Brookside Multicare Nursing Center
November 9, 2018 Certification Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 5, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident was provided with the necessary care and services to ensure that the resident's ability to communicate their needs to staff was available. This was evident for 1 (Resident #44) of 3 residents reviewed for communication. Specifically, Resident #44 spoke Greek as her primary language and had little understanding of the English language. The resident was not provided with a Greek translator is indicated in the resident's Comprehensive Care Plan (CCP). Additionally, there was no list available on the nursing unit with the names of staff who could speak foreign languages nor did the staff know how to access the language phone line to obtain a translator. The finding is: Resident #44 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 6, which indicated the resident was severely impaired for daily decision making. The MDS also documented that the resident can make herself understood and usually understand others. The Comprehensive Care Plan (CCP) developed for Communication dated 11/4/18 documented the resident's primary language was Greek but the resident is able to make simple needs known, there was Greek-speaking staff available, and that the resident can make her needs known to staff. The CCP documented interventions that included to utilize a Greek translator. An interview with the resident was conducted on 11/2/18 at 9:00 AM. The resident stated that she speaks Greek and sometimes it was hard for her to convey her message to the staff or for the staff to understand her. The resident stated that she had no language translator provided by the facility. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 11/7/18 at 11:15 AM. The RN stated that the resident speaks Fluent English. The RN also stated that the facility had a Greek translator available, but she could not provide the list of Greek translator available for the unit. An interview with the assigned 7:00 AM- 3:00 PM shift Certified Nursing Assistant (CNA) was conducted on 11/07/18 at 11:20 AM. The CNA stated that she only talks to the resident with simple sentences and questions that are answerable with yes or no. An interview was held with the Assistant Director of Nursing Services (ADNS) on 11/08/18 at 10:00 AM. The ADNS stated that the facility had Greek language translators, but the list was not provided on the unit. The ADNS stated that she would make sure that the language translator list would be available on the unit for easy access. 415.12(a)(2)

Plan of Correction: ApprovedDecember 17, 2018

I. Immediate Corrective Action
1. The RN, ADNS, and staff knew the names of the facility staff that are fluent in Greek and were able to express that to the surveyor. A copy of the language translator list and information on the language line was provided to the unit and posted for all staff to access.
II. Identification of Other Residents
1. All residents for whom English is a second language were reviewed for their ability to communicate in English by the RN Nurse Managers.
2. No residents were determined to have difficulty making their needs known.

III. Systemic changes
1. Additional copies of the list of staff translators and the translation telephone service were distributed to the units for posting.
2. The Administrator, Medical Director, and Director of Nursing reviewed the policy and procedure for Translation and/or Interpretation of Facility Services and found it to be compliant.
3. All staff will be in-serviced by the staff educator on this policy with an emphasis on the resources available to ensure the provision of language access services to individuals with limited English language proficiency.
IV. Quality Assurance
1. The DNS will develop an audit tool to assess compliance with the facility?s translation policy.
2. The Nurse Managers will complete audits on each unit weekly for one month then monthly thereafter. Any issues identified will have immediate corrective action taken by the unit manager and reported to the DNS.
3. Audits will be presented to the QAPI Committee monthly for evaluation and follow up as indicated.
V. Individual Responsible for Correction
1. The Director of Nursing is responsible for the completion of this correction by 1/05/2019.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(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: November 9, 2018
Corrected date: January 5, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident, which includes measurable objectives and timeframes to meet a resident's medical and nursing needs, that are identified in the comprehensive assessment. This was evident for 1 (Resident # 94) of 1 resident reviewed for respiratory care; for 1 (Resident #51) of 1 resident reviewed for hearing; for 1 (Resident #111) of 1 resident reviewed for [MEDICAL CONDITION]; for 1 (Resident #81) of 1 resident reviewed for [MEDICAL CONDITION]; and for 1 (Resident #180) of 1 resident reviewed for range of motion. Specifically, 1) Resident # 94 was not receiving Oxygen treatment according to the current physician's orders [REDACTED].#51, who refused to wear her hearing aids; 3) A CCP for TED stockings (compression stockings) use and a non-compliance CCP was not developed for Resident #81, who refused to wear TED (an anti-embolism compression ) stockings as ordered by the Physician; 4) a non-compliance care plan was not developed for Resident #111, who refused to wear a protective stockinet over the forearms for fragile [MEDICAL CONDITION]. 5) a non-compliance care plan was not developed for Resident #180, who refused to wear her Right Palm Protector. The findings include but are not limited to: 1) The facility policy on Oxygen Administration, effective 8/8/2017, states that staff must review the physician's orders [REDACTED]. The nasal cannula is a tube that is placed one-half inch into the resident's nose and held in place by an elastic band placed around the resident's head. After completing the oxygen setup or adjustment, the assessment data obtained before, during and after the procedure should be recorded in the resident's medical record. The staff must also document how the resident tolerated the procedure. Resident #94 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #94 had a Brief Interview for Mental Status (BIMS) Score of 12 indicating intact cognition. The MDS documented the resident was receiving oxygen therapy. A Physician Order, originally dated 5/10/2017, and renewed on 10/30/2018 documented to administer Oxygen at 2 liters/minute via Nasal Cannula Continuously every day. On 11/02/18 at 10:32 AM, Resident #94 was observed walking in the hallway with an oxygen tank secured onto her walker without the nasal cannula in place. On 11/05/18 at 11:52 AM, Resident #94 was observed waiting for her meal in the dining room without the nasal cannula in place. During an observation and interview on 11/06/18 at 10:27 AM, Resident #94 was observed reading a book in the day room without the nasal cannula in place. Resident #94 stated that she uses her oxygen as needed. She stated she would need it when she had shortness of breath and difficulty breathing. The Respiratory Comprehensive Care Plan (CCP), effective 4/28/2018 and last reviewed on 9/6/2018, documented Resident #94 was at risk for respiratory distress secondary to [MEDICAL CONDITIONS], and Cardiac Failure. The interventions included oxygen therapy as per the physician order, assess for respiratory distress or shortness of breath and maintain airway patency. A Medical Progress note dated 10/2/2018 documented that Resident #94 had no chest pain or shortness of breath. Resident #94's lungs were clear and without wheezes, rhonchi, or crackles. The physician's assessment documented that Resident #94 has [MEDICAL CONDITION] and Disease of Upper Respiratory Tract, unspecified. The physician documented to continue the treatment specified in the plan of care. During an interview on 11/07/18 at 9:20AM, Registered Nurse (RN) #1 stated that Resident #94 has a physician's orders [REDACTED]. Resident #94 also uses the [MEDICAL CONDITION] machine at night. RN #1 stated that Resident #94 rarely uses the oxygen therapy via nasal cannula during the day and is stable without the oxygen therapy. The physician's orders [REDACTED].#1. The RN stated that the order was old and the physician needed to update the order. During an interview on 11/08/18 at 12:38 PM, Nurse Practitioner (NP) #1 stated that Resident #94's medical order is continuous use of Oxygen therapy via nasal cannula. Resident #94 was initially treated with continuous oxygen therapy via the nasal cannula due to [MEDICAL CONDITION], Acute [MEDICAL CONDITION], and loss of breath during increased activity. NP #1 stated that Resident #94 has been stable without oxygen therapy and does not require continuous use. NP #1 stated that the order should have been updated to reflect as needed use of oxygen treatment. During an interview on 11/08/18 at 2:42 PM with the Medical Director, who was the resident's attending physician, the physician reported that Resident #94 is currently stable but has a history of [MEDICAL CONDITION] and Acute [MEDICAL CONDITION]. She currently uses the [MEDICAL CONDITION] machine at night to treat sleep apnea. The Medical Director reported that the current order for Oxygen therapy has not been updated to reflect Resident #94's current stability. The Medical Director stated that Resident #94 may use the oxygen therapy as needed use (PRN) and it should be available at all times in case she experiences respiratory distress. 2) Resident #51 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated the resident was independent for daily decision making. The MDS documented the resident had moderate difficulty of hearing and had no hearing aid during the review period. An interview with the assigned 7:00 AM- 3:00 PM shift Certified Nursing Assistant (CNA) was conducted on 11/08/18 at 1:40 PM. The CNA stated that the resident sometimes refuses to wear her hearing aids. An interview with the resident was conducted on 11/08/18 at 1:55 PM. The resident stated that her hearing aids are with the nurses, placed in a black case for safe-keeping. The resident also stated that she does not want to wear her hearing aids. An interview with the Registered Nurse (RN) Unit Charge Nurse/Manager was conducted on 11/08/18 at 2:07 PM. The RN stated that the resident regularly refuses to wear her hearing aids. The RN also stated that there should be a non-compliance CCP developed for the resident who was refusing to wear her bilateral hearing aids. 3) Resident #81 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Significant change MDS assessment dated [DATE] documented short and long term memory problems and moderately impaired cognitive skills for daily decision making. The MDS also documented Heart Failure, [MEDICAL CONDITION] (CAD), and [MEDICAL CONDITIONS]. The physician's orders [REDACTED]. The Cardiac CCP, dated 11/5/18, for potential for Shortness of breath (SOB), Chest Congestion, Chest Pain, and [MEDICAL CONDITION] secondary to [MEDICAL CONDITION], documented to observe for fluid build up. Review of the medical record revealed that there was no CCP developed for the use of the TED stockings as per physician's orders [REDACTED]. Review of the medical record revealed that there was no CCP developed for non-compliance for the use of TED stockings. The Treatment Administration Record (TAR) reviewed from 8/2018 through 11/2018 documented TED stockings on in AM. The TAR revealed the resident refused to wear the TED stockings for 54 of 67 days. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 11/06/18 at 10:00 AM. The RN stated that there was no CCP developed for the TED stockings. An interview with the Attending Physician was conducted on 11/06/18 at 9:23 AM. The Physician stated that he was not made aware by nursing staff that the resident regularly refused to wear the TED stockings from (MONTH) (YEAR) through (MONTH) (YEAR). The Physician stated he could have discontinued the order. An interview with the Director of Nursing Services (DNS) was conducted on 11/07/18 at 11:46 AM. The DNS stated that she could not locate any CCP for TED stockings. The DNS stated that the CCP for non-compliance should have been developed. 415.11(c)(1)

Plan of Correction: ApprovedDecember 17, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
1. Resident # 94 was assessed for respiratory status. The order for continuous O2 was changed to prn.
2. Resident # 51 was assessed for hearing deficits. None were found. The order for hearing aids was discontinued.
3. Resident # 111 was assessed for [MEDICAL CONDITION] on his forearms and none were found. This in no longer listed on the CNA instructions.
4. Resident # 81 was in the hospital at the time of survey. The use of TED stockings will be re-evaluated on her return.
5. Resident #180 was issued a palm guard by therapy not as a splint but to provide comfort to her contracted hand. Resident refuses to wear it at times so a Care Plan was created for refusal of care.

II. Identification of other residents
1. All residents have the potential to be affected by this issue
2. The DNS used the EMR to run a report on all residents currently receiving oxygen.
3. All resident O2 orders were reviewed. Those residents were assessed and evaluated for continued use of oxygen therapy and compliance with orders. No further issues were identified.
4. The RN nurse managers reviewed all eMARs, eTARS, and C.N.A. documentation for evidence of refusal of care. Any interventions that wee able to be discontinued were. The rest of the refusals were care planned for with education including the risks of refusing the care.
III. Systematic changes
1. The Administrator, Medical Director and Director of Nursing reviewed the policies and procedures for refusal of care and found it compliant
2. All licensed nursing staff will be in-serviced by the staff educator on this policy with emphasis on notification of the physician of refusal and care planning.
3. Any interventions that were able to be discontinued, were. The rest of the refusals were care planned for with education including the risks of refusing the care.

IV. Quality Assurance
1. The DNS developed an audit tool for observation of all residents on oxygen therapy.
2. The Nurse Managers will complete audits on each unit weekly x1 month then monthly thereafter. Any issues identified will have immediate corrective action taken by the unit manager and reported to the DNS.
3. The DNS developed an audit tool to monitor those residents who refuse care.
4. The Nurse Managers will complete audits on each unit weekly x1 month then monthly thereafter. Any issues identified will have immediate corrective action taken by the unit manager and reported to the DNS.
5. Audits will be presented to the QAPI Committee monthly for evaluation and follow up as indicated.
V. Individual Responsible for Correction
1. The Director of Nursing is responsible for the completion of this correction by 1/05/2019.

FF11 483.25:QUALITY OF CARE

REGULATION: § 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.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 5, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 (Resident #125) of 5 residents reviewed for unnecessary medication. Specifically, Resident #125 had a physician's orders [REDACTED]. Review of the Medication Administration Records (MAR) revealed that the licensed staff did not refer/notify the Physician for fingerstick results greater than 400 to evaluate for assessment and for any additional Insulin units to be administered. The MARs revealed that licensed staff provided additional Insulin units without a documented physician's orders [REDACTED]. The finding is: Resident #125 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was independent for daily decision making. The MDS also documented the resident received 7 days of Insulin injections during the review period. The Diabetes Comprehensive Care Plan (CCP) dated 9/14/18 documented to administer Insulin as ordered, fingerstick as ordered, and blood sugars to be monitored with Insulin adjusted accordingly. The physician's orders [REDACTED].= 5 Units and 301-400 = 10 Units and to monitor blood sugar for Type I DM. Review of the MAR for (MONTH) (YEAR) revealed the following: - on 8/5/18, the resident was administered 10 Units with a fingerstick result of 420. The medical record did not have documented evidence that the licensed staff notified the Physician for any additional Insulin units to be administered. Review of the MAR for (MONTH) (YEAR) revealed the following: - on 10/1/18, the resident was administered 5 Units with a fingerstick result of 303. - on 10/9/18, the resident was administered 12 Units with a fingerstick result of 475. The medical record did not have documented evidence that the 5 Units administered for the 303 Fingerstick result was an error, or that the physician was notified that 5 units, rather than 10 units, was administered. There was no documented evidence that the physician was notified and ordered 12 Insulin units for coverage of the 475 fingerstick result on 10/09/18. Review of the MAR for (MONTH) (YEAR) revealed the following: - on 11/1/18, the resident was administered 10 Units with fingerstick result of 447. - on 11/2/18, the resident was administered 10 Units with fingerstick result of 488. - on 11/6/18, the resident was administered 10 Units with fingerstick result of 472. - on 11/7/18, the resident was administered 10 Units with fingerstick result of 473. - on 11/8/18, the resident was administered 10 Units with fingerstick result of 454. The medical record did not have documented evidence that the licensed staff notified the Physician for any additional Insulin units to be administered. The three Licensed Practical Nurses (LPNs), who were responsible for the above mentioned dates, did not return the phone calls for interview. An interview with the LPN 3:00 PM- 11:00 PM shift was conducted on 11/08/18 at 1:28 PM. The LPN stated that the nurse is expected to notify the Physician if the fingerstick is greater than 400 for additional Humalog Insulin units. An interview with the Assistant Director of Nursing Services (ADNS) was conducted on 11/9/18 at 11:20 AM. The ADNS stated that she could not locate physician's orders [REDACTED]. The ADNS also stated that fingerstick result above 400 should have been reported to the Attending Physician for further assessment and additional Insulin Unit coverage. The ADNS could not locate any Nurse's Progress Notes documenting that the licensed staff had notified the Physician of fingersticks above 400. An interview with the Attending Physician was conducted on 11/9/18 at 11:50 AM. The Physician stated that the licensed staff did not made him aware that the resident's fingersticks were above 400. The Physician also stated that he expected the licensed staff to notify him if the fingerstick result was above 400 for additional Insulin unit injection. 415.12

Plan of Correction: ApprovedDecember 17, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
1. The Attending Physician was immediately notified of the sliding scale insulin order with parameters not including notification of MD for results over 400.
2. The order was changed by the physician to include parameters for MD notification.
3. The LPN that received the original order without the total parameters, received educational counseling from the DNS.
4. The RN that notified the MD of the finger stick results of over 400 but did not write an order for [REDACTED].
II. Identification of Other Residents
1. The DNS ran a report from the EMR of all residents receiving sliding scale insulin.
2. The RN Nurse Managers reviewed all orders for sliding scale insulin. All were written correctly.

III. Systemic Changes
1. The DNS and ADNS met with the Attending Physician to discuss the use of sliding scale insulin and basal bolus insulin. The Attending Physician agreed to review his sliding scale orders and switch to basal bolus whenever possible.
2. The Administrator, Medical Director, and Director of Nursing reviewed the facility policy for Diabetic Management, and it was found to be compliant.
3. All nurses will be in-serviced by the nurse educator on this policy with an emphasis on common symptoms of diabetes in need of medical interventions, nursing assessment and care. In addition, the key points of MD notification and nursing documentation will be included.
IV. Quality Assurance
1. The DNS will develop and audit tool to monitor compliance with sliding scale insulin parameters and overall diabetic management.
2. The RN Nurse Managers will complete audits on each unit weekly for one month then monthly thereafter. Any issues identified will have immediate corrective action taken by the unit manager and reported to the DNS.
3. Audits will be presented to the QAPI committee monthly for evaluation and follow up as indicated.
V. Individual Responsible for Completion of Correction
1. The Director of Nursing is responsible for the completion of this correction by 1/05/2019.

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: Pattern
Severity: Potential to cause minimal harm
Citation date: November 9, 2018
Corrected date: January 5, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident and staff interviews during the recertification survey, the facility did not ensure that medical records on each resident were maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was evident for 2 (Residents #44 and #103) of 2 residents reviewed for communication. This was also evident for 1 (Resident #125) of 5 residents reviewed for unnecessary medication and 1 (Resident #81) of 1 resident reviewed for [MEDICAL CONDITION]. Specifically, Residents #44 and #103 had documented primary language as English instead of Greek and German, respectively. Resident #81 had a physician's orders [REDACTED]. Resident # 125 had Humalog KwikPen Insulin injection that documented sliding scale dose administered the same as the blood fingerstick values reported. The findings include but not limited to: 1) Resident #44 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 6, which indicated the resident was severely impaired for daily decision making. The MDS also documented that the resident can make herself understood and usually understand others. Review of the electronic medical record (eMR) revealed that in the demographic section, the resident's primary language listed that the resident was fluent in English. The Social Work (SW) Progress Note dated 10/19/18 documented the resident's primary language is Greek and speaks and understands some English. The Comprehensive Care Plan (CCP) developed for Communication dated 11/4/18 documented the resident's primary language was Greek, but the resident was able to make simple needs known. An interview with the resident was conducted on 11/2/18 at 9:00 AM. The resident stated that she speaks Greek and sometimes it was hard for her to convey her message with the staff or the staff to understand her. An interview with the assigned 7:00 AM- 3:00 PM shift Certified Nursing Assistant (CNA) was conducted on 11/07/18 at 11:20 AM. The CNA stated that she only talks to the resident with simple sentences and questions that are answerable with yes or no. An interview with the SW was conducted on 11/07/18 at 11:40 AM. The SW stated that the resident can understand a little English and that the resident that could answer either yes or no questions. An interview with the Admitting Personnel, who completed the resident's Demographic information, was conducted on 11/08/18 at 10:05 AM. The Admitting Personnel stated that the primary language is Greek. He stated that the Admitting department should have revised or altered the demographic information for her primary language. 2) Resident #81 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Significant MDS assessment dated [DATE] documented short and long term memory problem and moderately impaired in cognitive skills for daily decision making. The MDS also documented Heart Failure, [MEDICAL CONDITION] (CAD), [MEDICAL CONDITIONS], and [MEDICAL CONDITION] as active diagnoses. The physician's orders [REDACTED]. An interview with the Attending Physician was conducted on 11/6/18 at 9:21 AM. The Physician stated that the [DIAGNOSES REDACTED]. The Physician stated that it was an error, that someone from the staff had chosen the wrong [DIAGNOSES REDACTED]. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 11/06/18 at 11:00 AM. The RN stated that she must have chosen the wrong [DIAGNOSES REDACTED]. 3) Resident #125 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's BIMS score of 13, which indicated the resident was independent for daily decision making. The MDS also documented the resident received 7 days of Insulin injections during the review period. The physician's orders [REDACTED].= 5 Units and 301-400 = 10 Units. The Medication Administration Record [REDACTED] - on 9/19/18, the Humalog KwikPen dose administered was 400 Units with the fingerstick of 400 - on 9/22/18, the Humalog KwikPen dose administered was 372 Units with the fingerstick of 372 - on 9/22/18, the Humalog KwikPen dose administered was 273 Units with the fingerstick of 273. The Medication Administration Record [REDACTED] - on 10/27/18, the Humalog KwikPen dose administered was 13 units with the fingerstick of 13. An interview with the Assistant Director of Nursing Services (ADNS) was conducted on 11/9/18 at 11:00 AM. The ADNS stated that the Humalog KwikPen doses documented were not correct since the values were for the fingersticks obtained. 415.22(a)(1-4)

Plan of Correction: ApprovedDecember 17, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
1. Resident #103?s primary language is English. She was born in Germany but never spoke the language. In this case the demographic of English as her primary language is correct.
2. Resident #44 demographic information was changed to Greek as her primary language.
3. The LPN who documented resident 125?s finger stick results instead of the sliding scale dose administered was given an educational counseling from the DNS.
4. The nurse that wrote the order for TED stockings for Age-Related [MEDICAL CONDITION] for resident 81 received an educational counseling from the DNS. The resident is currently in the hospital; continued use of TED stockings will be evaluated on return.
II. Identification of Other Residents
1. All current resident demographics were reviewed by the Nurse Managers. No other issues were identified.
2. All sliding scale documentation was reviewed by the Nurse Managers. The error of documenting the finger stick results in the box for dosage was isolated to the specific nurse documenting. No other resident documentation was affected.
3. All orders were reviewed by the QA team for correct diagnosis, no other discrepancies were found.
III. Systematic Changes
1. The Administrator, Medical Director, and Director of Nursing reviewed the policies and procedures on Charting and Documentation and found them to be compliant.
2. All clinical staff will be in-serviced on these policies with an emphasis on documentation being objective, complete, and accurate.
IV Quality Assurance
1. The DNS will formulate an audit tool to address resident demographics.
2. The Admissions Department will complete audits every week for one month and then monthly after.
3. The DNS will create an audit tool to monitor correct [DIAGNOSES REDACTED].
4. The audit tool developed for F684 will include addressing proper documentation of insulin administration on a sliding scale. As previously stated, this audit will be done by the nurse managers once weekly for one month and then monthly thereafter.
5. Audits will be presented to the QAPI Committee on a monthly basis for review, evaluation, and follow up.
V. Individual Responsible for the Completion of the correction.
1. The DNS will be responsible for the completion of this correction by 1/05/2019.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 1, 2019

Citation Details

2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, doors were not provided with a means suitable for keeping the door closed. This was noted on two of three units and the basement in the newer building. The findings are: On 11/5/18 & 11/6/18 between 9:30am- 2:30pm during the recertification survey, the following was noted in the newer building: 1) Inactive leaves of corridor doors were provided with manual flush bolts. As a result of this configuration, the flush bolts would have to be manually latched into the frame in order for the door to be positive latching. Examples include but are not limited to: a) Two storage rooms across from resident rooms S4 & S5 on the Spring unit b) Two supply closets across from resident rooms E36 & E37 on the Emerald unit c)(NAME)shop in the basement In an interview on 11/5/18 at approximately 9:58am, the Director of Maintenance stated that he can find automatic flush bolts. 2) The power sliding doors to the rehabilitation gym were observed to be held in the open position on 11/5/18 at approximately 10:05am. In an interview on 11/5/18 at approximately 10:05am, the Director of Maintenance stated that the doors are equipped with wave to open but was switched in bypass. He further stated that he will eliminate the switches and put in a key operated bypass so it cannot be disabled. 2012 NFPA 101: 19.3.6.3.5 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 3, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Plan of Correction:
1. All objects have been removed from the identified closets which will remain inactive until automatic flush bolts are installed.
2. All Flush bolts will be installed before or by 1/1/19. All parts to rectify this issue has been ordered on [DATE]
2. The switch for the automatic doors in teh rehab gym area has been positioned to keep the doors from remaining in the open position. We have contacted the manufacturer to remove the switch so that it doesn?t accidently switch the door into the open position.
3. The PT/OT gym staff were in-serviced on the automatic door, and the importance why it cannot be kept in an open position.
II. Identification of Others:
1. All resident can potentially be harmed. All closets and storage areas with double doors in the facility were checked for compliance with this citation, all other locations were in compliance.
2. All automatic doors have been checked to ensure they do not stay stuck in an open position in the entirety of the building. All other locations were in compliance.
III. Systemic Changes:
1. Maintenance director has developed an audit to ensure that all double door closets and storage areas have automatic flush bolts.
2. Maintenance director developed an audit to check the automatic doors so that they are not inadvertently left in the open position.
3. The Maintenance department will be in serviced by the maintenance director regarding this citation specifically on inspecting double doors of storage areas for automatic flush bolts and inspecting doors that have automatic doors to ensure that they do not remained fixed in the ?open? positions or have the capability to do so.
IV. Quality Assurance:
1. Maintenance director or designee will conduct monthly audits to check for compliance with this citation. The audits will then be present to the Quality assurance committee.
2. Maintenance department will continue these audits on a monthly basis and incorporate this into their monthly rounds. Any issues will be immediately reported to the Administrator

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 9, 2018
Corrected date: January 1, 2019

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not comply with Federal, State and local laws. The contact information in the Health Provider Network (HPN) Communications Directory was not current and updated timely. The findings are: On 11/6/18 between 12:00pm- 3:00pm during the recertification survey, review of the facility's Communications Directory on the HPN revealed that the contact information for the roles under the twenty four hour, seven days a week facility contact, Director of Nursing, Emergency Medical Supplies Receiving Office and the Office of the Administrator was not current and updated timely. This was contrary to the requirements of 10NYCRR 400.10 in that current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, are completed on a monthly basis. The last time these roles were updated in the HPN were as follows: 1) (MONTH) 11, 2013 for the twenty four hour, seven days a week facility contact and Emergency Medical Supplies Receiving Office and they indicated the contact information of a former Administrator 2) (MONTH) 30, 2014 for the Director of Nursing and the Office of the Administrator and it indicated the contact information of a former Director of Nursing and Administrator In an interview on 11/6/18 at approximately 3:15pm, the Administrator stated that they will update the HPN directory. 10NYCRR 400.10

Plan of Correction: ApprovedDecember 3, 2018

I. Immediate Plan of Correction:
1. Administrator went into Health Commerce System (HCS) program and updated Facility contact information for emergency communications such as the Director of nursing, Office of the administrator, and Emergency medical supplies receiving office information was updated
II. Identification of Others:
1. All Residents can potentially be affected. All pertinent communication and role descriptions for the Brookside Multicare Nursing Center account were updated in HCS.
III. Systemic Changes:
1. Administrator developed a monthly audit to check for and to update changes as needed.
IV. Quality Assurance:
1. Administrator or Designee will conduct monthly audits of the HCS system for 3 months and then quarterly thereafter. Any concerns will be immediately rectified by Administrator.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 1, 2019

Citation Details

2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6.1* Applicability. 2012 NFPA 99: 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99: 3-5.2.2.1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3-5.2.2.2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA 101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, Gas and Vacuum Systems (d) * Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 footcandles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3-5.2.2.3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3-5.2.2.3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3-5.2.2.3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas - task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c) * Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a. *The outside design temperature is higher than +20F (-6.7C), or b. The outside design temperature is lower than +20F (-6.7C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3-4.1.1.1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3-5.2.2.2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. 1999 NFPA 99: 3-5.2.2.4 Wiring Requirements. (a) * Separation from Other Circuits. The emergency system shall be kept entirely independent of all other wiring and equipment. (b) * Receptacles. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. Based on observation, document review (i.e., posted electrical panel directories), and staff interview, the facility was not provided with an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System in that Emergency System- Life Safety Branch wiring was not separated from Critical System wiring. This was noted for emergency power panels serving the pediatric vent unit in the newer building. The findings are: On 11/5/18 between 11:00am- 3:00pm during the recertification survey, Review of the POS [REDACTED]. Examples include but are not limited to: 1) The emergency power panel EM-CB1 in the Petals unit was observed to be feeding emergency power panel MPP1-SW-7 located in the soiled utility room on the Spring unit. Panel MPP1-SW-7 contained loads from both the Emergency System (#21 hall lights, #23 exit lights) and the Critical System (#7 P1 outlets, #25 outlets nurse station). 2) Emergency power panel EPP1-MW-5 located in the alarm panel room in the basement contained loads from both the Emergency System (#9 elevator hall lights, #2 exit signs by rm12, E17, Rec rm lts, corridor lts E11-E13) and the Critical System (#10 recept at recreational rm door, quad pack P15, #14 nurses east CLAA station, #24 spring nurses station call box). In an interview on 11/6/18 at approximately 10:00am, the Director of Maintenance stated that he will have the circuits moved. 2012 NFPA 99: 6.1, 6.1.1 1999 NFPA 99 Standard for Health Care Facilities: 16-3.3.2, 3-5 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 3, 2018

I. Immediate Plan of Correction:
1. Bright Bay Electrical Company was called to come to the facility to inspect the current electrical setup and to separate critical care and emergency care system for the Petals unit and for the panel in the basement.
II. Identification of Others:
1. All residents can potentially be affected. All panels were inspected by the electricians to see if emergency power and critical care power were separate.
III. Systemic Changes:
1. Maintenance director developed an audit to inspect electrical panels throughout the facility to check for mixed power loads and to check when changes are made to the electrical system.
2. Maintenance director in-serviced his staff on necessity and reasoning why emergency power and critical care power must be separated.
IV. Quality Assurance:
1. Maintenance director will conduct audits of the electrical panels monthly for 3 months and quarterly thereafter. Audits will be presented to the Quality Assurance Committee. Any concerns will be reported to the 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: November 9, 2018
Corrected date: December 17, 2018

Citation Details

2012 NFPA 99 6.3.2.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code. 2011 NFPA 70 517.19 Critical Care Areas. (A) Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. The branch circuit serving patient bed locations shall not be part of a multi-wire branch circuit. Exception No. 1: Branch circuits serving only special purpose receptacles or equipment in critical care areas shall be permitted to be served by other panelboards. Exception No. 2: Critical care locations served from two separate transfer switches on the emergency system shall not be required to have circuits from the normal system. 110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. Informational Note: Accepted industry practices are described in ANSI/NECA 1-2006, Standard Practices for Good Workmanship in Electrical Contracting, and other ANSI-approved installation standards. (A) Unused Openings. Unused openings, other than those intended for the operation of equipment, those intended for mounting purposes, or those permitted as part of the design for listed equipment, shall be closed to afford protection substantially equivalent to the wall of the equipment. Where metallic plugs or plates are used with nonmetallic enclosures, they shall be recessed at least 6 mm (1?4 in.) from the outer surface of the enclosure. (B) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating. The requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not install and maintain all electrical receptacles in accordance with 2011 NFPA 70. This occurred in one out of two buildings. The findings include: During the Life Safety Code (LSC) portion of the recertification survey on 11/5/2018 between 9:30 am and 2:00pm the following were noted: 1) The emergency electrical receptacles in the Petal Unit, resident rooms P3, P4, P19 and P20, were noted to be lacking required labels indicating the panelboard and circuit number supplying them. 2) An emergency receptacle in the Emerald Unit corridor located outside of Room E26 showed signs of damage. Specifically, there were scorch marks and areas of melted plastic on the receptacle cover. Upon interview concurrent with these findings, the Director of Maintenance stated that the emergency receptacles would be labelled and the damaged receptacle would be replaced. 10 NYCRR 711.2 (a) 2012 NFPA 99 2011 NFPA 70

Plan of Correction: ApprovedDecember 3, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Plan of Correction:
1. Emergency electrical receptacles in Petals unit in rooms 3, 4, 19 and 20 were relabeled with permanent ink on (MONTH) 6th, (YEAR).
2. The emergency receptacle outside of Emerald unit room [ROOM NUMBER] was replaced and relabeled with permanent ink on (MONTH) 6th, (YEAR).

II. Identification of Others:
1. All residents have the potential for harm. All emergency receptacles in the facility have been checked for proper labeling and inspected for signs of damage on (MONTH) 5, (YEAR).
III. Systemic Changes:
1. Maintenance director developed an audit to check emergency electrical receptacles for proper labeling and to check for any signs of damage.
2. Maintenance director in-serviced his staff on importance of inspecting all emergency receptacles for signs damage and proper labeling.
IV. Quality Assurance:
1. Maintenance director or designee will conduct monthly audits to check emergency electrical receptacles for proper labeling and for any signs of damage monthly for 3 months and then quarterly thereafter. All findings will be presented to the Quality Assurance Committee. Any concerns will be reported to the Administrator.

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: December 31, 2018

Citation Details

Physical Plant Violation - State Only NYCRR 415.29 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel and the public. (j) Housekeeping. (6) Waste: (i) solid wastes, including garbage, rubbish and other refuse, biological wastes and infectious materials, shall be collected, stored and disposed of in a manner that will prevent the transmission of disease and not create a nuisance or fire hazard, nor provide a breeding place for insects or rodents; and (ii) facilities shall manage regulated medical waste in accordance with the provisions of Part 70 of this Title. Subpart 70-2 of Part 70 Management of Regulated Medical Waste Section 70-2.2 - Containment and storage (3) Regulated medical waste shall not be stored for a period exceeding thirty (30) days, except that a site generating under fifty (50) pounds of regulated medical waste per month and not accepting regulated medical waste for treatment from other facilities, may store waste for a period not exceeding sixty (60) days. This requirement is not met as evidenced by: Based on record review and staff interview during the recertification survey the facility did not ensure that regulated medical waste was not stored onsite for a period not exceeding 30 days. Additionally, it could not be determined if the facility generated under fifty pounds of regulated medical waste to allow storage onsite for a period not exceeding 60days. The findings are: During a record review of the facility ' s regulated medical waste pick-up logs on 11/06/18 at approximately 12:15pm, the following was noted: 1. It was noted that the pick-up intervals of regulated medical waste exceeded 30 days. Examples include the following pick date intervals: - 1/22/18 - 3/22/18 - 5/28/18 - 7/23/18 - 9/24/18 2. The medical waste manifest did not indicate the volume by weight of medical waste pickup. The pickup dates further exceeded 60 days for less than 50 pounds of waste allowed to be stored onsite. In an interview on the same day at approximately 12:55pm, the Housekeeping Director stated that medical waste pick-up company would be contacted to pick up regulated medical waste on a timely basis as required.

Plan of Correction: ApprovedDecember 3, 2018

I. Immediate Plan of Correction:
1. Approved Storage and Waste Company (waste removal company) was contacted on (MONTH) 6th, (YEAR) with a request to change medical waste pickup to a monthly basis as required. The company replied that they would change the frequency to monthly pick up.
II. Identification of Others:
1. No residents have been affected at this time. All medical waste storage bins have been inspected and there are no concerns at this time. All areas housing medical waste storage were checked and were found to be compliant
III. Systemic Changes:
1. Housekeeping Director along with Administrator reviewed the policy on medical Waste storage and found it to be satisfactory. Housekeeping director developed an audit to monitor medical waste pickup dates on a monthly basis.
2. Weekly visual rounds will be also completed to check for excess build up of medical waste in the storage area by the director of housekeeping.
3. Housekeeping department employees who handle/transport medical waste will be in serviced on the medical waste storage policy.
IV. Quality Assurance:
1. Housekeeping director will prepare monthly audits for this citation and report the findings to the Quality Assurance Committee. Any discrepancies with timely pickup will be reported to Administrator.
2. Facility will continue to keep audits in place as regular Housekeeping rounds on a monthly basis.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2018
Corrected date: January 1, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 EXISTING NFPA 101 19.3.5.1 Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13 8.6.3.3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. 8.6.3.4.1 Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center. 8.6.3.4.2 Sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied: (1) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements. (2) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation. (3) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high. (4) The tops of baffles shall extend between 2 in. and 3 in. (51 mm and 76 mm) above the deflectors of upright sprinklers. (5) The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers. Based on observation and staff interview, the facility was not protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems in that: 1) some areas within the facility lacked sprinkler coverage; 2) sprinkler heads were observed to be installed within 4 inches from a wall; and 3) sprinkler heads were observed to be installed within six feet of each other. This was noted in two of two buildings. The findings are: On 11/5/18 between 9am to 2pm during the recertification survey, the following was observed: 1) Some areas within the facility lacked sprinkler coverage. Examples are: a. Closet within the social worker's office on the Emerald unit of the newer building b. Closet within resident room [ROOM NUMBER] on the Azalea unit in the older building 2) Sprinkler heads were installed within 4 inches from a wall in the newer building. Examples were: a. Within the basement storage room, a soffit was observed along a wall on the corridor side of the room. Two of the four provided pendent sprinkler heads were installed within 4 inches from the soffit. b. One pendent sprinkler head was installed approximately 1 inch from the wall in the clinical records storage room. In an interview on 11/6/2018 at 2pm, the Director of Maintenance said the sprinklers would be moved. 3) Sprinkler heads were installed within six feet of each other. Examples are: a. The bathroom on the Diamond unit near a resident room in the older building b. The storage room (toner closet) on the Broadway unit in the older building c. The Pedal unit near the nursing station in the newly renovated Multicare. In an interview on 11/6/2018 at approximately 2pm, the Director of Maintenance stated that a sprinkler head would be removed. Code references 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.6.3.3, 8.6.3.4.1, 8.6.3.4.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedDecember 3, 2018

I. Immediate Plan of Correction:
1. Parts/Supplies to add sprinkler lines in the social workers closet as well Azalea room closet have been ordered on (MONTH) 26th, (YEAR).
2. Additional parts will assist in placing us in compliance with the appropriate distance between sprinklers. This will be completed by 1/1/19
II. Identification of Others:
1. All residents have the potential to be affected. All areas of the building were checked for compliance with citation K351. No other issues were identified. Audit was completed on (MONTH) 6th, (YEAR).
III. Systemic Changes:
1. Maintenance director developed an audit to make sure the distance between sprinklers heads throughout the building are compliant for coverage and to inspect if adequate sprinkler heads were present in all areas in the facility.
2. Maintenance director in-serviced the maintenance department employees on the importance and need for a completely sprinklered building and to check for adequate spacing of the sprinkler heads.
IV. Quality Assurance:
1. Maintenance Director or designee will conduct monthly audits for 3 months and then quarterly thereafter. Findings from the audits will be reported to the Quality Assurance Committee. Any issues or concerns will be reported to the Administrator.

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: November 9, 2018
Corrected date: December 3, 2018

Citation Details

2011 NFPA 25: INSPECTION, TESTING, AND MAINTENANCE OF WATER-BASED FIRE PROTECTION SYSTEMS. 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion. 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. 5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. 5.2.3.1 Hangers and seismic braces shall not be damaged or loose. 5.2.3.2 Hangers and seismic braces that are damaged or loose shall be replaced or refastened. 5.2.3.3* Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection. 5.2.3.4 Hangers and seismic bracing installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility could did not ensure that the sprinkler piping was free of external loads and did not ensure that the pipe and fittings were maintained in good condition. This was noted in the basement. The findings are: During the Life Safety Code survey of the basement, conducted on 11/06/18 between 10:00am and 11:30am the following was noted: 1. A domestic water line was noted suspended by and supported by the sprinkler piping in the maintenance storage room. 2. Three sprinkler heads were noted sticking out from below the ceiling level and exposing the sprinkler piping in the kitchen dishwasher area. The sprinkler heads were not installed flush to the ceiling at the piping bases. In an interview on the same day at approximately 10:30am, a maintenance employee stated that the sprinkler piping seismic braces in the kitchen would be checked and adjusted as needed. In a separate interview on the same day at approximately 10:45am the maintenance employee stated that the water pipe would be removed from the sprinkler piping in the maintenance storage room. 2012 NFPA 101: 9.7.5, 9.7.7, 9.7.8 2011 NFPA 25: 5.2.2.1, 5.2.3 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedDecember 3, 2018

I. Immediate Plan of Correction
1. The bracing that attached the load to the sprinkler pipe/line from the domestic water line in the maintenance storage room was removed on (MONTH) 6th, (YEAR).
2. The three sprinkler heads in kitchen dish room have been raised and were made flush to be in compliance with this citation.
II. Identification of Others:
1. All residents have the potential for Harm. All other areas of the building were checked for compliance with K353 citation. No other issues were identified. Audit was completed on (MONTH) 6th, (YEAR).
III. Systemic Changes:
1. Maintenance director developed an audit to check all sprinkler heads and sprinkler lines for compliance throughout the building with this citation.
2. Maintenance department will be in-serviced by maintenance director on the audit process and regarding this citation. The in-service will include and discuss, how to keep sprinkler lines free of loads and how sprinkler heads should be mounted throughout the facility.
IV. Quality Assurance:
1. Maintenance Director or designee will conduct monthly audits. Findings will be reported to the Quality Assurance Committee.
2. Monthly audits will be included as regular maintenance rounds. Any concerns will be reported to the Administrator.