Cooperstown Center for Rehabilitation and Nursing
August 31, 2018 Certification/complaint Survey

Standard Health Citations

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

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(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: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure a comprehensive care plan was reviewed and revised after each assessment for three (3) (Residents #28, #58, #261) of thirty-four (34) residents reviewed. Specifically: for Resident #28 the facility did not revise the resident's care plan when there was a decline in the residents Activities of Daily Living (ADL) status; for Resident #58, the facility did not revise the resident's careplan for the resident's excessive bilateral pedal [MEDICAL CONDITION]; for Resident #261, the facility did not revise the resident's careplan to include a fall and behavior. This is evidenced by: Resident #28 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident required supervision for transfers, ambulation and dressing and that she ate independently after set up. Additionally, she usually understood and was understood by others. The Resident Nursing Instructions ( lets CNA know what kind of care the resident requires) dated 8/25/18, documented the resident was independent with eating after setup, required supervision with dressing, personal hygiene, ambulating in the corridor. A Progress Note dated 8/10/18 at 3:01 PM, documented that the resident was having trouble with simple tasks that she hadn't had any issues with before. A Progress Note dated 8/23/18 4:19 PM, documented that the resident was having increased issues with eating and being able to put sequences together, The resident was unable to use a spoon to pick up eggs this morning so this writer made her a sandwich that she was also unable to pick up so staff fed the resident. An MD Order dated 8/23/18, documented the diet changed to finger foods. A Progress Note dated 8/25/18 at 2:52 PM, documented that the resident was unable to do small tasks and staff must assist the resident extensively lately. During an interview on 08/30/18 at 01:13 PM CNA #5 stated the resident has had a change in her abilities. She was having more difficulty with utensil use and incontinence. The resident previously ate regular meals independently but now she has been changed to finger foods. During an interview on 08/30/18 at 01:25 PM, Registered Nurse Manager (RNM) #2 stated that she does the care planning and that since the middle of last week she has noticed difficulty eating, thinking different things are chairs and was aware of incontinence episodes but did not recall putting these things in her care plan for Resident #28. Resident #58: This resident was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. A Policy and Procedure for the Care Planning Process revised on 04/2018, documented a policy statement, of an individualized baseline and comprehensive careplan that is personalized and includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas; reflect treatment goals, timetables and objectives in measurable outcomes. A physician's orders [REDACTED]. A physician progress notes [REDACTED]. An electronic Treatment Administration Record (eTAR) for (MONTH) (YEAR) documented tubi grips were placed on 7-3 shift and removed on 3-11 shift from (MONTH) 1 to (MONTH) 28. The resident's Skin Integrity Care Plan did not document the resident had diagnosd bilateral ankle and pedal [MEDICAL CONDITION] and did not document an intervention of placing tubi grips to resident's legs every day. A goal also was not documented to address the resident's pedal [MEDICAL CONDITION]. During an interview on 08/01/18 at 11:26 AM, Licensed Practical Nurse (LPN) Nurse Manager (NM) #1 reviewed the resident's impaired skin integrity care plan and stated it should have been updated to include the resident's pedal [MEDICAL CONDITION] and an intervention per physician order. She stated the careplan had not been updated but should have been. Resident #261: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. An Admission Nurses Note dated 8/7/18, documented the resident was alert and oriented. He was slow to respond and may not respond. He is hard of hearing and wears hearing aids. A Nurses Progress Note dated 8/12/18 at 9:00 pm, documented the resident was found on the floor in front of the toilet with a 3 centimeter (cm) laceration to the top of his head. He was bleeding a large amount. Pressure and ice applied until the bleeding stopped. Resident was incontinent of bowel movement. His wheelchair was in the bathroom by the toilet. Apparently fell transferring self from wheelchair to toilet. He hit the back of his head on the toilet seat. Neuro checks were started. A Nurses Progress Note dated 8/12/18 at 10:05 pm, documented a loud bang was heard and resident was found lying on the floor in the bathroom. He was naked and covered in feces. His feet were under the sink and his head was in front of the toilet. A large pool of blood had already formed. Pressure and Ice were applied to the wound. Resident did not lose consciousness at any time. The laceration was cleaned and bandage applied. Resident started on neuro checks. He was reminded to ring for help and not get up on his own. He was also reminded to leave his non skid socks on his feet for safety. A Nurses Progress Note dated 8/12/18 at 6:52 AM, documented the resident had been reported to be taking off his brief and having a bowel movement all over the floor. A Nurses Progress Note dated 8/14/18 at 4:08 PM, documented the resident attempted to transfer himself in an unsafe manner and became combative and tried to push the nurses hand away or simply ignored direction when assisted. A Nurses Progress Note dated 8/15/18 at 6:46 AM, documented the resident made several attempts to get out of bed on his own. Taken to the toilet every time, voided once. A Physical Therapy Evaluation dated 8/7/18 documented the resident has muscle weakness on bilateral lower extremities, impaired static and dynamic sitting and standing balance, decreased safety awareness, decreased endurance and functional activity tolerance leading to increased supervision with transfers and ambulation with increased fall risk. A physician's orders [REDACTED]. An Incident and Accident Report dated 8/12/18 at 8:30 PM documented the resident attempted to toilet himself and fell causing laceration. Statement from LPN #12 documented the resident transfers himself and will not leave his socks or briefs on. Review of the resident's Fall Care Plan did not include documentation of the resident's fall with laceration occurring on 8/12/18 . The resident's behavior of removing his brief and having a bowel movement in his room and resident's noncompliance with waiting for assistance for transfers was not listed as possible causes for the resident falling. There is no documentation to indicate interventions initiated after the fall. During an interview on 08/28/18 at 11:15 AM, LPN NM #1 stated the falls careplan should have been revised to include resident's fall of 8/12 with laceration to his head. It should have been revised by the nurse who filled out the Incident and Accident Report (I & A). During an interview on 08/30/18 at 09:35 AM, CNA #2 stated documentation for toileting comes up only once per shift on kiosk. The documentation does not reflect when or how many times the resident was toileted. The resident will ring when he needs to be toileted. When she starts her shift, she gets report and goes around to each of her residents, checks and changes them and gets them out of bed if needed. 10NYCRR415.11(c)(2)(i-iii)

Plan of Correction: ApprovedOctober 2, 2018

Care plans for Residents #28, #58, and #261 were updated to reflect their current status. All residents with status changes have the potential to be affected by this practice. Unit Managers will review each care plan to verify reflection of current resident status.
Unit Managers will hold weekly meetings with nurses and CNA?s to review residents for ADL changes. Identified changes will be documented in each resident?s care plan.
All LPN?s will be educated on Care Planning and their role/scope of practice.
Unit Managers will be responsible to print 24 Hour New Orders Report to verify appropriate Care Plan changes were completed.
IDT will be re-educated on their responsibility to maintain current care plans with monitoring. All CNA?s will be re-educated on their ability to enter toileting data in the kiosk multiple times per shift.
DON/Designee will audit 10% of Care Plans to verify that care plans reflect current status and that monitoring notes are included x 6 months
Responsible: Director of Nursing

FF11 483.45(d)(1)-(6):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- §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2018
Corrected date: November 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during a recertification survey, the facility did not ensure the medication regimen for three (Resident #'s 64, #11 and #28) of seven residents reviewed for unnecessary medication, was free from unnecessary medication. Specifically: For Resident #64 and #11, as needed (PRN) narcotic pain medications were prescribed and not adequately monitored to determine the effectiveness of the medication and the need for its continued use; and for Resident #28, the facility did not ensure that the resident's antibiotic was discontinued when laboratory testing results returned and were negative for a Urinary Tract Infection [MEDICAL CONDITION]. This is evidenced by: Finding #1 The facility did not ensure that as needed (PRN) narcotic pain medications prescribed for Resident #'s 64 and #11, were adequately monitored to determine the effectiveness of the medication and the need for their continued use. A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control. AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): (MONTH) 18.23. A Policy and Procedure for Administering Pain Medications revised 10/2010, documented acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained. Standardized pain assessment using a five point or ten point Pain Intensity Scale with word modifiers should be used. Administer pain medications as ordered. Document results of the pain assessment, medication, dose, route of administration and results of the medication (adverse or desired). Resident #64: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/15/18, the resident was hospitalized for [REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. The Comprehensive Care Plan (CCP) for Actual Pain related to surgery to the right groin wound and right above the knee amputation documented to monitor the effectiveness of pain medication and adjust as indicated. A physician's orders [REDACTED]. The electronic Medication Administration Record [REDACTED]. The back of the MAR indicated [REDACTED] Nursing Progress Notes documented the following for the administration of PRN [MEDICATION NAME] for pain: -8/02/18 [MEDICATION NAME] given at 9:00 am with effect. -8/15/18 [MEDICATION NAME] give at 9:00 am with effect. -8/16/18 [MEDICATION NAME] 10 mg given as ordered. Resident has no compaint of pain at this time. -8/20/18 [MEDICATION NAME] given at 5:50 am for complaint of pain with good effect. -8/22/18 [MEDICATION NAME] 10 mg given for complaint of pain to left leg. Denies pain at this time. -8/23/18 [MEDICATION NAME] given at 7:23 pm for complaint of generalized pain. -8/25/18 [MEDICATION NAME] given at 7:00 pm as ordered -8/27/18 [MEDICATION NAME] given at 8:30 am, 11:45 am and 3:00 pm for complaint of severe pain. -8/29/18 [MEDICATION NAME] 10 mg given twice durng my tour, resident denies having pain at this time. Some effect noted. The electronic Medication Administration Record [REDACTED]. The back of the eMAR dated 7/2018 did not document effectiveness of the medication administered on 7/2/18 at 4:15 pm, 7/6/18 at 7:50 am, 7/8/18 at 12:08 am, 7/8/18 at 10:57 am, 7/9/18 at 10:35 pm, 7/11/18 at 4:17 am, 7/12/18 at 9:35 am, 7/13/18 at 4:44 am, 7/14/18 at 9:44 pm, 7/15/18 at 9:36 am, 7/15/18 at 10:25 pm, 7/16/18 at 10:02 pm, 7/20/18 at 10:48 am, 7/24/18 at 5:08 pm, and 7/28/18 at 10:30 am. Nursing Progress Notes documented the following with administration of PRN [MEDICATION NAME] for pain: 7/02/18 - [MEDICATION NAME] given at 4:30 pm for complaint of pain at a numeric level of 8. 7/05/18 - [MEDICATION NAME] given at 9:30 am with some effect and at 2:30 pm with pending effect. 7/06/18 - [MEDICATION NAME] given at 4:00 pm for complaint of pain to his right leg. No complaint of pain at 9:52 pm. 7/07/18 - [MEDICATION NAME] given as ordered. The resident denies pain at this time. 7/08/18 - [MEDICATION NAME] given at 11:00 am with effect. 7/11/18 - [MEDICATION NAME] given for complaint of pain of #10 with some effect. During an interview on 08/30/18 at 01:17 PM, LPN #3 stated the resident's pain was getting better. He was not complaining as much as in the past. In the last couple of weeks she stated she had not given him any PRN [MEDICATION NAME] and this was new for him as he was asking for it frequently. He was not in as much pain and his left leg was looking better since he started taking an antibiotic. Prior to giving the PRN pain medication she stated she asked the resident what his pain level was using the pain scale. The computer program prompts the nurse to enter the resident's pre-medication pain level using the pain scale and will not allow the nurse to go further if it is not entered. She stated she did not always ask the resident what his pain level was post-medication because she forgets. The nurse should also document in a progress note for the PRN pain medication and chart its effectiveness. She stated she should always ask the resident. She stated it was her fault the post-medication pain scale number was not documented as she does not always remember to go back and document the pain scale after giving medication. She stated she should always ask the resident. During an interview on 08/30/18 at 02:26 PM, the Assistant Director of Nursing (ADON) stated the computer software triggers the nurses to enter pre and post medication pain rate. It is ideal if the nurses are also writing a nurses note as there should be a note to indicate why the medication was given. She stated the nurses are not documenting post medication levels but should be. She stated pain is whatever the resident says it is. Resident #11: The resident was admitted to the nursing home on 12/21/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Physican orders dated: 7/02/18 documented [MEDICATION NAME] 5mg; 1 po q4h prn. 7/30/18 documented [MEDICATION NAME] 5mg; 1mg po q6hr prn. 8/25/18 documented [MEDICATION NAME] 5mg; 1 po q6h prn pain 6-10. The Comprehensive Care Plan (CCP) for Pain 7/3/18, related to amputation surgery, chronic pain and [MEDICAL CONDITION] documented to monitor the effectiveness of pain medication and adjust as indicated. The Medication Administration Records (MAR) dated 7/3/18 - 8/28/18, documented the resident recieved PRN [MEDICATION NAME] on 15 occassions and of those 15 occasions there was no documented post pain level on 6 occasions. During an interview on 08/27/18 at 09:04 AM, the resident stated that she had pain in her legs and at times they can not get it to go away. During an interview on 08/30/18 at 10:28 AM, Licensed Practical Nurse (LPN) #3 stated that she would ask the residents pain level on a scale of 1-10, and follow up with the resident one hour later to see what the pain level was. The computer prompted you to put a pre and post pain level in. During an interview on 08/30/18 at 02:26 PM, the Assistant Director of Nursing (ADON) stated the computer software triggers the nurses to enter pre and post medication pain rates. The nurses are not documenting post medication levels, but should be. During an interview on 08/31/18 at 10:10 AM, RNM #2 stated that nurses should be documenting what the pain level is before a pain medication is given and 1 hour later to reassess if it worked. Finding #2 Resident #28: The resident was admitted to the nursing home on 6/8/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. A Progress note dated 8/13/18 at 5:29 PM, documented that the resident was behaving aggressively toward staff and other residents and had gone into another resident's room and slapped her across the face with a book. She was crouched behind an easy chair conversing with people who were not there. The resident was sent to the emergency room due to her erratic behavior. A Progress Note dated 8/14/18 at 7:55 AM, documented that the resident returned from the hospital at 10:30 pm with a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A Urine Culture Report that was collected on 8/13/18 and resulted on 8/15/18, documented that less that 10,000 colonys/mililiter (the number of bactria cells in one sample) mixed gram positive flora. It was signed by the MD (medical doctor) and he documented there was no UTI and the urinalysis was negative. A MD progress note dated 8/17/18, documented that the resident was sent to the ER for behaviors and returned with a [DIAGNOSES REDACTED]. The urinalysis that showed negative [MEDICATION NAME], and the urine culture report showed less that 10,000 mixed contaminated. There is not evidence of a UTI. The Medical Record did not include an order to discontinue the use of the antibiotic. The Medication Administration Record [REDACTED]. During an interview on 08/31/18 at 11:36 AM, the MD stated that he tries to do everything to avoid antibiotics. He thought he got the results the day the antibiotic was to finish. It should have been discontinued when they got the negative results on 8/15/18. Additonally, a correct course would have been 5 days not a 10 days as written. 10NYCRR415.12(l)(1)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during a Post Survey Review (PSR), the facility did not ensure the medication regimen for two (Resident #'s 11, and 28) of three residents reviewed for unnecessary medication, were free from unnecessary medication. Specifically: For Resident #'s 11 and 28, as needed (PRN) narcotic pain medications were prescribed and not adequately monitored to determine the effectiveness of the medication and the need for its continued use. This is evidenced by: A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control. AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): (MONTH) 18.23. A Policy and Procedure for Administering Pain Medications revised 10/2010, documented acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained. Standardized pain assessment using a five point or ten-point Pain Intensity Scale with word modifiers should be used. Administer pain medications as ordered. Document results of the pain assessment, medication, dose, route of administration and results of the medication (adverse or desired). Resident #11: This resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment and was able to understand others and was able to be understood. The Comprehensive Care Plan (CCP) for Pain related to [MEDICAL CONDITION] and chronic low back pain documented to monitor the effectiveness of pain medication and adjust as indicated. A physician's orders [REDACTED]. It documented pain level follow-up was to be done 60 minutes after administration. A physician's orders [REDACTED]. The electronic Medication Administration Record [REDACTED]. The eMAR dated 10/2018, did not document the resident's post-medication evaluation for the 8:00 pm dose of [MEDICATION NAME] that was administered by LPN #4 on 10/22/18. The in-service regarding pain management for and pre and post- pain evaluations for pain medication administration sign-in sheet documented LPN #4 was in-serviced on 10/25/18. During a telephone interview on 10/25/18, LPN #4 (an agency nurse) was asked when the effectiveness of pain medication should be evaluated. During the course of the interview LPN #4 offered 3 answers to the question. LPN #4 stated after Physical Therapy, in 10 minutes, and that she did not know. Resident #28: The resident was admitted to the nursing home on 6/8/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. An MD order dated 10/9/18, documented Tylenol 1000 mg was to be administered three times a day for pain. It documented pain level follow-up was to be done 60 minutes after administration. A record review of the eMAR dated 10/2018, documented the resident received Tylenol 1000 mg at 2:00 pm on 10/23/18. The eMAR did not include was a post medication pain level. A record review of the eMAR dated 10/2018, documented the resident received Tylenol 1000 mg at 8:00 pm on 10/22/18 (administered by LPN #4) and 10/23/18. The eMAR did not include a post medication pain level. During an interview on 10/25/18 at 11:33 am, the LPN Unit Manager stated education was provided regarding administration of pain medications. It was the expectation that the nurses administering pain medications would document pre and post pain ratings. All nurses should be doing that. She stated she was reminding staff to complete their documentation prior to the end of their shifts. During an interview on 10/25/18 at 1:20 pm, the Director of Nursing stated she was unaware the post pain rating was not being completed. Audits were to be completed weekly. The audits had just started the previous week and she had not yet seen them. She stated she will review them when they were turned in. 10NYCRR415.12(l)(1)

Plan of Correction: ApprovedNovember 17, 2018

DON and Physician reviewed Pain Management and Antibiotic Stewardship policies without change.
All residents receiving pain medication or antibiotics have the potential to be affected by this practice.
Unit Managers and RN Supervisors will be responsible for checking the EMR Dashboard for pain follow-up one hour prior to the end of each shift. They will communicate to responsible nurse to obtain follow-up status and document in EMR.
Educator will re-educate all nurses on the Pain Management policy as well as the EMR Dashboard and its use in monitoring pain follow-up with an emphasis on documentation requirements.
ADON reviewed all residents currently receiving antibiotic therapy and confirmed all were appropriate.
DON will re-educate all practitioners on the Antibiotic Stewardship program and policies.
ADON / Designee will audit 10% of residents receiving pain medication to verify timely follow-up documentation weekly x 1 month, biweekly x 2 months, then monthly x 3 months and report results to QA Committee.
ADON / Designee will audit all antibiotic orders monthly x 3 months to verify necessity and report results to QA Committee.
Responsible: DON

FF11 483.70(e)(1)-(3):FACILITY ASSESSMENT

REGULATION: §483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include: §483.70(e)(1) The facility's resident population, including, but not limited to, (i) Both the number of residents and the facility's resident capacity; (ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population; (iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population; (iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and (v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. §483.70(e)(2) The facility's resources, including but not limited to, (i) All buildings and/or other physical structures and vehicles; (ii) Equipment (medical and non- medical); (iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies; (iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care; (v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and (vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. §483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on record review and interview during a recertification survey, the facility did not ensure that its Facility Assessment included an evaluation of the overall number of facility staff needed to ensure that a sufficient number of qualified staff were available to meet each resident's needs. This was evidenced by: The Facility Assessment did not include minimum staffing levels to ensure that resident's needs were being met. During an interview on 08/29/18 at 11:42 AM, the Staffing Coordinator stated she never staffed under 2 people on the day or evening shifts and did not know what minimum staffing levels were. During an interview on 08/28/18 at 12:30 pm the Administrator looked through the Facility Assessment and stated that the minimum staffing was not there. 10 NYCRR 483.70(e)(1)-(3)

Plan of Correction: ApprovedOctober 22, 2018

Administrator reviewed and revised the Facility Assessment to include minimum staffing levels that ensure resident needs are met. Staffing needs will be part of the full assessment review and update conducted at least annually.
Administrator will report on Facility Assessment, including staffing requirements, to QAPI Committee at least annually.
Administrator is responsible for this plan of correction.

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(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. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: October 25, 2018
Corrected date: November 19, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Specifically, the facility did not ensure that food preparation and serving areas were in good repair, that equipment was kept clean, and that the premises were free of insects. This is evidenced as follows. The main kitchen and kitchenettes were inspected on 08/26/2018 at 10:39 AM. In the main kitchen, the meat slicer, can opener, exhaust fan guards in the walk-in cooler, mixers, knife holder by the fryer, walls in walk in cooler, and bulk food storage bins were soiled with dust, grease or food particles. The floor tiles by the cook line were missing grout. The floor drains, floor in the mop sink closet, and floor on the cook line were soiled with grease and food particles. The walk-in freezer had a buildup of ice on the wall above the door. The automatic paper towel dispensers were either empty or not functioning. The unit kitchenettes are in the same area as the resident dining areas. The cabinetry, microwave ovens, floors, and refrigerators in the Oaks Creek, Star Haven, Gardenia Court, and(NAME)Way Kitchenettes were heavily soiled. Fruit fly activity was observed by the all-purpose sink in the Whispering Way Kitchenette. The gaskets on the freezer doors in the Oaks Creek and Gardenia Court Kitchenettes were in disrepair. The Director of Food Service stated in an interview conducted on 08/26/2018 at 2:15 PM, that she will remind staff about clean food prep and serving areas. The Director of Environmental Services stated in an interview conducted on 08/29/2018 at 12:15 AM that his department is responsible for pest control and cleaning the unit kitchenettes floors and cabinets. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.150 (c) 14-1.170.Based on observation and staff interview during the post survey revisit for the recertification and abbreviated survey dated 8/31/18, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Specifically, the facility did not ensure that food preparation and serving areas were clean. This is evidenced as follows. The main kitchen and kitchenettes were inspected on 10/24/18 at 9:50 AM. The floor drain in the mop sink closet was soiled with a thick layer of food particles and soot. The exhaust fans in the mop sink room had a thick layer of dust. Tongs with thick food particles were observed. The unit kitchenettes are in the same area as the resident dining areas. On Mountain Ridge, (Eagle Rock kitchenette) a large, metal serving container with a cover was used to store clean dishes. There were crumbs, kernels of corn, and a hairnet in with the clean dishes. On Rolling Hills (Emerald Way kitchenette) hair, and food particles were observed in the four-compartment bin that housed utensils. The Director of Food Service stated in an interview conducted on 10/24/2018 at 10:51 AM, that he had not yet cleaned the floor under the prep cook line, but he would have the area cleaned by the afternoon. He had not cleaned the floor drain or exhaust fan in the mop sink room but had plans to do so. A Dietary Aide stated in an interview conducted on 10/24/18 at 10:53 am, that the dietary aides are responsible for cleaning the kitchenettes, if they do it. During an observation on 10/25/18 at 10:32 am, the floor drain and exhaust fan in the mop sink room had not been cleaned. The Director of Food Service stated he would clean it as soon as possible. Later that day, it was observed that the mop sink room drain and exhaust fan had been cleaned. The Director of Food Service stated in an interview conducted 10/25/18 at 9:45 am, that the weekly schedule for cleaning the kitchenettes had not been devised or implemented. There were no audits started and a new audit tool would be created. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1, 14-1.110 (b), 14-1.110 (d), 14-1.150 (c) 14-1.170.

Plan of Correction: ApprovedNovember 17, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The main kitchen meat slicer, can opener, cooler exhaust fan guards, mixer, knife holder, cooler walls, and bulk food storage bins were cleaned on 8/26/18. The floor tiles by the cooks' line will be re-grouted. All identified floors were cleaned immediately. Ice was removed from the wall above the walk-in freezer door. Paper towel dispensers were repaired and filled.
The Oaks Creek, Star Haven, Gardenia Court, and Hollyhock Way kitchenettes were cleaned, including cabinetry, microwave ovens, floors, and refrigerators. The sink in Whispering Way was treated for [REDACTED].
All Food Service staff will be re-educated in cleaning standards, schedules, and responsibilities. A weekly deep-cleaning schedule has been developed for each kitchenette.
An audit will be conducted weekly x 3 months, then bi-weekly x 3 months of the main kitchen and all kitchenettes to verify cleanliness to standards. Audit results will be reported to QA Committee monthly.
Responsible: Food Service Director

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a recertification survey the facility did not ensure that they investigated an alleged violation of neglect for one (Resident #55) of 4 residents reviewed for abuse. Specifically, the facility did not ensure that an investigation was done after the resident reported concerns about the treatment she was receiving from a staff member. This is evidenced by: A Policy titled, Reporting Abuse to Facility Management updated 6/2018, documented that it assures prompt reporting of any incident or suspected incident of abuse, neglect mistreatment to facility management; that all staff report suspected incidents to their immediate manager/supervisor and that the manager/supervior would report suspected incidents to the Director of Nursing (DON), Director of Social Work (SW) or Assistant Director of Nursing (ADON). Resident #55: The resident was admitted to the nursing home on 5/13/16, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. During an interview on 08/29/18 at 10:11 AM, Resident #55 stated that in the past 2 weeks she has had issues with Certified Nursing Assistant (CNA) #11. She reported that CNA #3 put her on the commode one day and CNA #11 did not get her off the commode for 30 minutes, saying she had just gotten back from break. The resident was told that CNA #11 had been back for 15 minutes. Another time she put her call light on and CNA #11 did not answer it for one hour, but came in and answered the roommate's call bell. On Sunday 8/19/18, she had her light on and waited from 7:00 -7:50 PM to be toileted. She saw her CNA #11 in the hall and called out, but got no response. Licensed Practical Nurse (LPN) #12 went by and asked her if she needed anything, she told him what she needed and that is when CNA #11 came to toilet her. The resident stated that the next day she reported her concerns to the staffing coordinator, who told her she would tell the Social Worker (SW) and that the SW would come talk to her, but no one ever came. During an interview on 08/29/18 at 11:38 AM, the Staffing Coordinator (SC) stated that the resident did come to her with concerns about CNA #11 leaving her on the commode and not answering her call bell for an extended time. She reported it to SW #17, who is out on medical leave, who said she would report it to the resident's SW #3. She did tell the resident to talk to Registered Nurse Manager (RNM) #2, and she (SC) did talk to Assistant Nurse Manager, LPN #6 about it. During an interview on 08/29/18 at 12:08 PM, LPN #6 stated that she did not recall a conversation with the SC regarding issues between the resident and CNA #11. During an interview on 08/30/18 at 08:03 AM, SW #3 stated she was not aware that the resident had an issue. She was out and thought someone was covering her unit. They should have talked to the resident, done a grievance and started the investigation. Usually she would talk to the resident first and do a grievance form, then report to the ADON, DON, or Administrator. If they thought it was an issue they would report to the Department of Health. During an interview on 08/30/18 at 08:13 AM, the acting Director of Nursing (DON) was not aware of any issues between the resident and CNA #11. If the resident reported to someone it should have been reported to the nurse manager and investigated. It is in our abuse power point. Additionally, her number is on every unit and she can be reached 24/7 with any concerns. Abuse training is usually done annually and she has been doing it 2-3 times a year. During an interview on 08/30/18 at 12:32 PM, CNA #8 stated she had heard from residents that CNA #11 was rough. She did not report it but probably should have. They have complained to the RNM that CNA #11 just leaves the unit, but they do not say anything. During an interview on 08/31/18 at 12:10 PM, the acting Director of Nursing (DON) stated she did see a grievance form yesterday afternoon and followed up on it but has not talked to staff yet. It should have been investigatied at the time it was reported. 10NYCRR 483.12(c)(2)-(4)

Plan of Correction: ApprovedOctober 1, 2018

Social Worker met with Resident #55 to complete the facility?s formal grievance process to address resident's concerns. All other residents could be affected by the practice.
All residents cared for by CNA #11 who are capable of being interviewed will be asked if they have any unresolved grievance or any concern which has not been adequately and/or timely addressed.
RN Educator will re-educate all staff on Abuse with an emphasis on reporting any suspected or potential abuse, neglect, exploitation, or mistreatment. The facility?s grievance policy and procedure will be re-educated at this time as well.
SW Staff will audit 25% of all residents able to be interviewed monthly x 4 months.
Responsible: Director of Nursing

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during a recertification survey the facility did not ensure all drugs and biologicals were safely stored in accordance with currently accepted professional standards for 2 of 5 nursing units inspected. Specifically, Also, refrigerators in medication rooms on 2 of 5 units used to store insulin had temperature logs that were not maintained daily. This is evidenced by the following: Finding #1: Winding Brook A document titled Medication Refrigerator Temp Log (MRTL) dated 8/2018, documented the following: The RN or LPN will check and record the refrigerator temperature daily on two separate times (7 to 3 shifts and 3 to 11 shifts). The temperature for the refrigerator should be between 36- 46 degrees Fahrenheit. If out of range, readjust the temperature. If still out of range in 24 hours, notify maintenance by completing a maintenance request form. During observation on 8/31/18 at 9:00 AM, the medication refrigerator in the medication storage room contained 3 vials of Humalog insulin, one vial of [MEDICATION NAME] insulin, 2 boxes of [MEDICATION NAME] suppositories, and 2 vials of PPD (purified protein derivative, for [MEDICATION NAME] testing). The refrigerator temperature was noted to be 32 degrees Fahrenheit. During record review on 8/31/18 at 9:30 AM, the MRTL dated 8/1/2018 to 8/31/18, was found to have missing recorded temperatures for the refrigerator in the Medication Storage room [ROOM NUMBER] out of 31 days. No recorded temperatures were found for the 3 to 11 shifts. Documented temperatures for 17 days on the 7 to 3 shifts were below the acceptable 36 degrees, with 5 occasions where the temperature was below 30 degrees F. There were no documented interventions to readjust the temperature of the medication storage refrigerator. During an interview on 8/31/18 at 9:40 AM, LPN #12 stated she does the medication storage temperature log for the unit. She said she has reported the inconsistency in temperatures and missing temperatures to the LPN Assistant Unit Manager (LPNAUM). She was not sure what is being done to correct this, but stated it is common for her to come to the unit after the weekend and evenings and the log is not done. During an interview on 8/31/18 at 11:15 AM, LPNAUM stated she was not aware of any inconsistencies in the MRTL. She stated no one had told her there was any problem and she had not looked at the temperature log. It was the job of the nurses who were passing medications to monitor this daily. She stated she was not sure if a work order had been done for maintenance to correct the instability of the temperature of the refrigerator. Insulin is kept in there and should have been discarded if the refrigerator was not kept at the proper temperature. No record of this being done was documented. During an interview on 8/31/18 at 12:45 PM, the covering physician for the facility stated insulin will be fine at room temperature for a time of about 28 days, but a freezing temperature will cause the insulin to break down and it will lose its effectiveness. Once insulin is frozen it should be discarded. Monitoring the temperature of a refrigerator where insulin is stored is important to ensure the potency is not affected with constantly changing temperatures. Rolling Hills During record review on 8/31/18 at 10:30 AM, the MRTL dated 7/1/2018 to 7/31/18, was found to have missing recorded temperatures for the refrigerator in the Medication Storage Room for 11 out of 31 days. During an interview on 8/31/18 at 11:30 AM, LPN Unit Manager #10 stated it is everyone's job to make sure temperatures are maintained in refrigerators where medication is stored. Sometimes it doesn't get done. The refrigerators are supposed to be checked 2 times a day and any discrepancies are supposed to be reported. It used to be once a day but sometime in (MONTH) it was changed to twice a day. Staffing is not always the best, especially on nights and weekends and things get missed. Temperature logs are collected, but LPNUM #10 stated she wasn't sure what they did with them after being removed from the unit. During interview on 8/31/18 at 11:41 AM, the ADON Director of Nursing (ADON) stated it is the responsibility of the night nurse to check the medication carts nightly to identify outdated or expired medications and overfilled sharps containers. The ADON stated it is the responsibility of the day nurse to check the medication room weekly for outdated or expired medications or biological's. The temperatures on the medication refrigerators on each unit are to be done twice a day. The ADON stated that the medication room and carts were not checked as is the expectation of the facility. The refrigerator temperature logs are collected monthly by the Unit Manager and brought to the (DON) Director of Nursing to be reviewed and filed. If there was any problem with temperatures for any of the medication refrigerators the unit nurses should have notified maintenance or a supervisor. No work order, requesting a maintenance check for the refrigerator on Winding Brook for the month of (MONTH) (YEAR) was provided. 10NYCRR415.18(e)(1-4)

Plan of Correction: ApprovedOctober 2, 2018

Maintenance staff checked the identified refrigerator and adjusted the temperature setting. Re-checks verified the appropriate temperature was maintained.
All residents receiving medications requiring refrigeration have the potential to be affected by this practice.
RN Educator will re-educate all nurses on Proper Medication Storage and related responsibilities.
Unit Mngrs / Weekend Manager On Duty will audit medication refrigeration temperature documentation daily x 1 month, then 2x weekly x 2 months to verify daily maintenance of temperature logs and appropriate response for out-of-range temperatures. DON will report audit results to QA Committee monthly.
Responsible: Director of Nursing

FF11 483.15(d)(1)(2):NOTICE OF BED HOLD POLICY BEFORE/UPON TRNSFR

REGULATION: §483.15(d) Notice of bed-hold policy and return- §483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies- (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; (ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; (iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and (iv) The information specified in paragraph (e)(1) of this section. §483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not ensure one (1) (Resident #162) of one (1) resident reviewed for hospitalization , received a bed-hold notice upon transfer. Specifically, for Resident #162, the facility did not ensure that the resident and the resident's representative were notified in writing of the bed hold policy when the resident was transferred to the hospital. This was evident by: Resident #162: The resident was admitted to the nursing home on 4/26/18, with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had intact cognition with the ability to make self-understood and understand others. A medical provider progress note dated 6/8/2018, documented to transfer the resident to the ER for emergency treatment. A nursing progress note dated 6/8/2018 at 11:54 am, documented the resident's acute health status with transfer to hospital emergency room via medical transport. A nursing progress note dated 6/8/201 at 9:59 pm, documented the resident was admitted to the hospital with [REDACTED]. A review of the medical record did not include documentation of a specific bed hold. During an interview on 08/29/18 at 03:07 pm, Social Worker (SW) #2 stated nursing sends the transfer to the hospital and bed holds are sent by finance department. SW #2 did not think the Social Work Department does this. During an interview on 08/29/18 at 03:36 pm, SW #1 stated the business office manages the bed hold policy upon admission with the resident or resident's representative. The form is filed in the business office with the admissions paperwork. If the resident is sent out, they ask the admissions department if they have a policy on a resident. However, she is not sure where it goes from there. During an interview on 08/30/18 at 01:20 PM, the Assistant Director of Nursing (ADON) was not sure if a second bed hold policy was given at the time of transfer and will check with the finance office. During an interview on 08/30/18 at 01:45 PM, the ADON stated the facility does not provide bed hold notices upon transfer and was unaware of the regulatory requirement. They will do this from here on out. 10NYCRR 415.

Plan of Correction: ApprovedOctober 1, 2018

Resident #162 is no longer a resident of the facility. All residents discharged from the facility have the potential to be affected by this practice.
The Bed Hold Policy & Procedure was reviewed. All Nurses, Social Workers, and Finance staff will be trained on the Bed Hold Policy & Procedure.
At each weekday morning clinical meeting, IDT will verify that all transfers/discharges since prior morning meeting were conducted and documented appropriately.
Social work will conduct monthly audits x 6 months of all transfers/discharges to verify appropriate bed hold documentation was completed timely.
Responsible: Director of Nursing, Director of Social Work

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the recertification survey, the facility did not ensure one (Resident #162) of one resident reviewed for hospitalization , received written notice of discharge and the reasons for the move in writing in a language and manner they understand. Specifically, the facility did not ensure that written notification of discharge was provided to the resident and the resident's representative(s). Also, the facility did not ensure a copy of the discharge was sent to the Office of the State Long-Term Care ombudsman. This was evident by: Resident #162: The resident was admitted to the nursing home on 4/26/18, with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had intact cognition with the ability to make self-understood and understand others. Review of the Facilities Notice of Transfer/Discharge form revealed that it specifically defines a section to be completed by the Nurse at time of transfer to hospital. There was no evidence in the resident's record that the notice was provided. Review of the Facilities Policy on Transfer/Discharge Process dated 3/2018, did not include any language that the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. A medical provider progress notes with a date of service of 6/8/2018, documented to transfer the resident to the ER for emergency treatment. A nursing progress note dated 6/8/2018 at 11:54 am, documented the resident's transfer to the hospital emergency room via medical transport. A nursing progress note dated 6/8/201 at 8 9:59 pm, documented the resident was admitted to the hospital with [REDACTED]. During an interview on 08/29/18 at 03:07 pm, Social Worker (SW) #2 stated nursing sends the transfer to hospital notices. Bed hold notices are sent by the finance department. SW #2 stated she did not think social work does this. During an interview on 08/29/18 at 03:36 pm, SW #1 stated the she completes the Notice of Transfer for all planned discharges/transfers. The SW department does not complete notices for any emergent transfers. Nursing or the nursing supervisor ususally does this. Sending notice of transfer just started last year. During an interview on 8/30/2018 at 12:00 pm, the Assistant Director of Nursing (ADON) stated there was no documented evidence in the chart that the facilities notice of transfer was provided. During an interview on 08/31/18 at 09:20 am, SW #2 stated she guessed that the SW who is out on leave was responsible for this. SW #2 was not aware of the regulation and the need of written notice and did not know if there was a completed monthly report to the Ombudsman. During an interview on 08/31/18 at 09:31 am, the Administrator stated the Social Work Department was responsible for notices of transfer/discharge and that this has not been done. At the beginning of the year they talked with the Ombudsmen who stated a monthly report is acceptable. To date, no monthly report had been sent to the Ombudsmen. 10NYCRR 415.

Plan of Correction: ApprovedOctober 1, 2018

Resident #162 is no longer a resident of the facility. All residents discharged from the facility have the potential to be affected by this practice.
The Transfer/Discharge Policy & Procedure was reviewed. All Nurses and Social Workers will be trained on this policy.
At each weekday morning clinical meeting, IDT will verify that all transfers/discharges since prior morning meeting were conducted and documented appropriately.
Social work will conduct monthly audits x 6 months of all transfers/discharges to verify appropriate documentation was completed timely and sent to the Office of State LTC Ombudsman.
Responsible: Director of Nursing, Director of Social Work

FF11 483.20(k)(1)-(3):PASARR SCREENING FOR MD & ID

REGULATION: §483.20(k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. §483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. §483.20(k)(2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. §483.20(k)(3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure the Pre-Admission Screening was completed for all residents prior to admission for 2 (Resident #'s 28, and 119) of 34 residents reviewed. Specifically, for Resident #28, the SCREEN form did not include the signature of the qualified screener, and for Resident #119, the screen was not completed. This is evidenced by: Finding #1 The facility did not ensure the Preadmission Screen and Resident Review (PASARR) form included the signature of the qualified screener. Resident #28: The resident was admitted to the nursing home on 6/8/17, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and was understood by others. The SCREEN form DOH-695 dated 5/8/17, was blank for the following areas: the resident's name, the name of the qualified screener and the qualified screeners identification number. During an interview on 08/30/18 at 04:47 PM, Social Worker (SW) #3 stated that it was not an appropriate screen because it was not filled out correctly. Finding #2 The facility did not ensure a Preadmission Screen and Resident Review (PASARR) form was completed prior to admission. Resident #119: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed the resident was understood, understands others, and was independent with daily decision making. On 8/27/18 at 12:30 PM, the resident's medical record did not include a SCREEN (DOH-695 PASARR form). During interview on 8/27/18 at 12:42 PM, SW #15 stated the resident did not have a SCREEN prior to admission. SW #15 asked the Administrator for more information about Resident #119's SCREEN and stated they knew since last survey there was no SCREEN. During re-interview on 08/29/18 at 03:25 PM, SW #15 stated that when a patient comes to the facility they have to have a PRI (Patient Review Instrument) and SCREEN for admission. SW #15 stated that social work makes sure the facility receives the SCREEN. SW #15 stated the SCREEN is supposed to come before the resident arrives to the facility. 10NYCRR415.11(E)

Plan of Correction: ApprovedOctober 2, 2018

A SCREEN form (DOH-695) for Residents #28 and #119 were completed and signed by a qualified screener on 9/14/18 and 8/27/18, respectively, which included all required information.
All other residents have the potential to be affected by the practice. All resident SCREENs will be reviewed for completeness.
Social work will audit all new resident SCREENs to verify presence and completeness monthly x 6 months and report results to QA Committee.
Responsible: Director of Social Work

FF11 483.20(f)(5); 483.70(i)(1)-(5):RESIDENT RECORDS - IDENTIFIABLE INFORMATION

REGULATION: §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey the facility did not ensure resident records were readily accessible. Specifically, for Resident #'s 44, #54, and #152, the facility did not ensure that dictated medical provider progress notes were entered into the electronic medical record (EMR) in a timely manner. This was evidenced by: The Policy & Procedure (P&P) titled Attending Physician Responsibilities dated (MONTH) 2014, documented that each attending Physician will be responsible for providing appropriate, timely and pertinent documentation. At each visit the attending Physician will provide a progress note (written, typed or electronic) in a timely manner for placement in the medical record. The note should either be written or entered at the time of the visit or, if dictated or otherwise prepared after the visit, should be returned to the facility for placement on the chart within a week. Over time, these progress notes should address significant active problems and risk factors, reasons for changing or maintaining current treatments or medications and an evaluation of how medical treatments relate to the individuals overall function and quality of life. Resident #44: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition and was able to understand others and was able make himself understood. The following dictated progress notes were not entered into the residents EMR in a timely manner: Nurse Practitioner (NP) progress note dated 6/11/18 was entered into the EMR 7/11/18. Physician (MD) progress note dated 6/12/18 was entered into the EMR until 7/12/18. MD progress note dated 6/29/18 was not entered into the EMR until 7/14/18. MD progress note dated 7/20/18 was not entered into the EMR until 7/30/18. MD progress note dated 8/15/18 was not entered into the EMR until 8/27/18. Resident #152: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was cognitively intact. The resident was able to be understood and able to understand others. The following dictated progress notes were not entered into the residents EMR in a timely manner: NP note dated 6/13/18 was not entered into the EMR until 7/11/18. NP note dated 7/18/18 was not entered into the EMR until 7/30/18. MD note dated 7/20/18 was not entered into the EMR until 8/9/18. MD note dated 7/20/18 was not entered into the EMR until 8/9/18. MD note dated 8/3/18, was not entered into the EMR until 8/13/18. During an interview on 08/29/18 at 02:57 PM, MD #1 stated the facility had been working on the problem of dictation being placed in the computers in a timely manner. The system a few months back was that we would dictate our notes for the previous company and they would send them back to the facility and it would go into the EMR, and it was not always timely. There was a transition with a new company in July, the MD notes are in the new format that you now see. The beginning was difficult with a delay in the notes put into the EMR. Now they are placed in the EMR and the Physician can sign them electronically. During an interview on 08/30/18 at 08:27 am, Licensed Practical Nurse Manager (LPNNM) stated the delay in Physician and MD and NP notes still exists. There are no paper copies of MD, NP progress notes, they are only available in the EMR. The Nurse Managers have no access to review the MD notes until they are placed in the EMR. Two months ago the delay started to get bad. During an interview on 8/30/18 at 11:48 am, the Assistant Director of Nursing (ADON) stated there is still a lag in the placement of medical staff documentation in the EMR. When the new dictation company went live there was a lag of 3-4 days. Was aware of MD & NP concerns in the delay of dictated notes being put in the EMR during that time. The ADON was not aware of a month long lag in documentation entered into the EMR. During an interview on 8/30/18 at 03:03 pm, NP #1 stated the facility changed the dictation process and contracted with another vendor in (MONTH) (YEAR). There are delays with he process for placement of MD/NP progress in the EMR. The MD & NP documentation goes to the dictation company, it is then sent to the Medical Record person and she puts the dictated notes in the EMR. In the dictation process the MD/NP can see their own notes previously written, the nurses do not see them until they are placed in the EMR. During an interview on 8/31/18 at 1:15 pm, the Medical Records Director stated that in (MONTH) (YEAR), the dictation was coming in late. The Medical Records Director was told the facility stopped the contract with the previous company. In (MONTH) (YEAR), the new dictation company started, dictated notes started coming in mid to late (MONTH) and I did not know what to do with them. At the end of (MONTH) there was approximately 200 dictated notes to put in the EMR. Resident #54: The resident was admitted to the nursing home on 6/15/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having intact cognitive skills for daily decision making. It documented that the resident understood and was understood by others. Physician (MD) Orders dated 6/15/18, documented [MEDICATION NAME] 500 mg; Give 0.5 tablet twice daily. MD Orders dated 6/19/18, documented to discontinue [MEDICATION NAME]. The medical record did not include documentation for the reason [MEDICATION NAME] (a diabetes medication) was discontinued. During an interview on 08/27/18 at 12:07 PM, the resident stated that he went to his vascular surgery appointment last week and they asked why he was not on his [MEDICATION NAME], because he should be. He asked when he got back, but has not gotten an answer. The medical record did not include MD documentation of his 6/19/18 visit in which he discontinued the [MEDICATION NAME]. During an interview on 08/30/18 at 09:25 AM, Assistant Nurse Manager, LPN #6 did not see a note in the medical record regarding the reason [MEDICATION NAME] was discontinued. LPN #6 looked in a composition notebook near her desk, and stated that the MD saw the resident on 6/19/18. She did not know why there was no note in the chart and did not know why [MEDICATION NAME] was discontinued. During an interview on 8/30/18 at 11:48 am, the Assistant Director of Nursing (ADON) stated there is still a lag in the placemnt of medical staff documentation in the EMR. The ADON was not aware of a month long lag in documentation entered into the EMR. During an interview on 8/31/18 at 1:15 pm, the Medical Records Director stated that in (MONTH) (YEAR), the dictation was coming in late. The Medical Records Director was told the facility stopped the contract with the previous company. In (MONTH) (YEAR), the new dictation company started, dictated notes started coming in mid to late (MONTH) and I did not know what to do with them. At the end of (MONTH) there was approximately 200 dictated notes to put in the EMR. During an interview on 08/31/18 at 1:25 AM, the MD stated that he understood what the surveyor was saying about having the documentation in the chart. 10NYCRR415.

Plan of Correction: ApprovedOctober 2, 2018

All medical provider progress notes for Residents #44, #54, and #152 are entered into the electronic medical record (EMR). All residents have the potential to be affected by this practice.
Medical Records Director will verify that all dictated progress notes have been entered into the EMR since the implementation of the new dictation process (mid-July (YEAR)).
Finance Office is now responsible to provide daily dictation log to Medical Records after each provider visit. Medical records then enters dictated progress notes into the EMR within one week.
Medical Records Director will audit medical progress notes to verify timely receipt of dictated notes and entry into the EMR.
Responsible: Medical Records Director

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that hallway light fixtures on 5 of 5 units were free from debris. This is evidenced as follows. The light fixtures in all the hallways were inspected on 08/29/2018 at 12:00 PM. The corridor light fixtures had numerous dead flies in the light covers. The Director of Environmental Services stated in an interview conducted on 08/29/2018 at 12:15 PM, that his department was responsible for cleaning the light fixtures. He stated that the lights were cleaned 3 weeks ago and that he will increase the frequency for cleaning hallway lighting in the summer months. 483.10(i)(2)

Plan of Correction: ApprovedOctober 1, 2018

All hallway light fixtures were cleaned of debris by 9/10/18. Housekeeping Director created a monthly schedule for cleaning the hallway light fixtures.
All Housekeeping staff will be re-educated on hallway light fixture cleaning responsibilities.
Housekeeping Director will audit all hallway lights bi-monthly x 6 months

Responsible: Housekeeping Director

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee interview and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities ensure patient care-related electrical equipment (PCREE) is tested and inspected prior to being placed in service and maintained with consideration of the owner's manual. Section 10.5.6 requires that instruction/maintenance manuals be accessible. Specifically, PCREE observed was not maintained as prescribed in the owner's manual. This is evidenced as follows. Observations on 08/30/2018 at 1:30 PM, revealed that nebulizers found in resident rooms 264 C and 132 B on Winding Brook Unit and 126 A on Country Meadows Unit were not in use and plugged into the electrical receptacles. Review of the owner's manual for the Teleflex nebulizer on 08/30/2018, revealed on page 4, that the unit should be unplugged after use. The Assistant Director of Nursing stated in an interview conducted on 08/30/2018 at 1:30 PM, that the nebulizers are not unplugged after each use and that the facility's staff has not received training to unplug the nebulizers. Observations on 08/29/2018 at 12:00 PM, revealed oxygen concentrators were found to be stored against the wall in both room [ROOM NUMBER] on the Mountain Ridge Unit and room [ROOM NUMBER]B on the Winding Brook Unit. On 08/30/2018 at 9:30 AM, one oxygen concentrator was observed against the wall in room [ROOM NUMBER]. All concentrators were in use during these observations. The Assistant Director of Nursing stated in an interview on 08/30/2018 at 9:30 AM, that she was not aware that according to the operation manual, oxygen concentrators that must be kept 12 away from walls during operation, but this requirement will be included in the annual training to staff. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedOctober 2, 2018

Portable patient-care related electrical equipment (PCREE) owner's manuals for the identified equipment was reviewed for manufacturer operation and maintenance recommendations and requirements.
All staff with the potential to use such PCREE will be educated on the procedures to comply with these recommendations and requirements.
All other PCREE manuals will be reviewed with similar identification of procedures and staff training.
DON or designee will audit 10 PCREE uses per week to verify that staff use of equipment complies with manufacturer recommnedations. Audits will be conducted weekly x 3 months, then bi-weekly x 3 months, then monthly x 3 months.
Responsible: Director of Nursing

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on staff interview and record review during post survey review, the facility did not maintain the emergency generator as required by adopted regulations. NFPA 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3.8 requires that a fuel quality test shall be performed at least annually using tests approved by ASTM standards. Specifically, within the past year the diesel fuel used to power the emgencey generator was not subject to the require fuel quality tests. This is evidenced as follows. The emergency generator inspection and maintenance records were reviewed on 08/28/2018. The inspection reports dated 03/20/2017 and 03/29/2018 did not include a fuel quality test. No other records were available for review documenting a fuel quality test was performed on the emergency generator fuel reserve. The Maintenance Supervisor stated in an interview conducted on 08/29/2018 at 11:15 AM, that he cannot find documentation of a fuel quality test. 42 CFR 483.70 (a) (1); 2010 NFPA 110 8.3.8

Plan of Correction: ApprovedOctober 2, 2018

A fuel quality test using approved ASTM standards was completed for the diesel used in the emergency generator on 8/29/18. Results were received on 9/12/18. Annual testing is scheduled.
Responsible: Maintenance Supervisor

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on observation and employee interview during the recertification survey, the facility did not inspect electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Sections 6.3.3.2 and 6.3.4.1 requires that receptacles not listed as hospital-grade, at patient bed locations shall be tested at intervals not exceeding 12 months; the testing shall include: the physical integrity shall be confirmed by visual inspection; the continuity of the grounding circuit shall be verified; correct polarity of the hot and neutral connections shall be confirmed; the retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). Specifically, the facility did not ensure receptacles not listed as hospital-grade, in patient rooms and rest rooms, were tested as required. This is evidenced as follows. Observations on 08/29/2018 at 12:00 PM, revealed receptacles not listed as hospital-grade were found; in resident rooms 104, 108, 112, 118, 126, 151, 161 on resident Country Meadows Unit, in resident rooms 208, 217, 226, 251 on Rolling Hills Unit, in resident rooms on 103, 109, 132, 133, 157, 168, 179 on Winding Brook, in resident rooms 203, 204, 216, 227, 264, 269, 279 on Mountain Ridge, and resident rooms 101 118, 148, 151, 163, 164, 167, 169 on Serenity Place. The Maintenance Supervisor specified in an interview conducted on 08/29/2018 at 12:15 PM that every resident room has non-hospital grade receptacles in both the bedroom and bathroom areas. He stated that these non-hospital grade receptacles were not tested annually as required. 42 CFR 483.70 (a) (1); 2012 NFPA 99 6.3.3.2, 6.3.4.1

Plan of Correction: ApprovedOctober 2, 2018

All residents' rooms contain one outlet that is not hospital grade. Testing was completed on each of these receptacles according to NFPA 99 Standard, 2012 Edition. Annual testing of these outlets is scheduled.
Responsible: Maintenance Supervisor

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 edition sections 14.4.5 and 14.4.2.2 and Table 14.4.2.2 14(d) require that fixed temperature heat detectors require annual heat and/or function tests. Specifically, fixed temperature heat detectors and smoke detectors were not heat and/or function tested in the past year. This is evidenced as follows. Record review of the facility's fire alarm testing records on 08/28/2018 revealed that the 10 heat and the 5 smoke detectors located in the elevator shafts were not tested within the past 12 months. The Maintenance Supervisor confirmed in an interview conducted on 08/28/2018 at 11:15 AM that heat detectors and smoke detectors in the elevator shafts were not tested during the (YEAR) and (YEAR) annual inspections adding that the fire alarm testing company would not access the elevator shafts without the assistance of the elevator repair company. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.6.1.3; 1999 NFPA 72: 14.4.5; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-2.2, 7-3.2

Plan of Correction: ApprovedOctober 2, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The ten heat and five identified smoke detectors located in the elevator shafts were tested on [DATE]. All other detectors were verified to have been tested within the past year.
Future testing will be scheduled at least annually with coordination between the elevator and alarm service companies.
Responsible: Maintenance Supervisor

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on observation and staff interview during the recertification survey, exits were not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 7.1.10.1 requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, all means of egress were not free of obstructions to full instant. This is evidenced as follows. On 08/29/2018 at 2:15 PM the door to room D269 would not open from the egress side; the surveyor tested the door for the inside and could not leave. Dietary Aid #1 stated in an interview on (MONTH) 29, (YEAR) at 2:15 PM that one could not get out of the bathroom (room D269) because the door would stick closed. Additionally, he stated that he told the nursing staff about two weeks ago assuming a work order would be submitted to maintenance, but he did not himself submit a work order. The Maintenance Supervisor state in an interviewed on 08/29/2018 at 2:20 PM; that bathroom D269 is for resident use, his department did not receive a work order from Dietary Staff or Nursing staff regarding the malfunctioning bathroom, and the door will be repaired immediately. 42 CFR 483.70 (a) (1); 2000 NFPA 101 7.1.10.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedOctober 2, 2018

The door to D169 was repaired on 8/29/18 to restore full egress. All other bathroom doors were checked for proper egress and were verified to be functional.
Maintenance will audit 33% of all bathroom doors monthly x 3 months to verify that all maintain proper egress function. Audit results will be reported to QA Committee monthly.
Responsible: Maintenance Supervisor

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, the facility did not ensure that sprinkler heads were not found with a coating of dust. This is evidenced as follows. Observations of the sprinkler system on 08/30/2018 at 10:10 AM, revealed 2 sprinkler heads in the attic, 6 sprinkler heads under the awning in front entrance of the building and 4 sprinkler heads outside by the awning next to the loading dock were found with a coating of dust. The Maintenance Director stated in an interview conducted on 08/30/2018 at 10:45 AM, that there was not a regular cleaning schedule for the sprinkler heads. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedOctober 2, 2018

All identified sprinkler heads (two in attic, six under awning, and four by awning next to dock) were cleaned on 9/26/18. All sprinkler heads throughout the facility were observed and cleaned as indicated.
A cleaning schedule has been developed and implemented to ensure the heads are free of dust build-up.
Maintenance will audit 20% of all exposed sprinkler heads monthly x 5 months to verify no dust build-up. Results will be reported to QA Committee monthly.
Responsible: Maintenance Supervisor

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on observation and staff interview during the recertification, the facility did not maintain electrical wiring and equipment in accordance with the adopted regulations. NFPA 70 National Electrical Code 2011 edition Article 210.8 requires that Ground Fault Circuit Interrupter protection (GFCI) be provided on electrical outlets within six-feet of a sink rim or water source. Specifically, electrical outlet GFCI protection was not provided near water sources on resident units. This is evidenced as follows. Observations of the washing machines on the washing machine closets (one closet on each of 5 units) 08/29/2018 at 12:20 PM, revealed that the electrical outlets next to the hose bibbs on each unit did not have GFCI protection. The Maintenance Supervisor stated in an interview conducted on 08/29/2018 at 12:20 AM, that he will install GFCI outlets in the areas found. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.5.1.1; 9.1.2; 2011 NFPA 70 Article 210.8; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 9.1.2; 1999 NFPA 70 Article 210.8

Plan of Correction: ApprovedOctober 16, 2018

Maintenance staff checked all washing machine closets to verify GFCI protected electrical outlets next to the hose bibbs.
All electrical outlets in these areas were replaced on 9/12/18 with GFCI outlets, including in the five identified washing machine closets.
Maintenance staff will audit all water sources to verify that GFCI outlets are in place wherever the outlet is within 6 feet of the water source.
Responsible: Maintenance Supervisor

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: August 31, 2018
Corrected date: October 19, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be continuous. Specifically, the rated floor/ceilings assembly in the basement had unsealed penetrations, were not continuous, and did not maintain the required fire resistance rating. This is evidenced as follows. Observations on 08/27/2018 at 2:00 PM, revealed multiple unsealed holes and penetrations in the rated ceiling in the basement room C 022. The Maintenance Supervisor stated in an interview conducted on 08/27/2018 at 2:30 PM, that there are more than 15, 4-inch holes in the rated ceiling, and he will seal all the holes in the fire rated ceiling. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3

Plan of Correction: ApprovedOctober 2, 2018

Maintenance staff surveyed the facility and found additional unsealed penetrations in the fire rated floor/ceiling assemblies.
All identified penetrations will be sealed, including those found in basement room C022.
Progress reports on the work will be reported to the QA Committee monthly until completed.
Responsible: Maintenance Supervisor