the kitchen areas. The findings include : On (MONTH) 7 and (MONTH) 8, 2019, between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that the facility hazardous areas were provided with an automatic fire extinguishing system. The smoke resistance rating construction of the enclosure walls to the storage closet off the vestibule at the facility entrance, storage room adjacent to the business office, and the food storage room, off the first floor corridor was compromised by the presence of transfer grilles in the enclosure walls. The kitchen storage room, off the kitchen areas lacked a door with at least the smoke resistance rated construction On (MONTH) 8, 2019 at approximately 12:00 PM, the facility's Assistant Director of Maintenance stated that the transfer grilles in the enclosure walls to doors to storage room/closets will be sealed with smoke resistance rated construction. The Director further stated the kitchen storage room will be provided with an appropriate door. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 8, 2019

On 1/12/19, the maintenance department removed the transfer grills from the lobby entrance, the food storage room off the 1st floor corridor, and the kitchen storage room. Sheetrock was installed in all areas.
No residents were affected.
The Assistant Director of Maintenance will purchase the door for the kitchen storage room on 2/15/19.
The work to be done will ensure that the facility meets the requirements that hazardous areas equipped with automatic extinguishing system were enclosed with at least smoke resistance rated construction.
No residents have the potential to be affected by this deficient practice since residents don?t have access to the kitchen storage room.
Provide in-service to Dietary department staff regarding the use of the smoke resistance door.
Director of Maintenance will keep the inspection log with documented negative findings, if any.
The Director of Building will ensure that there is documented evidence on hand to verify that the hazardous areas equipped with automatic extinguishing system meets the recommended standard.
The Director of Building will conduct quarterly inspections of the facility that the deficient practice remained corrected and will report to the QA Committee quarterly about any negative findings and corrective actions.
Responsible party: Director of Building

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the lack of sprinkler coverage for a number of areas in the building, examples include : In room # series 016, the recessed alcove containing a light fixture lacked sprinkler coverage; the hydraulic elevator machine room in the basement; the generator room in the basement both lack sprinklers, sprinklers were lacking under the greater than four feet wide overhang/low ceiling in the kitchen; sprinkler coverage was lacking under the hood system containing electrical motor for the dish washer; storage closet, off the rehab area; and the recessed storage alcove off the finance room, at the first floor The findings include: On (MONTH) 7 and (MONTH) 8, 2019 , between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that automatic sprinklers were lacking or the sprinklers were obstructed in a number of areas of the building, so as not to provide coverage for the entire protected area. in accordance with NFPA 13. The examples include but are not limited to the following : (1) In the resident room # series 016 on resident floors, the recessed alcove space adjacent to the room door containing light fixture above the hand washing sink, a wall mounted paper towel dispenser, and a waste basket, lacked sprinkler coverage. The existing sprinkler in the vicinity of the alcove was obstructed by the turn of wall. (2) The hydraulic elevator machine room, off the [MEDICAL TREATMENT] storage area in the basement lack sprinklers. (3) The generator room, in the basement lacks automatic sprinkler protection. (4) Automatic sprinklers were lacking under the greater than four feet wide overhang/low ceiling in the kitchen. (5) In the central tub room, on the 6th floor, the dressing area encircled by curtains with less than 18 inches mesh on the top, lack sprinklers. (6) A large recessed alcove space containing storage boxes and miscellaneous items off the finance room on the first floor lacked sprinklers. The existing sprinkler in the vicinity of the alcove was obstructed by the turn of wall and did not to provide coverage for the alcove area (7) The storage closet off the rehab area lacked automatic sprinklers. (8).In the kitchen area, sprinkler coverage was lacking under the hood system containing electrical motor components for the dishwasher. The existing sprinkler adjacent to the hood system was obstructed by the hood walls so as not to provide coverage for the electrical motor components. (9) In the storage closet off the recreation area on the first floor, the sprinkler was located approximately eleven feet from the wall, instead of the maximum of six feet from the wall. (10) A number of concealed sprinklesr lacked the required cover plates. Examples were : concealed sprinkler in the central shower room on the 5th floor, and at least two concealed sprinklers in the recreation area on the first floor lacked cover plates. (11) The sectional sprinkler control valve in the elevator machine room on the roof was not identified with a sign indicating the section of sprinkler system it controls. On,January 8, 2019 at approximately 12:30 PM, the facility's director of maintenance stated that the facility sprinkler company will be contacted to evaluate and provide automatic sprinklers throughout the building, as per NFPA13. The Director further stated that shower curtains located within the central tub areas will be provided with a minimum of 18 inches mesh on the top of the curtains to provide sprinkler coverage for the entire protected area, including the dressing area. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedFebruary 8, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/8/19, The assistant Director of Maintenance installed the required cover plates in the central shower room on the 5th floor and recreation areas.
The Director of Maintenance conducted an inspection of the facility?s entire sprinklers installation system to ensure that there were no negative findings or deficient practice. No others were noted.
NO residents were affected by the deficient practice
The Director of Building/Designee contacted the services of WNW & Sons Fire Suppression, Plumbing & Heating Corp to fully install sprinklers on 2/8/19 in the facility in accordance with regulations in the following areas:
1 ) in the residents? room # series 016 on the residents floors, the recessed alcove space adjacent to the room door
2) the hydraulic elevator machine room, off the [MEDICAL TREATMENT] storage areas
3) the generator room
4) overhung/low ceiling in the kitchen
5)in the central tub room on the 6th floor
6) a large recessed alcove space containing storage boxes off the finance room
7) the storage closet off the rehab areas
8) in the kitchen area under the hood system containing electrical motor components for the dishwater
9) in the storage closet off the recreation area on the first floor
The WNM & Son Corp will also provide the sign that indicates the section of sprinkler system that it controls for the sectional sprinkler valve in the elevator machine room on the roof
The Director of Maintenance and WNW & Sons Fire Suppression, Plumbing & Heating Corp will conduct an inspection of the facility?s entire sprinklers installation system to ensure that there were not negative findings or deficient practice.
A record of all curtains in residents? rooms will be kept including, shower curtains that have 18 inches mesh.
The Director of Building will ensure that there is documented evidence on hand to verify that the sprinkler installation system is up to date and meets the requirements.
The Director of Building/ Designee will document the dates and times of the sprinkler installations and cover plates quarterly.
The Director of Building will report to the QA Committee quarterly about any negative findings and corrective actions.
Responsible party: Director of Building

K307 NFPA 101:SPRINKLER SYSTEM - SUPERVISORY SIGNALS

REGULATION: Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that all sprinkler control valves were electrically supervised so as to sound at a continuously attended location when sprinkler operation is impaired, as per 9.7.2.1. Reference is made to the sprinkler control valve located in the elevator machine room on the roof that was not electrically supervised so as to sound at a constantly attended location when valve is closed. The findings include: On (MONTH) 7 and (MONTH) 8, 2019 at 10:00 AM to 3:00 PM,during the annual recertification survey of the facility, it was observed that although the facility had provided supervisory attachments for the sprinkler control valve, at least one sprinkler control valve located within the elevator machine room was lacking an electrical supervisory attachment to sound an alarm at a continuously supervised location when the valve is impaired/close On (MONTH) 8, 2019 at approximately 11:30 PM, the facility's Director of Maintenance stated that the sprinkler company will be contacted to provide electrical supervisory attachments for all sprinkler control valves to sound an alarm at the constantly supervised location when the valve(s) are close. 711.2 (a)(1) 2012 NFPA 101 2014 NFPA 72.

Plan of Correction: ApprovedFebruary 8, 2019

On 1/8/19, Administrator/Designee contacted the services of Tikva Security to provide electrical supervisory attachments for the sprinkler valve within the elevator machine room on the roof
ON 1/11/19 WNW & Sons Fire Suppression Corp conducted sprinkler alarm test in the facility. NO negative findings were found
No residents were affected by the deficient practice
The facility will continue to use the services of WNW & Sons Fire Suppression to conduct monthly fire safety drills during which time the display panels will be inspected to ensure that it functions as designed and displayed trouble conditions.
The Director of Building conducted an inspection of the facility?s entire sprinklers system/ fire alarm system to ensure that there were not negative findings or deficient practice. None were found.
The Director of Building will ensure that there is documented evidence on monthly fire alarm drills and monthly sprinkler alarm inspections.
The Director of Building will report to the QA Committee quarterly about any negative findings and corrective actions regarding fire alarm/sprinkler alarm testing.
Responsible party: Director of Building

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

Section 7.1.8, 2012 NFPA 101, states that guards in accordance with 7.2.2.4 shall be provided at the open side of the means of egress that exceed 30 inches (760 mm) above the floor of the finished ground level below. This standard is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that guards provided at the open side of the exit stair landings were at least 42 inches high as per 7.2.2.4. Reference is made to the guards provided at the top of exit stair North and exit stair South that were approximately 36 inches above the landing floor instead of the required minimum of 42 inches high from the stair landing floor. The findings include: On (MONTH) 7 and (MONTH) 8, 2019 at 9:00 AM to 3:00 PM, it was observed that the facility had provided guards at the open side of the exit stair landings. The guard provided on the top landing of the North exit stair and South exit stair measured approximately 36 inches high from the stair landings floor .instead of the minimum of 42 inches high from the stair landing floor. On (MONTH) 8, 2019 at approximately 11:00 AM, the facility's Assistant Director of Maintenance stated that the guard rails at the open side of the stair landings will be extend to the required minimum height. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 8, 2019

The Director of Building contacted S&P handrails company to correct the deficient practice on 1/8/19.
No residents affected by this deficient practice
The deficient practice doesn?t have the potential to affect residents since no residents have access to the roof.

ON 2/4/19 the handrails of the stairs on the North and South side have been extended to the height of 42? to be in compliance with state regulations.
There are no East or West sides.
Director of Maintenance will keep the quarterly inspection log with documented negative findings, if any.
The Director of Building will ensure that there is documented evidence on hand to verify that the handrails were corrected to the meet the requirements.
The Director of Building will conduct quarterly inspections of the facility and will report to the QA Committee quarterly about any negative findings and corrective actions.
Responsible party: Director of Building

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2019
Corrected date: February 25, 2019

Citation Details

NYCRR 713-1.9 (j): Bedpan-flushing devices shall be provided on each resident floor. This requirement is not met as evidenced by : Based on observation, it was determined that the facility did not ensure that bedpan-flushing devices were provided in each resident toilet rooms. Reference is made to the lack of bedpan flushing devices on all resident floors. The findings include: On On (MONTH) 7 and (MONTH) 8, 2019 , at 10:00 AM to 3:00 PM, it was observed that all resident floors lack bedpan flushing devices. An interview with the facility's Assistant Director of Maintenance revealed that the bedpan-flushing attachments had been removed from the resident room toilet rooms. On (MONTH) 8, at approximately 11:15 AM, the facility's Assistant Director of maintenance stated that the facility Administration will be made aware of the lack of bedpan- flushing devices on all resident floors. The Assistant Director further stated that the bedpan-flushing attachments will be provided at least at the central location on each resident floor. NYCRR 713-1.9 (k) Vacuum breakers shall be installed on hose bibbs and on all fixture to which hoses or tubings can be attached, such as janitor's sinks and bed pan-flushing attachments. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that vacuum breakers were installed on all fixtures to which hoses were attached. Reference is made to the water fixtures located in the shower room , on the 2nd floors and the water fixtures janitor's closet off the kitchen, that had hoses attached to them and lacked vacuum breakers. The findings include : On On (MONTH) 7 and (MONTH) 8, 2019 , at 10:00 AM to 3:00 PM, during the recertification survey of the facility, it was observed that the facility had hoses attached to the water fixtures in the centralized shower room , on the 2nd floors and the water fixtures in the janitor's closet off the kitchen area. These water fixtures lacked the required vacuum breakers. On (MONTH) 8,2019, at approximately 1:00 PM the facility's assistant director of maintenance stated that all water fixtures with hoses attached will be provided with vacuum breakers.

Plan of Correction: ApprovedFebruary 8, 2019

The Director of Building/Designee installed vacuum breakers on hose bibbs on 2nd floor shower room and janitor?s closet off the kitchen on 1/9/19
The Director of Building/ Designee contacted WNW & Sons Fire Suppression, Plumbing Corp to install bedpan ? flushing devices in a shower room on each unit
NO residents were affected by this deficient practice.
The Director of Building/ Designee inspected all water fixtures with hoses attached in the facility and no negative findings were found.
The Director of Building / Designee will continue to perform monthly inspections of all water fixtures with hoses attached and keep the record of each inspection.

The Director of Building / Designee will continue to perform monthly inspections of bedpan-flushing devices in shower rooms on each unit and keep the record of each inspection.
The Director of Building will report to the QA Committee quarterly about any negative findings and corrective actions.
Responsible party: Director of Building