Livingston Hills Nursing and Rehabilitation Center
July 20, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey and abbreviated surveys (Case #'s NY 690, NY 202, and #NY 888) the facility did not ensure each residents drug regimen was free from unnecessary drugs. Specifically, for four (Residents#'s 1, 96, 121, and #122) the facility did not ensure the resident's pain was adequately monitored to evaluate the effectiveness of narcotic and non-narcotic pain relievers. This was evidenced by: A policy and procedure titled Pain Assessment and Management (undated), documented pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. It documented under the heading recognizing pain; implement the medication regimen as ordered, carefully documenting the results of the interventions. Resident #96: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively impaired, sometimes able to understand and be understood. A physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) and progress notes from 7/1/17 through 7/17/17, documented [MEDICATION NAME] was administered 39 times. There was no documentation of a pain scale prior to administering [MEDICATION NAME] for 3 of the 39 times, and for 36 administrations there was no documentation of a follow-up pain scale. During an interview on 7/17/17 at 1:45 pm, the Nurse Manager reported pain scales are documented on the MAR before medication is given and follow-up is documented as effective or ineffective. Some nurses document a follow-up pain scale in the Progress Notes as they should. This resident is able to appropriately report a pain level and the number should be documented on the MAR, instead of just documenting effective. Resident #121: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was able to understand others and make himself understood. A physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) and progress notes from 5/24/17 through 5/31/17, documented that [MEDICATION NAME] 10 mg was administered 13 times without consistent documentation of pain location, pain severity before, and pain severity after, using the same pain scale. A review of the MAR and progress notes from 6/1/17 through 6/14/17, documented that [MEDICATION NAME] 10 mg was administered 25 times without consistent documentation of pain location, pain severity before, and pain severity after, using the same numerical pain scale. Resident #122: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was able to understand others and make himself understood. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) and progress notes for 2/23/17 through 2/28/17, documented that [MEDICATION NAME] 10 mg was administered 9 times without consistent documentation of pain location, pain severity before, and pain severity after, using the same pain scale. A review of the MAR and progress notes from 2/23/17 through 2/28/17, documented that [MEDICATION NAME] 600 mg was administered 4 times without consistent documentation of pain location, pain severity before, and pain severity after, using the same numerical pain scale. During an interview on 7/19/17 at 1:45 pm, the Director of Nursing stated that nurses should be documenting pain level and location before giving the medication and documenting the effect an hour after. The nurses should be using the pain scale, not documenting effective. 10NYCRR415.12(1)(1)

Plan of Correction: ApprovedAugust 28, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- All Nursing Staff involved were re-educated and disciplined as appropriate for correct documentation of pain scale after giving a PRN medication .
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-25% of all other PRN pain medication given over the past 30 days were audited for compliance.
SYSTEMIC CHANGES
-Inservice to be provided to nursing staff to reinforce the Policy and Procedure for PRN pain medication result documentation correctness. To include a pre medication scale that can be compared to a post medication scale. Notation of pain location in the medical chart with review of effectiveness.
MONITORING
-Over the next three months, 25% of PRN pain medication result documentation will be audited for correctness, with results communicated to the QA Committee and Administrator for follow up as needed.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Nursing

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility was not in compliance with adopted food safety regulations.The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that potentially hazardous foods is to be cooled to 41 degrees Fahrenheit (F) within 6 hours, and food contact surfaces and floors are to be kept clean. Specifically, the internal temperature of tuna salad was greater than 41 F six hours after preparation, and food contact surfaces and the floor were not clean. The inside of the microwave and the refrigerator / freezer in the kitchinette on the East Unit were not clean and sanitary for the storage of resident's food. This is evidenced as follows: Finding #1: The main kitchen was inspected on 07/17/2017 at 9:30 am. The temperature of tuna salad stored in the reach-in refrigerator was 52 F, the floor was not clean in corners and next to the walls, and the can opener, microwave oven, mixing machine, handwashing sink, and floor fan required cleaning. The inside of the microwave and the refrigerator / freezer in the kitchinette on the East Unit were not clean and sanitary for the storage of resident's food. This is evidenced as follows The Food Service Director stated in an interview conducted on 07/17/2017 at 9:30 am, that the tuna salad was prepared from canned tuna on 07/16/2017 and that the cooling process temperature was not monitored. Additionally, the Food Service Director stated that she will have the floor and the food surfaces noted above cleaned. Finding #2: East Unit During Tour of the East Unit on 7/17/17 at 10:15 am, the locked kitchenette door was unlocked by pressing the numerical security code in order to complete the tour of the kitchenette. Observations of unsanitary conditions were as follows: The microwave had a large amount of spillage of dried brown colored beverage inside the microwave on the inner upper, lower, and bilateral panels. The freezer of the refrigerator was observed to have a very large amount of brown liquid spillage on the door, bilateral sides, upper and lower panels of the inside of the freezer. The freezer contained 2 pints of opened ice cream not labeled or dated , a empty box of snickers ice cream bars. The refrigerator was observed to have 1 opened and outdated squeezable container of Mayonnaise with an expiration date of 7/14/17. There were 2 supermarket bags containing lettuce and tomatoes that were not labeled or dated. The refrigerator also had a large amount of food and liquid spillage on the inside panel of the refrigerator door and shelves. The small sink in the kitchenette was totally covered by a tray of residents used dishes and cups, making it difficult for staff to wash their hands, because there was not another clean surface area in the kitchenette to place the tray. During an interview and observation of the kitchenette with a Licensed Practical Nurse (LPN) on 7/17/17 at approximately 11:30 am, the LPN stated that the spillage in the refrigerator and freezer was not acceptable and that food brought in by families is to be dated and labeled with the resident's name. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.40(b), 14-1.110, 14-1.170

Plan of Correction: ApprovedAugust 28, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Areas cited were immediately cleaned and sanitized. Tuna Salad was immediately discarded by staff, after being made to stay out longer than normal due to the extra temperature check needed by Surveyor.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-Other areas audited for compliance with no issues noted.
SYSTEMIC CHANGES
-Inservice to be provided to nursing staff and dietary staff to reinforce the Policy and Procedure on cleanliness of areas and food temperatures that are safety approved.
MONITORING
-Over the next three months, food temps and kitchenettes will be audited with a daily log,to assure compliance, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Food Service

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. The facility must provide for a sanitary, orderly, and comfortable interior. Specifically, floors and a window were not clean on 2 of 3 resident units. This was evidenced as follows: The resident unit corridor floors were inspected on 07/18/2017 at 10:20 am. The corridor floors on the North Unit and East Unit were soiled with dirt and old wax build-up next to walls and in corners. Additionally, the window in resident room 408 was soiled with bird droppings. The Director of Housekeeping stated in an interview conducted on 07/18/2017 at 12:10 pm that the window in room 408 will be cleaned immediately, and it is difficult to schedule floor cleaning as this task may only be conducted at night. 483.10(i)(2)

Plan of Correction: ApprovedAugust 28, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Outside window in room 408 immediately cleaned, with bird droppings cited were found to have been fresh from that day when a bird hit the window that morning. Wax build up was scrapped and removed immediately and hallways will remain on the routine cleaning and waxing schedule, as told to the surveyor during survey, who did not review the documented rotating cleaning schedule, with hallways continued to be done at night for resident ease, as is routine and customary.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-All other resident rooms and hallways were checked with no issues found, as wall as all outside windows for further bird impact marks.
SYSTEMIC CHANGES
-An inservice will be provided to Housekeeping staff to assure that they identify any potential issues quickly and report them to the right staff for follow up.
MONITORING
-Over the next three months, 100% of the Resident Unit and Rooms will be audited for compliance, with findings communicated to the QA committee and Administrator for suggestion and follow up.
With specific detailed attention paid to the unit corners and floors.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Housekeeping

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification and abbreviated survey (Case #NY 996) the facility did not have evidence that alleged violations involving abuse, neglect or mistreatment were investigated during a recertification survey for one (Resident #120) of fourteen residents reviewed. Specifically, for Resident #120, the facility did not ensure that two of the resident's falls were thoroughly investigated to rule out abuse mistreatment or neglect. This was evidenced by: Resident #120: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact and was usually able to understand others and was able to make herself understood. Finding #1: Review of a nursing progress note dated 1/27/17 at 3:30 pm, documented, Resident called the rehab department this am, (and) stated I am on the floor. Therapists went to unit, notified nursing staff who stated resident did not yell out to let them know she was on floor. Nurse assessed resident, therapists assisted her back to wheelchair. No report of pain or other issues. Resident stated she was on phone, was not paying attention and slid out of wheelchair. Review of a nursing progress note dated 2/11/17 at 9:35 am, documented, resident not helping with transfers, sat herself on the floor, and the staff, myself included tried to pick her up off the floor. Review of a nursing progress note dated 2/12/17 at 9:01 am, documented, correction, CNA lowered resident to the floor on her legs. There was no documented evidence of Incident or Accident (I&A) Reports for the above falls and no evidence the above falls were investigated. During an interview on 7/19/17 at 1:45 pm, the Director of Nursing (DON) stated there was no Incident and Accident (I&A) for the falls dated 1/27/17 or 2/11/17, and there should have been. She stated she was not the Director of Nursing (DON) at that time. During an interview on 7/20/17 at 10:45 am, the Administrator stated that for a fall there should be an evaluation by a Registered Nurse and the physician should be notified. There should be statements obtained from any witness, and an I&A should be started by the Registered Nurse Supervisor. The I&A should be forwarded to the Assistant Director of Nursing (ADON) and the DON and they follow up on the investigation. The Administrator's role is to review the I&A when it is completely done. The Administrator stated he was not aware that I&A's were not being done, but then he heard that the previous DON was not doing them or finishing them. 10NYCRR415.4(b)(1)(ii)

Plan of Correction: ApprovedSeptember 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Resident 120 was discharged on [DATE]. The DON who was responsible for not performing the A and I?s no longer works at the Facility.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-3 months of Fall Accident and Incident reports were audited to assure compliance, with no issues being noted.
SYSTEMIC CHANGES
-A Directed Inservice will be performed by(NAME)Edwards, LNHA, consultant with 15+ years of Long Term Care Experience in the next three weeks, to all Department Heads and Management Staff on how to properly perform, investigate, and document fall Accidents and Incident Reports.
MONITORING
-Over the next three months, 25% of all monthly Fall Accident and Incident Reports will be audited for correctness with Findings being reported to the QA committee for follow up and suggestions. Electronic Medical Records that are now in place record on the 24 hour report, and those notes are printed and used daily since this time to assure nothing needing and A and I report is missed. In addition, the E-MAR dashboard automatically flags anything that may need such a report.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Nursing
A- comitte meeting discussion agrees 24 hour report and electronic record not being in use led to the breakdown in communication of incidents. process breakdown evident by Incident and accident reports not being made by RN on duty.
B- Supervisor re education of Incident and accident of what warrants an investigation and expectation of review of high risk notes made by staff. Staff reeducation on what warrants an investigation. Scheduled for 8/31/17 at 8am for Interdisciplinary team and 2pm on 9/5/17 for all other staff. Mandatory for attendance.
C- Daily IDMM involving unit review of all notes. Discussion of all Incidents and follow up needed. Reports filed of this log of discussion for QA purposes to be kept in DON office. All Incidents to be maintained in DON office with Monthly filing.
D- QA will involve a rotating assignment of RN staff random pulling of 3 charts for audit each and review over three month period totalling 20 Incidents. To be reported on at QA with oversight of DON for completion proper handling.

NOTE: RESUBMITTING, AS REQUESTED INFORMATION WAS SENT TO DOH OFFICE. Thank you!

FF10 483.25(g)(1)(3):MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

REGULATION: (g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident?s comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observation during a recertification survey, the facility did not ensure it maintained acceptable parameters of nutrition, such as usual body weight, for 4 (Resident #'s 2, 41, 46, and #93) of 14 residents reviewed for weights during the recertification survey. Specifically, the facility did not ensure that re-weights were done or significant weight changes were addressed. For Resident #41, the facility did not ensure reweighs were obtained for significant gains in the resident's weight; For Resident #46, the facility did not obtain a reweight for a gain of 5% or greater; For Resideny #93, the facility did not obtain a re-weight or notify the Dietician and/or Physician of the 2/4/17 weight showing a 37-pound weight gain in one month and no Dietary notes or assessments documenting/ addressing the weight change between 1/8/17 and 2/4/17. This was evidenced by: Resident #41: The resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], assessed the resident understands, is understood and cognitively intact. The Weight and Vital Sign Summary documented the following significant weight gains : 1/9/17 145.4 lbs (pounds) 2/2/17 166.0 lbs 3/3/17 176.8 lbs 4/9/17 189.4 lbs 5/1/17 193.2 lbs 7/4/17 197.0 lbs There was no documentation of reweight's done on 2/2/17, 3/3/17, 4/9/17, 5/1/17, and 7/4/17. A Nutrition Department Weight Change Notification Form dated 3/3/17, signed by the Registered Dietician (RD ) documented the resident's current weight is 166 # (pounds) with a weight gain of 14.7 % over 30 days. The resident's ideal body weight documented 99 - 121. The RD also documented the resident has a good po (by mouth) intake and gain is after a serious illness/ surgery which may have resulted in an initial loss. Superfoods at meals are to be discontinued secondary to weight gain. During an interview with the Certified Nursing Assistant (CNA) on 7/19/17 at approximately 1:30 pm, the CNA stated that reweight's are to be done on residents who have had a 3 lb or greater weight loss or gain since their previous weight. The CNA also stated that the NM (Nurse Manager) or the medication nurse will tell the CNA who needs to have a reweight and also there also is a binder at the nurses station which contains a list of the residents previous weight. During an interview with the Registered Nurse (RN) /Nurse Manager (NM) on 7/19/17 at approximately 2:30 pm, the RN/UM stated she had been present at times when the resident had a reweigh done, but she did not document the reweight. The RN/NM also stated that the reweighs are checked, but not recorded on the weight list or in the computer. During an interview with the Registered Dietician (RD) on 7/20/17 at approximately 11:30 am, the RD was asked how she was certain that recorded weight gain was correct, when there was no documentation that a reweigh was obtained. The RD stated that she had not noticed that there were no reweighs recorded on the weight list when the resident had significant weight gains, because she had expected the resident to gain weight. The RD also stated that she did not question the accuracy of the resident's significant weight gain when assessing and evaluating the resident's nutritional needs and concerns. Resident #46: The facility did not reweigh Resident #46 during her initial admission stay when the resident had a gain of 5% or greater. The resident was initially admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. The resident also developed an unstageable pressure ulcer on the left heel and lateral Malleolus on 3/6/17, an unstageable pressure ulcer to the right gluteal fold on 3/9/17, and a stage 3 pressure ulcer to the left gluteal medial fold on 3/9/17. The admission assessment dated [DATE], assessed the resident as able to understand, is understood, and cognitively intact for daily decision making skills. The Weight and Vital Signs Summary documented the following : 3/23/17 - 192. lbs 4/23/17 - 188.2 lbs 5/01/17 - 201.4 lbs 5 % or greater change (Comparison Weight) 4/23/17 188.2 lbs +7 %, +13.2 lbs A Nutrition Quarterly Assessments dated 5/16/17, signed by the RD documented the resident's current weight as 201.4 and BMI 34 with a weight change of +7.01. A Nutrition Department Weight Change Notification Form dated 5/22/17, documented the resident 's current weight was 201.4 lbs, with a weight gain of 7.01 % over 30 days. There was no documentation of a reweight on 4/23/17. During an interview with the Certified Nursing Assistant (CNA) on 7/19/17 at approximately 1:30 pm, the CNA stated that reweight's are to be done on residents who have had a 3 lb or greater weight loss or gain since their previous weight. The CNA also stated that the NM (Nurse Manager) or the medication nurse will tell the CNA who needs to have a reweight and also there also is a binder at the nurses station which contains a list of the residents previous weight. During an interview with the Registered Nurse (RN) /Nurse Manager (NM) on 7/19/17 at approximately 2:30 pm, the RN/NM stated she had been present at times when the residents were reweighed, but she did not document the reweight. The RN/NM also stated that the reweighs are checked, but not recorded on the weight list or in the computer. Resident #93: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 5/ /17, assessed that the resident understands, was understood and had severely impaired cognitive ability. The Weights and Vitals Summary documented the following weights in pounds: 1/8/17 - 160, 2/4/17 - 197, 3/8/17 - 145, 4/7/17 - 142. There was no documentation of a re-weight or notification to the Dietician and/or Physician of the 2/4/17 weight showing a 37-pound weight gain in one month. There were no Dietary notes or assessments addressing the weight change between 1/8/17 and 2/4/17. A Nutrition Annual assessment dated [DATE], documented the Resident's weight as 145 pounds, with no documentation in the section for weight changes over the previous 6 months and the word stable written across and underlined. A Nutrition/Dietary Note dated 3/8/17, documented the resident's weight as 145 pounds, with unintended weight loss recently. The amount of weight lost was not documented. A form titled, Nutrition Department Weight Change Notification dated 3/15/17, signed by the Registered Dietician (RD), documented; current weight = 145 pounds, 9.9% loss over 30 days and under comments documented planned weight loss. During an interview on 7/19/17 at 9:25 am. CNA #'s 1, 2, 3, and 4 reported if a resident's weight is changed by 3 pounds since last weight then a reweight is done immediately and the Unit Manager is informed of the change. During an interview on 7/19/17 at 9:30 am, the Nurse Manager reported that any 3 pound or more change in weight is re-weighed and if confirmed, reported to the RD immediately. She does not recall if this resident was re-weighed or the RD notified of the 2/4/17 weight change. During an interview on 7/19/17 at 9:45 am, the RD reported the Certified Nursing Assistant (CNA) should have obtained a re-weight and notified me on 2/4/17 when the resident's weight was significantly higher than the previous month. The RD documents weights for each resident on a Monthly Loss/Gain Tracker. For (MONTH) (YEAR), documented NW (no weight). The RD stated I should not have documented NW, I should have gotten a weight. She further stated I should have addressed the weight change and did not. 10NYCRR415.12(i)(1)

Plan of Correction: ApprovedAugust 11, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Resident 2 discharged [DATE]
- Resident 41 super foods were discontinued, RD reviewed and MD aware.
- Resident 46 resident was reweighted with accurate weight obtained. Monthly monitoring to continue, MD to monitor.
- Resident 93 care plan reviewed, weight is stable at this time. Resident (who is of mind) educated about healthy weights and PO intakes.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-All monitored weights were audited and any re-weights needed were obtained and communicated to MD if needed.
SYSTEMIC CHANGES
-Inservice to be provided to nursing staff to reinforce the Policy and Procedure for re-weights. The Registered Dietician has created an MD communication tool to assure that MD reviews and signs off on weights that are being monitored.
MONITORING
-Over the next three months, 25% of monitored weights will be audited for compliance, with results communicated to the QA committee and Administrator for review and follow up.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Registered Dietitician

FF10 483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: 483.10 (c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. (c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident?s strengths and needs. (iii) Incorporate the resident?s personal and cultural preferences in developing goals of care. 483.21 (b) Comprehensive Care Plans (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident?s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident?s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

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 the Comprehensive Care Plans (CCP) for 2 (Resident #'s 43 and 46) of the 24 residents reviewed were revised when there were changes in the resident's condition or treatments. Specifically, for Resident #43, the facility did not revise and update the resident's ADL( Activities of Daily Living) Care Card, (a tool which is posted inside the door of the resident's armoire and used as a reference by the CNAs and Nurses) prior to administering care, to include documentation that the resident has a PICC (peripherally inserted central catheter inserted into a vein in the upper arm and then advanced in the chest to near the heart) Line in her upper arm. For Resident #46, the facility did not revise the resident's CCP for Pressure Ulcers to inform the nursing staff that the resident had a Wound Vac (a medical device with a pump used for the treatment and healing of wounds and pressure ulcers) to her left ankle, and did not update the resident's ADL Care Card to include the Wound Vac to the resident's left ankle, a PICC line in her left upper arm, and blue protective booties to the resident's bilateral heels. This was evidenced by: Resident #43: The facility did not ensure that the resident's ADL Care Card dated 7/10/17 was updated to include the resident has a PICC line in her left upper arm and inform the CNA of any restrictions or precautions to prevent the dressing from getting wet or the PICC line from becoming dislodged. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cogntively intact for daily decision making skills. Review of a hospital Progress Record dated 6/16/17, documented the resident had a PICC line inserted in her left basilac vein (located in the area of the bend of the elbow) on 6/16/17. The CCP documented the resident required a PICC line for the administration of the antibiotic related to the treatment of [REDACTED]. The resident's ADL Card did not include documentation that the resident had a PICC line in her arm or any special instuctions /precautions to prevent the PICC line from becoming dislodged during care. The ADL Card did not include specific instructions regarding bathing and protecting the PICC Line from becoming wet. Resident #46: The facility did not ensure that the resident's CCP for Pressure Ulcer was revised to include documentation that the resident had a Wound Vac to the left heel pressure ulcer. The resident's ADL Care Card was not updated to include documentation that the resident had a Wound Vac to the left heel and a PICC line in her left upper arm to alert the CNAs to be cautious of the wound vac dressing and tubing and the PICC line in the resident right upper arm to pre vent the Wound Vac tubing from being disconnected or the PICC line from becoming dislodged when providing care. During observation of the resident on 7/18/17 at 4:00 pm, the resident had a Wound Vac to the left heel and a PICC line in the left antecubital area (arm /bend of elbow area). Review of the resident's Weekly Wound Assessment ( Pressure) documented that on 6/12/17, the heel wound was assessed as Stage 4 measuring 2 cm x 1 cm x 0.5 cm, with undermining and treatment changed to a Wound Vac. Review of the resident's CCP dated 3/6/17, documented the resident has actual impairment to skin integrity of left heel. The CCP did not include documention of the revised treatment of [REDACTED]. Review of the resident's ADL Care Card dated 3/31/17, did not include any documentation of a Wound Vac to the left heel , and the presence of a PICC line in the residents left antecubital area. During an interview on 7/19/17 at 5:00 pm, the ADON/Wound Care Nurse stated that she does not document the specific pressure ulcer treatments on the CCP, because the treatments change . The ADON stated that she probably should have included the Wound Vac because it is a special medical equipment being used for the treatment of [REDACTED]. The ADON also stated that it would be helpful to the CNAs if the PICC line was documented on the resident's ADL Card. 10 NYCRR 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedSeptember 20, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Res #43 ADL care card updated immediately to reflect PICC line.
Res # 46 CCP updated to include pressure ulcers with wound vac therapy and ADL Card updated to reflect PICC line, wound vac and protective booties to bilat heels.
2. Upon admission or any changes of condition MD and IDT will be included in the decisions and follow through will be shown by evidence of care plans and ADL card to include, PICC lines, [DEVICE], and skin protective devices. All staff to be inserviced with completion within 30 days, to new policy changes.
3. Care plan, Care Card audits to include 25% of house for 3 months or until compliance is met. Constant re evaluation of process with review in QA. House audit of any residents having picc lines, [DEVICE] or adaptive equipment to update care card information with any missing documentation. Outcome shows No missing information was found. This included a comparison to MD eval new orders/ care card/ Care Plan. Policy and procedure updated to include above information. Re education to be completed within 30 days with all clinical staff to include policy and procedure and changes to care plans.
4. Reportable directly to DON for compliance review.

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey and abbreviated survey (Case #NY 690) the facility did not ensure services were provided by qualified persons in accordance with each resident's written plan of care. Specifically, for Resident #1, a Certified Nursing Assistant (CNA)/Central Supply Staff was observed setting the liter flow on an oxygen concentrator. This was evidenced by: Resident #1: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. A physician's orders [REDACTED]. The bedside kardex report (undated) documented oxygen settings: oxygen via nasal cannula @ 4 liters per minute continuously, humidified with bubbler. During an observation on 7/18/17 at 10:10 am, a CNA/Central Supply Staff was observed removing an oxygen concentrator and replacing it with a concentrator with a humidifier (bottle of water attached to concentrator to moisten the oxygen) and then resetting the concentrator to administer the oxygen at 4 liters per minute. During an interview on 7/18/17 at 10:15 am, CNA/Central Supply Staff stated she usually will set up concentrators, the resident is usually on 2-3 liters, but she asked the resident and the resident stated 4 liters. If she had questions she would ask the nurse. During an interview on 7/18/17 at 11:15 am, the Director of Nursing stated oxygen is considered a medication and should be regulated by nurses. 10NYCRR 415.11(c)(3)(ii)

Plan of Correction: ApprovedSeptember 6, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Resident 1 was checked by Nursing Staff with no issues and correct oxygen.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-CNA staff re-educated to only allow LPN and RN staff to set oxygen levels. All Oxygen users evaluated for correct setting and delivery with compliance confirmed.
SYSTEMIC CHANGES
-Oxygen will not be administered by non licensed staff as per policy. All Nursing department staff will be educated on this for understanding that it is policy that only Licensed staff may administer oxygen.
-Over the next three months, 25% of oxygen users will be spot checked for correct levels and correct equipment used for delivery as stated on care plan and Kardex. Residents will be interviewed to assure that only Nursing Staff administered the Oxygen, with results communicated to the QA committee and Administrator for review and follow up.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. Specifically, non-compliant power strips were used to power patient care-related equipment and non-patient care electrical devices in patient care areas in 3 of 10 resident rooms checked. This is evidenced as follows: When inspected on 07/18/2017 at 10:20 am, a non-compliant power strip was used to power telephone equipment and a hospital bed in resident room [ROOM NUMBER]; a non-compliant power strip was used to power a table fan and a hospital bed in resident room [ROOM NUMBER]; and a non-compliant power strip was used to power telephone equipment, a table fan, and a hospital bed in resident room [ROOM NUMBER]. The Director of Maintenance stated in an interview conducted on 07/18/2017 at 12:00 pm, that unknown to the maintenance department, family members may have brought in the power strips found, but they will be removed. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedAugust 11, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Outside power strips identified were removed
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- Other resident rooms checked for outside power strips with none found.
SYSTEMIC CHANGES
-Inservice to be provided to Housekeeping and Nursing Staff on how to identify safe power strips and a memo will go out to residents and families about assuring that only proper power strips are used, and given to Maintenance to inspect prior to usage.
MONITORING
-Over the next three months, 25% of Resident rooms will be audited monthly for compliance, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance

K307 NFPA 101:FIRE DRILLS

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

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on staff interview and record review during the recertification survey, facility staff were not familiar with the basic response to fire, and fire drills were not conducted in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 19.7.2.3 states that employees shall be trained in the use of a code phrase to insure the transmission of an alarm when the individual who discovers a fire must immediately go to the aid of an endangered individual (code phrase for fire), and section 19.7.1 requires that fire drills (drills) shall be scheduled under varied conditions. Specifically, 4 of 9 employees interviewed were not familiar with the code phrase for fire, and fire drills were conducted at the same time of day for each work shift. This is evidenced as follows: Certified Nursing Assistant #1 stated she would announce fire upon discovery of fire when interviewed on 07/17/2017 at 10:40 am. Unit Assistant #1 stated he would announce there is a fire upon discovery of fire when interviewed on 07/17/2017 at 11:20 am. Housekeeper #1 stated she would announce fire upon discovery of fire when interviewed on 07/17/2017 at 11:35 am. Maintenance Employee #1 stated he would announce there is a fire upon discovery of fire when interviewed on 07/17/2017 at 11:40 am. The facility emergency fire procedure was reviewed on 07/17/2017. The policy requires that staff persons are to announce Code Red and the room number upon discovering a fire situation. The fire drill evaluations of the past 12 months were reviewed on 07/17/2017. This review revealed that the 7-3 shift drills were always conducted during the 1:00 pm hour, the 3-11 shift drills were always conducted during the 4:00 pm hours, and the 11-7 shift drills were always conducted between 5:00 am and 6:00 am. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.1, 19.7.2.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7.1, 19.7.2.3

Plan of Correction: ApprovedAugust 28, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Upcoming 3 fire drills to be at random times, approved by Administrator
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- All fire drill times for the next 6 months to be approved by Administrator prior to performing.
SYSTEMIC CHANGES
-Inservice to be provided to Maintenance staff to assure that fire drill times are random and not repeating. Re education of how to announce a fire and how to ensure all occupants are aware there is a fire will be conducted with all staff.
MONITORING
-Over the next three months, the timing of the monthly Fire Drill will be audited monthly. Spot checks with all shifts will be done by questioning of the staff for understanding of routiene fire procedures by auditors to ensure they know to page code red three times, and pull the nearest pull station, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not store pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.6.5.3 requires that empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. Specifically, empty cylinders were not marked in 2 of 4 oxygen cylinder storage areas. This is evidenced as follows: The Main Oxygen Storage room and the South Unit oxygen storage room were inspected on 07/18/2017 at 10:20 am. The empty cylinders in these rooms were not marked. The Director of Maintenance stated in an interview conducted on 07/18/2017 at 12:00 pm, that he will speak with the vender about labeling the empty oxygen cyliners. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.6.5; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-3.5.2.2(b)2

Plan of Correction: ApprovedAugust 11, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Temporary labels hung in oxygen rooms.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- Oxygen provider contacted for permanent way to mark empty and full oxygen tanks.
SYSTEMIC CHANGES
-Inservice to be provided to Housekeeping and Nursing Staff on proper marking of empty and full oxygen tanks.
MONITORING
-Over the next three months, 25% of oxygen storage rooms will be audited monthly for compliance, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Nursing

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on staff interview and record review during the recertification survey, the facility did manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide continuing education associated with the handling of medical oxygen cylinders. This is evidenced as follows: No records were available for survey review documenting that the facility provided training on the risks and use of oxygen cylinders. The Administrator stated in an interview conducted on 07/18/2017 at 2:45 pm, that the facility does not provide training on the risks and use of oxygen cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedAugust 11, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Education to be provided to nursing staff on the risks and use of oxygen cylinders
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- This education will become part of the Facilities Mandatory Education rotation.
SYSTEMIC CHANGES
-Policy and Procedure updated to assure that oxygen cylinder education is mandatory for all new employees as well as a part of the yearly mandatory educations.
MONITORING
-Over the next three months, staff will be spot checked monthly for compliance, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview during the recertification survey, it was determined that the means of egress were not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Section 19.2.2.2.5 permits the use of resident room door locks when specialized, protective measures for residents are required. Specifically, locks were installed improperly on doors in resident rooms. This is evidenced as follows. Resident rooms [ROOM NUMBERS] were inspected on 07/17/2017 at 10:20 am. Exterior-only locks were installed on the closet doors in these rooms; the closets were large enough to accommodate an adult person. The Director of Maintenance stated in an interview conducted on 07/18/2017 at 12:00 pm that family members might have installed the locks found, but they will be removed. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.2.2.2.5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.2.1, 7.2.1

Plan of Correction: ApprovedAugust 17, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Locks removed on cited doors.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
-Other areas audited for compliance with no issues noted.
SYSTEMIC CHANGES
-Inservice to be provided to nursing staff and Housekeeping staff to identify items installed improperly by families or residents.
MONITORING
-Over the next three months, 25% of resident rooms will be audited monthly to assure compliance, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. The Centers for Medicare and Medicaid Services published a Final Ruling in the Federal Register on (MONTH) 13, 2008 (73 FR ) requiring all long term care facilities to have full automatic sprinkler protection in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition by (MONTH) 13, 2013. Specifically, automatic sprinkler protection was not provided in all areas. This is evidenced as follows: An assessment of the sprinkler system was conducted on 07/18/2017 at 10:20 am. Automatic sprinkler protection was missing in the lawn maintenance storage room. The Director of Maintenance stated in an interview on 07/18/2017 at 12:00 pm, that he assumed sprinkler protection was not required in this area. 42 CFR 483.70 (a) (1); 73, FR ; 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.6.5.1.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101: 19.3.5; 1999 NFPA 13: 5-13.3.2

Plan of Correction: ApprovedAugust 11, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Area identified to be corrected by contracted Sprinkler Vendor.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- Other areas audited to assure sprinkler coverage, with no areas identified.
SYSTEMIC CHANGES
-Inservice to be provided to Maintenance staff to identify areas on that need a sprinkler head.
MONITORING
-Over the next three months, the 25% of Facility sprinkler heads will be audited monthly, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2000 edition section 8.5.6 requires that smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling. Specifically, 1 of 1 smoke barrier walls observed was not continuous through all concealed spaces. This is evidenced as follows: The East Unit north smoke barrier was inspected on 07/18/2017 at 1:45 pm. All observations were from above the ceiling. In resident room 311, a 1-inch unsealed hole and a 2-foot by 1-inch section of loose joint compound was found. In both resident rooms 324 and 325 two small unsealed holes each were found. In the corridor a 2-foot length of unsealed 4-inch by 6-inch spaces where the wall meets the underside of the roof was found. The Director of Maintenance stated in an interview conducted on 07/18/2017 at 2:45 pm, that some hard-to-see spaces in the smoke barriers were not sealed. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedAugust 11, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Area identified to be corrected by Maintenance Staff.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- Other areas audited to assure complaince, with no areas identified.
SYSTEMIC CHANGES
-Inservice to be provided to Maintenance staff to identify areas on that may need correction on the Smoke Barrier Walls.
MONITORING
-Over the next three months, the 25% of Facility smoke barrier walls will be audited monthly, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 20, 2017
Corrected date: September 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain the stairwell in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.6.2 requires that walls to vertical openings, such as stairwells, be continuous from floor to roof. Specifically, the walls of the stairwell were not continuous from floor to roof. This is evidenced as follows: The stairwell was inspected on 07/18/2017 at 2:45 pm. Observing from inside the kitchen storeroom, a 6-inch by 2-inch space of loose masonry block was found and the wall did not meet the underside of the roof. Observing from the corridor, a 10-inch by 10-inch hole was found. Observing from inside the boiler room, an 8-foot by 2-inch unsealed space between the door frame and wall was found. The Director of Maintenance stated in an interview conducted on 07/18/2017 at 2:45 pm, that the hard-to-see areas of the stairwell wall were not sealed and the corrections from the last survey were not double-checked. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.2; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3.2.3.1(2), 8.2.3.2.4.2

Plan of Correction: ApprovedAugust 11, 2017

CORRECTIVE ACTION FOR RESIDENTS LISTED IN THE SOD:
- Area identified was corrected.
CORRECTIVE ACTION FOR OTHER RESIDENTS WHO MAY BE AFFECTED:
- The stairwell cited is the only vertical opening in the Facility.
SYSTEMIC CHANGES
-Inservice to be provided to Maintenance staff to identify areas on the vertical opening that may need correction.
MONITORING
-Over the next three months, the stairwell will be audited monthly, with results communicated to the QA committee and Administrator for follow up and suggestion.
DATE OF CORRECTION / TITLE OF PERSON RESPONSIBLE FOR CORRECTION
9/15/2017, Director of Maintenance