Dunkirk Rehabilitation & Nursing Center
March 8, 2017 Certification Survey

Standard Health Citations

FF10 483.20(b)(2)(ii):COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 8, 2017
Corrected date: April 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard Survey completed on 3/8/17, the facility did not complete a comprehensive resident assessment when there is a significant change. One (Resident #21) of 17 residents reviewed for Care Plans lacked a significant change of assessment within 14 days and Care Plan revision of the resident with a decline in ADLs (activity of daily living) for eating assistance and the development of a Stage IV pressure ulcer. The finding is: 1. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 1/14/17 revealed the resident has severely impaired cognition impairment. a.) Further review of the MDS dated [DATE] section M revealed the resident had a Stage II pressure ulcer and Section G revealed the resident had a decline from an extensive assist with one staff member to totally dependent on staff for feeding. Review of the current MDS 3.0 RAI (Resident Assessment Instrument) Manual revealed that a significant change in assessment is appropriate if there are either two or more areas of decline; any decline in an ADL physical functioning area where a resident is newly coded total dependence; emergence of a new pressure ulcer at Stage II or higher or worsening in pressure ulcer status. During an interview on 3/8/17 at approximately 10:00 AM, Registered Nurse (RN) #2 stated, I must've overlooked the information on the MDS and should've recognized a significant change in assessment was required. I will schedule a significant change. b.) Review of the Comprehensive Care Plan (CCP) initiated 12/8/16 revealed the resident had a Stage II pressure ulcer on her right buttock. The plan was to administer treatments as ordered and monitor for effectiveness; back to bed after meals; bariatric bed with low air loss mattress; roho cushion in chair; weekly treatment documentation to include measurements. Review of the Wound Weekly RN assessment dated [DATE] revealed the resident had a Stage IV pressure ulcer on the right buttocks measuring 6 cm (centimeters) x 3 cm x 4.5 cm. Further review of the CCP revealed a lack of revision to the CCP to include the progression of the Stage II pressure ulcer to a Stage IV pressure ulcer. Interview with RN #1 Resident Care Coordinator on 3/8/16 at 11:56 AM revealed the CCP should have been revised on 2/21/17 or shortly thereafter when the pressure ulcer advanced form a Stage II to a Stage IV. 415.11(a)(3)(ii)

Plan of Correction: ApprovedApril 10, 2017

The facility does ensure that that a comprehensive assessment will be completed within 14 days after the facility determines or should have determined that there had been a significant change in the residents physical or mental condition.
1.ADDENDUM: A SIGNIFICANT CHANGE FOR RESIDENT #21 completed by the Interdisciplinary team and care plan AND SIGNIFICANT CHANGE MDS WAS COMPLETED 3/23/17 to reflect the appropriate staging of the pressure injury and the implemented interventions accordingly.
2. 100% of all residents with pressure injuries care plans were reviewed to ensure that the correct staging of any pressure injuries were documented
accordingly.
3. Re-inservicing was done for all licensed nurses and Interdisciplinary team members on identifying significant changes and timely completion of comprehensive assessments and updating changes on the comprehensive care plant to reflect any all changes. ADDENDUM: MDS COORDINATOR WILL BE RE-INSERVICED UPON RETURN FROM DISABILITY ON REVIEWING OF ACCURATE INFORMATION TO ENSURE THE CORRECT TYPE OF MDS IS COMPLETED.
4.Significant Change Analysis Report from Point Click Care program will be reviewed and audited weekly by the interdisciplinary staff x 2 months and then every other week x 2 months. The Significant Change Analysis Report will then be reviewed, on an individual basis as each resident comes up for care plan conference to ensure that significant changes are identified and comprehensive reassessments are completed, care planned accurately and in a timely manner.
Results of audits will be brought to the monthly QA meetings x's four months.
Responsible Party- Director of Nursing or Designee.

FF10 483.20(d);483.21(b)(1):DEVELOP COMPREHENSIVE CARE PLANS

REGULATION: 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident?s medical record. (iv)In consultation with the resident and the resident?s representative (s)- (A) The resident?s goals for admission and desired outcomes. (B) The resident?s preference and potential for future discharge. Facilities must document whether the resident?s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 8, 2017
Corrected date: April 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed 3/8/17, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Three (Residents #36, 38, 50) of 17 residents reviewed for care plan development did not have a care plan to address anticoagulant use (blood thinning medication) (Resident #38); antipsychotic and antidepressant medication use (Resident #36); and the status of a resident's eating assistance (Resident #50). The findings are: 1. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 12/9/16 revealed the resident has severe cognitive impairment and received anticoagulant medication. Review of a Report of Consultation dated 10/19/16 revealed a cardiology recommendation to stop Eliquis (anticoagulant) and start [MEDICATION NAME] (anticoagulant). Review of a physician's orders [REDACTED]. Review of a physician progress notes [REDACTED]. Review of the current Comprehensive Care Plan (CCP) revealed the CCP did not address the use of an anticoagulant medication and did not include interventions for staff to monitor for signs of bleeding or other adverse side effects of the medication. Review of the Kardex Report (care plan used by certified nurse aides (CNAs) to provide care) dated 3/7/17 revealed there was no documentation that the resident was on an anticoagulant medication and to monitor for signs of bleeding. During an interview on 3/7/17 at 2:55 PM, the Director of Nursing (DON) stated, Yes, it (anticoagulant) should be on the care plan. 2. Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS dated [DATE] revealed the resident needs extensive assistance of one person for eating. Review of the CCP dated 9/1/16 and the Kardex Report dated 3/7/17 revealed there was no documentation regarding the resident's ability to eat. Interview with a Registered Nurse (RN) #2 on 3/8/17 at 8:51 AM revealed that if the MDS is updated with a significant change regarding a resident's self-feeding status, then it is nursing's responsibility to update or develop the care plan. Interview with the DON on 3/8/17 at approximately 9:00 AM revealed the DON should have updated or created the care plan. The DON stated that they discuss significant changes or updates at morning report. The situation is discussed and the care plan should be created or updated. Review of a facility policy and procedure (P&P) entitled Care Plans dated 8/2008 revealed that the interdisciplinary team should update the care plan routinely with changes in resident status. 3. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, usually understands, and is usually understood. Review of a physician's orders [REDACTED]. Review of the current CCP revealed the CCP did not address the use of the antipsychotic and antidepressant medications. During an interview on 3/8/17 at 9:11 AM, the Social Worker stated, Yes I expect the antipsychotic and antidepressant medications to be listed on the care plan. I must have overlooked it. When interviewed on 3/8/17 at 10:30 AM, the DON stated, Yes, the (antipsychotic and antidepressant) medications should be on the care plan. 415.11(c)(1)

Plan of Correction: ApprovedApril 10, 2017

The facility maintains all resident assessments completed within 15 months in the resident active record and use of the results of the assessments to develop,review and revise the resident's comprehensive care plan.
1. Residents #36,#38 and #50 Comprehensive Care
Plans ADDENDUM: AND C.N.A. KARDEXS were reviewed and revised by the interdisciplinary team as follows, #36 Care Plan revised to reflect use of antipsychotic and anti depression medication.#38 Care Plan/KARDEX revised to reflect the use of warafin and need for ongoing monitoring for risk of bleeding.#50 Care Plan/KARDEXS WERE revised to reflect the residents' level of assist with eating.

2. A 100% audit of all residents receiving anticoagulants, anti-depressants and anti-psychotic medications were completed and care plans/KARDEXS were revised to reflect any changes or additions as needed on the care plan/KARDEXS.
3. All full and part time nurses,therapies and the social worker were re-inserviced on addressing all Anti-depressant, Anti-psychotic and Anticoagulant medications including monitoring any risks of the medications on resident care plans and kardexs. In-servicing also included the need for the care plan to reflect accurate level of needed assistance required by residents for eating abilities on their care plans and KARDEXS.
4. 10 residents Care Plans will be audited weekly for one month and random audits of 10% of the residents care plans will be done monthly x's 2 months. ADDENDUM: FINDINGS WILL BE BROUGHT TO THE MONTHLY QA MEETING AND AT THE END OF 2 MONTHS THE COMMITTEE WILL DETERMINE THE NEED FOR ADDITIONAL MONITORING.
Responsible Party - Director of Nursing and Director of Social Work.

FF10 483.24, 483.25(k)(l):PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING

REGULATION: 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 8, 2017
Corrected date: April 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/8/17, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #21) of one resident reviewed for quality of care lacked adequate pain management of the resident during the treatment of [REDACTED]. The finding is: 1. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 1/14/17 revealed the resident has severely impaired cognition impairment. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan (CCP) dated 12/16/16 revealed the resident has chronic pain related to disease process with the following plan to monitor/ record characteristics of pain; Quality (sharp, burning); Severity (1-10 scale); anatomical location; onset; duration; aggravating factors; relieving factors. Review of the Nursing Wound Weekly Registered Nurse (RN) assessment dated [DATE] revealed the resident developed a Stage II pressure ulcer to her right inner buttock, measuring 2.4 centimeters (cm) x 2 cm with pink granulation (formation of tissue in the process of healing) present and no pain related to wound identified. Review of the Nursing Wound Weekly RN assessment dated [DATE] revealed the area on the right inner buttock worsened to a Stage IV pressure ulcer with slough present (soft, moist dead tissue may be white, yellow, tan or green) and necrotic (dead tissue) and no pain related to wound identified. Review of a physician's orders [REDACTED]. Review of a Physician Note dated 2/21/17 revealed the resident had a Stage IV sacral (area above the tail bone to right and left buttocks) decubitus (pressure) ulcer and her pain is currently controlled with Tylenol [MEDICATION NAME] medications every six hours. Review of a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The [MEDICATION NAME] was initiated as administered one time on 3/1/17 and one time on 3/5/17. During observation on 3/7/17 at 11:24 AM, RN #1 rolled the resident onto her left side to reveal a Stage IV pressure ulcer. RN #1 stated the wound measured: 7 cm x 3.6 cm x 3.8 cm. When RN #1 cleansed the wound with normal saline and gauze the resident stated, ouch and verbal moans upon touch and movement, and positioning. RN #1 stated, I'm sorry, but I have to finish the treatment. I'm almost finished. During an interview on 3/7/17 at 11:37 AM, Resident #21 stated, I'm not having any pain now, it hurts when they change my dressing on my bottom. I'm ok. During an interview on 3/7/17 at 11:39 AM, RN #1 stated, I should've had the nurse give her pain medication at least 45 minutes before I did the treatment. I'll have her give her some now. She always moans and doesn't get out of bed much. I didn't feel that she was in pain or I would've stopped and medicated her. She moans all the time. During an interview on 3/7/17 at 11:49 AM, the Director of Nursing (DON) stated, I would expect my nurses to pre-medicate at least 30 minutes prior to a treatment, and stop during the treatment if the resident complains of pain during the treatment. During an interview on 3/8/17 at approximately 7:58 AM, the Certified Nurse Aide (CNA) #2 stated, She (Resident #21) usually makes moaning noises when I work with her. Normally I'd stop when someone's in pain, and let the nurse know. During an interview on 3/8/17 at 8:01 AM, Licensed Practical Nurse (LPN) #2 stated, I usually don't pre-medicate her (Resident #21) before I do her treatment. She always moans, but she'll tell you if she hurts. I usually give her [MEDICATION NAME] in the evening. During an interview on 3/8/17 at approximately 11:45 AM, CNA #4 stated, Resident #21 is in pain all the time. Normally I'd stop and tell the nurse at the time about the pain and continue care later if someone was in pain. During an interview on 3/8/17 at approximately 11:00 AM, the Administrator stated if someone was experiencing pain with hands on care or during a treatment I would expect them to stop giving care and notify the nurse and medicate the resident prior to resuming care or proceeding with the treatment. Review of the Facility Pain Assessment/ Management form revised 11/2013 revealed the following: All residents will be assessed for pain at the time of admission and re-admission, quarterly and as needed with onset of new pain. Notify the physician of a resident response to their medication if not satisfactory. 415.12

Plan of Correction: ApprovedApril 2, 2017

The facility does ensure and provide that each resident receive the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.
1. Resident #21 care plan was review and the resident levels of pain were reassessed using the pain assessment tool and reviewed by the interdisciplinary team. Care plan was update to reflect that resident will be medicated prior to administration of pressure ulcer treatments.

2. 100% of residents with pressure ulcer treatments had Care Plan revised to reflect need for pain medication administration prior to treatment as needed.
3. All full and part time nurses were in-serviced on the facility pain management policy and the timely administration of pain medication. All Nursing staff will monitor effectiveness of pain medication and notify the Physician of a resident response to their pain management if not satisfactory.
4. On going monitoring of MARS will be done for all residents with pressure ulcers to ensure that pain medication has been administered and is effective prior to any treatment or procedure that may cause pain or discomfort. Monitoring will be done x's 3 month. Findings will be brought to the monthly QA meeting at the end of 3 months the committee will
will determine need for additional monitoring.

Responsible party Director of Nursing or Designee

FF10 483.45(f)(2):RESIDENTS FREE OF SIGNIFICANT MED ERRORS

REGULATION: 483.45(f) Medication Errors. The facility must ensure that its- (f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 8, 2017
Corrected date: April 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 3/8/17, the facility did not ensure that residents are free of any significant medication errors. One (Resident #38) of five residents reviewed for unnecessary medications did not receive an anticoagulant medication ([MEDICATION NAME]- used to prevent blood from clotting) for a period of five days resulting in a sub-therapeutic INR (international normalizing ratio - standardized normalized blood coagulating values). The finding is: 1. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/9/16 revealed the resident has severe cognitive impairment and receives anticoagulant medication. Review of a Report of Consultation dated 10/19/16 revealed a cardiology recommendation to stop Eliquis (anticoagulant) and start [MEDICATION NAME] (anticoagulant). Review of a physician's orders [REDACTED]. Review of a physician progress notes [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of a Laboratory Report dated 1/23/17 revealed an INR level of 4.12 (normal value is between 2-3 for valvular [MEDICAL CONDITION]) with a handwritten note on the bottom of the report that documented hold two days then c/w (continue with) same dose, rpt (repeat) in one week. Review of a Physician order [REDACTED]. Additional review of the physician's orders [REDACTED]. Additional review of the MAR indicated [REDACTED]. Review of a Laboratory Report dated 1/30/17 revealed an INR level of 1.46. During an interview on 3/7/17 at 2:37 PM when asked what the resident's INR range was supposed to be the Registered Nurse (RN) #1 Unit Manager (UM) stated, They like it between 2 and 3. RN #1 UM further stated, There was no order to hold it ([MEDICATION NAME]) from the 25th to 29th. I can't answer to what happened. During an interview on 3/7/17 at 2:46 PM regarding the [MEDICATION NAME] order, the Director of Nursing (DON) stated, There is just an order to hold it on the 23rd and 24th. The DON reviewed the Laboratory Report dated 1/23/17. When asked if the resident should have received [MEDICATION NAME] starting on 1/25/17, the DON stated, The way I read this, yes he should have. When asked if this is considered a medication error, the DON stated, Yes and I would've done a report if I knew about it. Review of a Medication Error Report dated 3/7/17 revealed the medication as ordered was [MEDICATION NAME] ([MEDICATION NAME]) 1.5 mg po daily, except for Monday, Wednesday, and Friday, give [MEDICATION NAME] 1 mg. Additional review of the Medication Error Report revealed the following: - Description of the error: Order was not put in PCC (computer). - Outcome to resident: Decreased INR. - Corrective action taken: MD (medical doctor) notified, medication restarted 1/30/17. - Measures taken to prevent the recurrence of similar error(s): At end of shift, review new orders with another nurse. - The reason for error: Transcription error. 415.12(m)(2)

Plan of Correction: ApprovedApril 2, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility does ensure that residents are free of any significant medication errors.
Resident #38 Physicians orders were reviewed for correctness and completion. MD was notified of medication error and medication was continued. A medication error report was completed on 3/7/2017 by Director of Nursing and nurse making error was counseled.
2. A 100% audit of all physician orders [REDACTED].
3. All full and part time licensed Nurses were in-serviced on completing transcription of Physician order [REDACTED]. All anticoagulant orders will be reviewed by a nurse for accuracy of the physician order.

4. All residents on anticoagulants will have transcribed orders and/or changes in coagulants monitored for 60 days by the Director of Nursing/designee with findings brought to monthly QA meeting.
At the end of the two months the committee will evaluate the need for continued monitoring.
Responsible Party: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 8, 2017
Corrected date: April 5, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 3/8/17, power strips and extension cords were being used to supply a permanent supply of power to electrical appliances. Issues included power strips that were plugged into other power strips (daisy chained) and power strips that were plugged into extension cords that were being used to supply power to various electrical appliances. This affected one (generator room) of one generator room, one (dining room) of one dining room, one (Business / Human Resources office) of one Business / Human Resources office, one (Administrator's office) of one Administrator's office. The findings are: 1. Observation in the generator room on 3/3/17 at approximately 9:21 AM revealed a power strip that was plugged into an extension cord was supplying power to various components of the building's computer and telephone systems. Interview with the Maintenance Director at the time of the observation revealed he was not aware the extension cord was plugged into the power strip. Further interview with the Maintenance Director at this time revealed the power strip and extension cord were part of the upgrade to the budding's computer and telephone systems that were installed by an outside contractor in the mid-summer of (YEAR). 2. Observation in the dining room on 3/3/17 at approximately 9:43 AM revealed a power strip was plugged into a second power strip (daisy chained) and was supplying power to a television and a digital versatile disc player (DVD) player. 3. Observation in the Business / Human Resources office on 3/3/17 at approximately 9:50 AM revealed a power strip was plugged into a second power strip and was supplying power to a computer, a fax machine and a printer. Interview with the Maintenance Director at the time of the observation revealed he was not aware the two power strips were plugged in together. 4. Observation in the Administrator's office on 3/3/17 at approximately 10:48 AM revealed a power strip was plugged into an extension cord that was supplying power to two computer monitors and other components of the building's camera system. Per the 2012 edition of the National Fire Protection Association (NFPA) 99, Health Care Facilities Code, multiple outlet connection, two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart-mounted, provided means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.2.3.6 2011 NFPA 70: 400.8(1) 2000 NFPA 101: Life Safety Code

Plan of Correction: ApprovedMarch 30, 2017

K 920-The facility will ensure power strips in patient care vicinity are only used for components of movable patient-care related electrical equipment assembles that have been assembled by qualified personal. The facility will ensure in non-patient care rooms that power strips meet UL standards.
1. The power strip that was plugged into an extension cord supplying power to various components of the buildings computer and telephone system was removed. The power strip that was plugged into a second power strip supplying power to a television and disc player was removed and directly plugged into the wall.
The power strip plugged into a second power strip in the Business office/Human Resource Office was removed and directly plugged into the wall outlet.
The extension cord in the Administrator's office was removed. this work was completed as of 3-27-2017.
2. The Housekeeping Supervisor and Maintenance Director was re-in-serviced on K920 by the Administrator.
3.A 100% audit was completed by the Maintenance Director and Housekeeping Supervisor of the entire facility to ensure no inappropriate extension cords were being used and the correct UL power strips are used in the facility.
4. On going monitoring will be conducted weekly for 60 days and any findings of improper extension cords and power strips will be removed. Findings will be reported at the monthly Safety meeting for 2 months.
Responsible Party: Administrator

K307 NFPA 101:ELECTRICAL SYSTEMS - OTHER

REGULATION: Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 8, 2017
Corrected date: April 5, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during a Life Safety Code survey completed on 3/8/17, electrical equipment was not properly maintained. Issues included ground prongs (a metal prong that is designed to divert electrical current into the ground instead of back into a piece of equipment in case of a short circuit) were missing from the plugs on flexible cords of electrical appliances. This affected one (kitchen) of one kitchen, one (resident unit) of one resident unit, and one (service corridor) of one service corridor. The findings are: 1. Observations in the kitchen on 3/3/17 at approximately 9:11 AM and 9:25 AM revealed the plug for the flexible cord on the mobile plate warmer was missing its ground prong. Interview with the Maintenance Director and the Food Service Director on 3/3/17 at approximately 9:25 AM revealed they were not aware the plug for the mobile plate warmer was missing its ground prong. 2. Observation in the corridor, on the resident unit, near resident room [ROOM NUMBER] on 3/3/17 at approximately 10:07 AM revealed the plug for the flexible cord of a power strip attached to a Computer On Wheels (COW) was missing its ground prong. Interview with the Maintenance Director at the time of this observation revealed he was not aware that the plug for the flexible cord of the power strip attached to the COW was missing its ground prong. 3. Observation in the service corridor on 3/3/17 at approximately 1:32 PM revealed the plug for the flexible cord on a vacuum was missing its ground prong. 4. Observation in the corridor, on the resident unit, near resident room [ROOM NUMBER] on 3/6/17 at approximately 9:32 AM revealed the plug for the flexible cord on a carpet cleaning machine was missing its ground prong. 5. Observation in the corridor, on the resident unit, near resident room [ROOM NUMBER] on 3/6/17 at approximately 10:22 AM revealed the plug for the flexible cord on a wall mounted fan was missing its ground prong. Per the 2011 edition of National Fire Protection Association (NFPA) 70, National Electrical Code, where a flexible cord is provided with an equipment grounding conductor and equipped with an attachment plug, the flexible cord shall properly terminate in a grounding- type attachment plug with one fixed grounding contact. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.1, 6.1.1, 1.3, 1.3.2.1, 6.3.2, 6.3.2.1, 2011 NFPA 70: 110.3(A)(1), 110.3 (A)(8), 400.3, 400.24, 250.138(A) 2000 NFPA 101: Life Safety Code

Plan of Correction: ApprovedMarch 30, 2017

K911- The facility will ensure electrical equipment be properly maintained. The ground prongs will be on the plugs on the flexible cords of electrical appliances.
1. The plug for the flexible cord on the mobile plate warmer was replaced. The plug for the flexible cord of a power strip attached to the computer on wheels was replaced with a brand new ground prong. The plug for the flexible cord on the vacuum was replaced. The ground plug for the carpet cleaning machine was replaced. The flexible cord on the wall mounted fan had the ground plug replaced. All work was completed by the Maintenance Director as of 3-07-17.
2.A 100% audit was completed on 3-30-17 of all electrical cords to ensure ground plugs were intact and not missing on the equipment. If any ground plugs were missing they were replaced by the Maintenance Director.
3.The Maintenance Director and Housekeeping Supervisor were re-in serviced on K911 by the Administrator.
4.On going monitoring will be conducted weekly for 90 days and any findings of missing metal prongs will be repaired or replaced as needed. Findings will be brought to the monthly|
safety meeting and reviewed for 3 months.
Responsible Party: Administrator