Saratoga Center for Rehab and Skilled Nursing Care
April 25, 2018 Certification/complaint Survey

Standard Health Citations

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

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure the comprehensive care plan (CCP) was developed and updated to include implemented interventions and tasks which were an accurate representation of actual experiences for one (1) (Resident #143) of thirty six (36) residents reviewed. Specifically for Resident #143, the facility did not ensure the resident's High Risk for Falls Careplan was updated following a fall on 4/12/18 resulting in a rib fracture and pneumothorax (collapsed lung). Also, the facility did not revise the Oxygen Therapy Careplan to reflect a physician order [REDACTED]. Resident #143: This resident was admitted on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition, was able to understand others and was able to be understood. The CCP for Oxygen Therapy Care Plan dated 11//05/17, documented the resident has oxygen therapy related to ineffective air exchange secondary to [MEDICAL CONDITION] and history of pneumonia. The resident receives oxygen via nasal cannula at 3 liters per MD (medical doctor) order. An intervention initiated on 11/05/17 documented oxygen settings at 3 liters continuously. physician's orders [REDACTED]. During an interview on 4/23/18 at 9:34 am, LPN (licensed practical nurse) NM (nurse manager) #4 stated the care plan should have been updated to indicate the physician's orders [REDACTED]. The careplans should be revised with a change and every 3 months. She stated the care plan revision should have been included with the 12/2017 oxygen order change to 2 liters. Since she is an LPN, the supervisors sign off on the careplans. The evening supervisor received the x-ray report of the resident's fractured rib and it was this supervisor's responsibility to update and revise the careplan. It should have been done but was not. 10NYCRR415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJune 1, 2018

I. Immediate Corrective Actions
Residents #143:
1. The Director of Nursing in conjunction with the interdisciplinary team reviewed and revised, as indicated, the Resident?s care plan to ensure appropriate care and services were reflected.
2. Nurse Manager #4 was counseled by the Director of Nursing for failure to ensure that the Resident?s care plan was properly reviewed and revised to ensure current and accurate care and treatment, specifically with regard to the Resident?s high risk for falls and use of oxygen. A copy of the counseling was filed for validation.
3. The evening Nurse Supervisor was counseled by the Director of Nursing for failure to ensure that the Resident?s care plan was properly imitated to ensure current and accurate care and treatment, specifically with regard to the Resident?s fall. A copy of the counseling was filed for validation.
4. Currently the Resident resides in the facility with all needs met.

II. Identification of Other Residents
1. The Director of Nursing in conjunction with the Nursing Supervisors and Nurse Managers identified and reviewed the care plans of all residents with falls in the last 30 days and all residents with oxygen orders to ensure the residents? care plans were current and accurate.
2. Any negative findings will be immediately corrected by the Director of Nursing/designee.
3. The Director of Nursing maintained a list of any corrected records.

III. Systemic Changes
1. The Director of Nursing reviewed the policy for care plan development and evaluation.
2. All Licensed Nursing staff will be in-serviced on this policy to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure a care plan is initiated, and/or reviewed and revised, when there is a change in the Resident?s care and treatment; and the communication regarding care planning and review.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Nursing developed an audit tool to track compliance with the requirements for a current and accurate plan of care.
2. Audits will be done on Residents who sustained a fracture from a fall to ensure current plan of care was initiated/updated, weekly x4, bi-weekly x2, monthly x4.
3. Audits will be done on residents with oxygen orders to ensure current plan of care was initiated and updated, weekly x4, bi-weekly x2, monthly x4.
4. Audits with negative findings will have immediate correction by the Director of Nursing/designee.
5. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: DON

FF11 483.20(e)(1)(2):COORDINATION OF PASARR AND ASSESSMENTS

REGULATION: §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not refer residents with newly evident or possible serious mental illness for PASSAR level I to determine if a PASSAR level II review was needed for one (Resident #89) of four residents reviewed for PASRR (Preadmission Screening and Resident Review). Specifically, the facility did not ensure that Resident #89 was referred for the completion of a new Screen when the resident experienced a newly evident possible serious mental illness and a new [DIAGNOSES REDACTED]. Resident #89: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 2/15/18, assessed the resident understands, was understood and had severely impaired cognitive ability. It documented the resident had anxiety disorder, depression, and [MEDICAL CONDITION]. The Screen form dated 7/6/15, documented under Level 1 Review for possible Mental Illness-Question #23: Does this person have a serious mental illness? -NO. The initial Social History and Profile on 7/7/15, documented the resident had mood disorder with treatment of [REDACTED]. The resident was laterally transferred from another nursing home. The Admission Minimum Data Set (MDS) on 7/13/15 documented: Section A - no serious mental illness; Section I - depression, no other psychiatric or mood disorders identified. A Psychiatric Progress Note on 3/4/16 documented the resident had some confusion and forgetfulness. No signs/symptoms of mania/[MEDICAL CONDITION] and no evidence of delusions/paranoia. [DIAGNOSES REDACTED]. Recommend to discontinue [MEDICATION NAME]. A Psychiatric Progress Note on 4/9/16 documented per nursing staff the resident was experiencing hallucinations of people and animals walking in room. The resident was distressed by this and asked staff to change her room to get away from them. [DIAGNOSES REDACTED]. The recommendation was to restart [MEDICATION NAME] (anti-psychotic medication). During interview on 4/20/18 at 2:30 pm, the Psychiatric Nurse Practitioner stated a mood disorder is not a [MEDICAL CONDITION]. During interview on 4/24/18 at 2:40 pm, the Director of Social Work (DSW) stated she could find no information of a prior [DIAGNOSES REDACTED]. She stated [MEDICAL CONDITION] does show up in notes here. We did another screen on 12/14/15 due to a lateral transfer request by the family, but none for the new [DIAGNOSES REDACTED]. She stated there were no records of [MEDICAL CONDITION] from her previous placement. 10NYCRR415.11(c)

Plan of Correction: ApprovedJune 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
Resident #89:
1. The Director of Social Services immediately completed a new Level I PASSAR screen and the evaluation did not indicate the need for a Level II evaluation.
2. Upon receipt of this determination, the Director of Social Services reviewed the resident?s care plan to ensure appropriate care and services were reflected. The plan of care was found to be appropriate.
3. Currently the resident?s psychosocial needs are being met.

II. Identification of Other Residents
1. The Director of Social Services reviewed the medical records of all Residents with a newly evident or possibly serious mental illness or a significant change in the last 30 days to ensure that the PASSR Screening process has been completed appropriately upon admission and when indicated by a new [DIAGNOSES REDACTED].
2. Any negative findings will have immediate corrective action by the Director of Social Service.
3. The Director of Social Service will maintain a list of any corrected records.

III. Systemic Changes
1. The Director of Social Service reviewed/revised the policy for PASSAR screening and documentation.
2. A QAPI Committee was formed to develop a process to ensure the facility refers all residents with newly evident or possible serious mental illness for PASSAR Level I to determine if a PASSAR Level II is needed.
3. All Admissions staff, Social Services staff, and Licensed Nursing staff will be in-serviced on this policy/process to ensure understanding and compliance.
4. A copy of the lesson plan and attendance will be filed for validation.

IV. QA Monitoring
1. The Director of Social Services developed an audit tool to track compliance with PASSAR requirements.
2. Audits will be done on all new admissions and all residents with a newly evident or possible serious mental illness or developmental disability weekly x4, bi-weekly x2, monthly x4 by the Director of Social Service/designee.
3. Audits with negative findings will have immediate correction by the Director of Social Service.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: Social Service Director

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: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, during a recertification survey the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Resident #'s 72, 187, and 589) of 36 resident's reviewed. Specifically: For Residents #72 and Resident #589, the facility did not develop a comprehensive care plan (CCP) for eye infections; For Resident #187, the facility did not develop a CCP for the use of oxygen. This was evidenced by: Resident #72: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severely impaired for cognition, was able to understand others and was able to be understood. A physician's orders [REDACTED]. The electronic Medication Administration Record [REDACTED]. A Physician's Progress Note dated 3/09/18, documented the patient will be treated for [REDACTED]. Review of the Comprehensive Care Plans (CCP's) did not include a CCP for the [DIAGNOSES REDACTED]. During an interview on 4/25/18 at 9:02 am, Nursing Supervisor #2 stated the physician saw the resident and ordered [MEDICATION NAME] eye drops for the [DIAGNOSES REDACTED]. Nursing Supervisor #2 stated a careplan was not initiated, but should have been. Resident #187: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The electronic Treatment Administration Record (eTAR) dated 3/9/2018 through 3/20/2018 documented; Oxygen flow liters @ 3 liter per minute (3L/M), related to Acute [DIAGNOSES REDACTED]. From 3/21/2018 through 3/31/2018 the eTAR documented, Oxygen flow liters @ 1 liter per minute (1L/M), related to Acute [DIAGNOSES REDACTED]. The comprehensive care plans (CCP) dated 3/9/18 did not include the use of oxygen. During an interview on 04/24/18 at 09:40 am, Registered Nurse Manager #4 stated if a resident is receiving oxygen they should have a respiratory care plan for oxygen. The resident was admitted to the facility on oxygen for an acute respiratory problem. Resident #589: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was understood and could understand with a moderately impaired cognition. The resident has received antidepressant medication for the last seven days. A physician order [REDACTED]. The eMAR for (MONTH) (YEAR), documented the resident received [MEDICATION NAME] HCL Solution 0.3% eye drops, 2 drops, three times a day to right eye from 4/12 through 4/19/18 for eye infection. A nurse practitioner (NP) progress note date 4/12/18, documented the sclera (white part) of the residents right eye was red and had drainage. [DIAGNOSES REDACTED]. The resident will start [MEDICATION NAME] and frequent hand hygiene will be encouraged. Review of CCP's did not include a CCP for the [DIAGNOSES REDACTED]. During an interview on 04/23/18 at 11:11 am, Licensed Practical Nurse (LPN) #5 (charge nurse) stated the resident had been diagnosed with [REDACTED]. Frequent handwashing was recommended. She could not find a CCP addressing this. Only a Registered Nurse (RN) can develop and implement a CCP for the residents. The RN Supervisor covering the unit was in charge of doing the CCP for the residents on the unit. During an interview on 4/24/18 at 2:50 pm, RN Supervisor #2 stated a CCP had not been started for the resident to address the eye infection with interventions for antibiotics, precautions, monitoring, or goals. A CCP should have been started upon the identification of the [DIAGNOSES REDACTED]. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedJune 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
Residents #72 and #589:
1. The Director of Nursing in conjunction with the nurse managers and nursing supervisors reviewed and revised, as indicated, the Residents? care plans to ensure appropriate care and services are reflected.
2. Nursing Supervisor #2 and Nurse Manager #4 were counseled by the Director of Nursing for failure to ensure that the Residents? care plans were properly reviewed and revised to ensure current and accurate care and treatment, specifically when the Resident was treated for [REDACTED].
3. Currently the Residents reside in the facility with all needs met.
Residents #187:
1. The Director of Nursing in conjunction with the nurse managers and nursing supervisors reviewed and revised, as indicated, the Resident?s care plan to ensure appropriate care and services are reflected.
2. Nurse Manager #4 was counseled by the Director of Nursing for failure to ensure that the Resident?s care plan was properly reviewed and revised to ensure current and accurate care and treatment, specifically with regard to oxygen use. A copy of the counseling was filed for validation.
3. Currently the Resident resides in the facility with all needs met.

II. Identification of Other Residents
1. The Director of Nursing/designee in conjunction with the Nursing Supervisors, nurse managers identified and reviewed the care plans of all residents with eye infections or the use of oxygen to ensure the plans were current and accurate.
2. Any negative findings had immediate corrective action by the Director of Nursing.
3. The Director of Nursing will maintain a list of any corrected records.

III. Systemic Changes
1. The Director of Nursing reviewed the policy for care plan development and evaluation.
2. All Licensed Nursing staff will be in-serviced on this policy to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure a care plan is initiated, and/or reviewed and revised when there is a change in the Resident?s care and treatment and the communication regarding care planning and review.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Nursing developed an audit tool to track compliance with the requirements for a current and accurate plan of care.
2. Audits will be done on all Residents diagnosed with [REDACTED].
3. Audits with negative findings will have immediate correction by the Director of Nursing/designee.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: DON

FF11 483.60(i)(4):DISPOSE GARBAGE AND REFUSE PROPERLY

REGULATION: §483.60(i)(4)- Dispose of garbage and refuse properly.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation, staff interview, and policy record review during the recertification survey, essential equipment was not maintained in safe operating condition. Specifically, plumbing fixtures in the main kitchen were not functioning properly. This is evidenced as follows. The main kitchen was inspected on 04/18/2018 at 9:56 am. When tested , hot water was not available at the handwashing sink. The faucets servicing handwashing sink, 2-compartment sink, and the mop sink dripped, and the drain plug servicing the middle bay of the 3-compartment sink would not function. The Director of Facility Services stated in an interview conducted on 04/20/2018 at 9:59 am that due to a plumbing quirk, hot water will not always be supplied at the handwashing sink, and he will make the necessary repairs to all the sinks noted. Further he stated that the Dietary Department had verbally notified and had not submitted a work-order, as would be normal procedure, for these items found. Record review of the facility policy Work Order Procedure on 04/20/2018 revealed that work orders are to be submitted to assure equipment is repaired in an effective and efficient manner. 10 NYCRR 415.5(e)(1)(2)

Plan of Correction: ApprovedJune 1, 2018

1. The Director of Plant Operations developed a plan to repair: the faucets servicing the handwashing sink in the main kitchen; 2-compartment sink; the mop sink; and the drain plug servicing the middle bay of the 3-compartment sink.
2. The Administrator and Director of Plant Operations will develop a plan to address the availability of hot water to the handwashing sink.
3. The plumbing repairs is scheduled for (MONTH) 1, (YEAR).
4. The Administrator educated the Director of Food and Nutrition Services for failure to follow facility procedure for Work Orders.

II. Identification of Other Residents
1. All Residents are potentially impacted by the deficient practice.
III. Systemic Changes
1. The Administrator and the Director of Plant Operations reviewed the Work Order Procedure.
2. All Food and Nutrition staff will be in-serviced on this policy by the Director of Plant Operations/designee to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure a work order is completed when the need for repair or replacement of food service equipment is identified and the process for completing a work order.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Plant Operations developed an audit tool to track compliance with the requirements of the Work Order Procedure.
2. Environmental rounds will be conducted weekly x4 weeks then monthly by the Director of Plant Operations/designee to ensure the plumbing fixtures in the main kitchen are functioning properly to include hand-washing sink, two ?compartment sink, mop sink and drain plug servicing the middle bay of 3- compartment sink.
3. Audits with negative findings will have immediate correction by the Director of Plant Operations.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: Director of Plant Ops

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation, staff interview, and policy record review during the recertification survey, essential equipment was not maintained in safe operating condition. Specifically, plumbing fixtures in the main kitchen were not functioning properly. This is evidenced as follows. The main kitchen was inspected on 04/18/2018 at 9:56 am. When tested , hot water was not available at the handwashing sink. The faucets servicing handwashing sink, 2-compartment sink, and the mop sink dripped, and the drain plug servicing the middle bay of the 3-compartment sink would not function. The Director of Facility Services stated in an interview conducted on 04/20/2018 at 9:59 am, that due to a plumbing quirk, hot water will not always be supplied at the handwashing sink, and he will make the necessary repairs to all the sinks noted. Further he stated that the Dietary Department had verbally notified and had not submitted a work-order, as would be normal procedure, for these items found. Record review of the facility policy Work Order Procedure on 04/20/2018 revealed that work orders are to be submitted to assure equipment is repaired in an effective and efficient manner. 10 NYCRR 415.5(e)(1)(2)

Plan of Correction: ApprovedJune 1, 2018

F908
1. The Director of Plant Operations developed a plan to repair: the faucets servicing the handwashing sink in the main kitchen; 2-compartment sink; the mop sink; and the drain plug servicing the middle bay of the 3-compartment sink. Repairs are scheduled for 6/1/18.
2. The Administrator educated the Director of Food and Nutrition Services for failure to follow facility procedure for Work Orders.
II. Identification of Other Residents
1. All Residents are potentially impacted by the deficient practice.
III. Systemic Changes
1. The Administrator and the Director of Plant Operations reviewed the Work Order Procedure, and found same compliant.
2. All Food and Nutrition staff will be in-serviced on the work order procedure policy by the Director of Plant Operations/designee to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure a work order is completed when the need for repair or replacement of food service equipment is identified and the process for completing a work order.
4. A copy of the lesson plan and attendance was filed for validation.
5. The Director of Plant Operations/designee will continue the preventative maintenance program to ensure all mechanical, electrical, and patient care equipment are in safe operating condition.

IV. QA Monitoring
1. The Director of Plant Operations developed an audit tool to track compliance with the requirements of the Work Order Procedure.
2. The Director of Plant Operations will review the preventative maintenance log to identify potential concerns with mechanical, electrical and patient care equipment.
3. Negative findings will have immediate correction by the Director of Plant Operations.
4. Findings will be presented to the QA committee/safety committee for evaluation and continuation.
V
Responsible Party: Director of Plant Ops

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

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that food packages shall be in good condition so that the food is not exposed to adulteration or potential contaminants; food contact surfaces shall be cleaned after use; and floors are to be kept clean. Specifically, cans of food were dented, and food contact surfaces, and cabinetry were not clean. This is evidenced as follows. The main kitchen and unit kitchenettes were inspected on 04/18/2018 at 9:56 am. One #10 can of diced pears that was bulging was found in the common stock. The floor mixer, slicer, scales, fire extinguisher, red caution cone, spice rack, stove, service corridor floor, and dry storage room door were not clean. B-1 and B-3 Unit kitchenettes' cabinets under the sink, and the refrigerator doors gaskets on the A-2, A-3, and B-3 units' kitchenettes were not clean. The Director of Food and Nutrition stated in an interview conducted on 04/18/2018 at 10:23 am, that the dented can should not have been with the common stock and she will address the cleaning issues found. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.32, 14-1.85, 14-1.110

Plan of Correction: ApprovedJune 1, 2018

1. On 4/18/18 The Director of Food and Nutrition had the cans of food in the main kitchen and unit kitchenettes inspected and any damaged items removed immediately.
2. The Director of Food and Nutrition in conjunction with the Director of Facility Services developed a plan for a thorough cleaning of the main kitchen and unit kitchenettes.
3. The floor mixer, slicer, scales, fire extinguisher, red caution cone, spice rack, stove, service corridor floor, and dry storage room door were cleaned 4/18/18.
4. The unit kitchenettes cabinets under the sink on B1 and B3 and refrigerator door gaskets A2, A3 and B3 unit kitchenettes were cleaned 4/19/18.
5. The Administrator educated the Director of Food and Nutrition Services for failure to maintain compliance with food safety requirements.

II. Identification of Other Residents
1. All Residents are potentially impacted by the deficient practice.

III. Systemic Changes
1. The Administrator and the Director of Food and Nutrition reviewed the policies relative to maintaining food safety and environmental cleanliness standards.
2. All Food and Nutrition staff will be in-serviced on this policy by the Director of Food and Nutrition to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure food is stored, prepared, and distributed in accordance with standards for food service safety.
4. All housekeeping staff will be in-serviced on the unit kitchenettes and cleaning schedule by the Director of Facility Services to ensure understanding and compliance.
5. The lesson plan concentrates on the responsibility to ensure unit kitchenettes including cabinet under the sink and refrigerator door gaskets are cleaned.
6. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Food and Nutrition developed an audit tool to track compliance with the requirements food is stored, prepared, and distributed in accordance with standards for food service safety.
2. The Director of Facility Services developed an audit tool to track compliance with the plan for maintaining cleanliness of the units? kitchenettes.
3. Audits will be done weekly x4, biweekly x2 and monthly x4 for the main kitchen and each unit kitchenette by the Director of Food and Nutrition /designee and the Director of Facility Services/designee.
4. Audits with negative findings will have immediate correction by the Director of Food and Nutrition and/or Director of Facility Services.
5. Audit findings will be presented to the QA committee for evaluation and continuation.

V
Responsible Party: Director of Food Services

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #131) of five residents reviewed for unnecessary [MEDICAL CONDITION] medications. Specifically: For Resident #131, the facility identified a gradual dose reduction (GDR) failed without behavior monitoring and documention of a change in behavior. This is evidenced by: Resident #131: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 3/1/18 assessed the resident understands, was understood, had severely impaired cognitive ability and that the resident received routine antipsychotic medication daily. A GDR had not been documented as clinically contraindicated by a physician . A Psychiatric Consultation Report on 8/15/17 by the Psychiatric Nurse Practitioner documented the resident was receiving [MEDICATION NAME] 15 mg (milligrams) daily, and had no signs of mania, [MEDICAL CONDITION], delusions or paranoia. A pharmacy recommendation dated 9/15/17, documented to consider a taper of [MEDICATION NAME] ([MEDICATION NAME]). Current dose 15 mg daily, suggested dose of 10 mg daily. [DIAGNOSES REDACTED]. The patient has had several falls in the past month. On 10/9/17, the physician checked to recommendation form that he agreed with the recommendation. A physician order [REDACTED]. Nursing Progress Notes documented: 10/10/17 - MD (medical doctor) reviewed the pharmacy recommendation and agreed to decreasing [MEDICATION NAME] to 10 mg and watch for delusional behavior; 10/12/17 at 1:24 pm - Resident has been swearing since around 9:00 am about wanting to see his social worker. Resident was given the phone to use since his son didn't answer. His behavior became worse, continuing to swear at staff and refusing to sit down. Writer feels the resident is at risk to fall as he is non compliant with walker and is unsteady on feet; 10/13/17 at 2:35 pm - No behavioral issues and at 4:01 pm resident able to be redirected without increased agitation; 10/14 and 10/15/17 - no issues noted this shift. A physician order [REDACTED]. A physician 60 day/Interim Renewal note on 10/20/17, documented the resident received [MEDICAL CONDITION] medications [MEDICATION NAME], and klonapine. The note documented that medications were reviewed. It did not include documentation regarding the [MEDICATION NAME] dose reduction or the reason the dose was increased. A Psychiatric Consultation Report on 11/9/17, written by the Psychiatric Nurse Practitioner documented the resident was receiving [MEDICATION NAME] 15 mg (milligrams) once a day, had no signs of mania, [MEDICAL CONDITION], delusions or paranoia. It documented a failed GDR of [MEDICATION NAME] on 10/20/17. The report did not include documentation regarding the reason for the failure. A physician progress notes [REDACTED]. It documented the resident gets [MEDICATION NAME] for [MEDICAL CONDITION]. The note did not include the failed GDR or the reason for the failure. During interview on 4/23/18 at 2:17 pm, Licensed Practical Nurse Unit Manager (LPNUM) #3 stated there was a nurses note on 10/10/17 about the Zypreza decrease to 10 mg a day. She stated there was no follow up documentation regarding any increased behaviors after that. LPNUM #3 stated the [MEDICATION NAME] order changed back on 10/19/17 to 15 mg. There were no notes as to why it was changed. The nursing note dated 10/12/17 for refusal of care would not be a reason to increase [MEDICATION NAME] again. Refusal of care would not be a reason to consider a failed GDR. During interview on 4/23/18 at 03:05 pm, the SWD (Social Work Director) remembered an incident last year for this resident. She stated she noticed [MEDICATION NAME] was decreased in report. The Unit Manager at the time read something about throwing his walker and mentioned he had a medication decrease. The SWD stated there should be documentation of behaviors, but she did not see it in the notes except for on 10/12/17. She said she would look for other monitoring documentation. She did not provide any further documentation regarding any behavior concerns. During telephone interview on 4/23/18 at 3:25 pm, the Psychiatric Nurse Practitioner (PNP) stated the decrease in [MEDICATION NAME] was from a pharmacy recommendation. It was not brought to her attention and she was not involved at all in the decision. She stated they should have consulted her. The PNP remembered the resident used to throw his walker when she first saw him. The PNP saw the resident in (MONTH) (YEAR) and the [MEDICATION NAME] dose was the same as the previous time she had seen the resident. The reason for increasing [MEDICATION NAME] (10/19/18) was not shared with her. One episode of agitation/screaming was not a reason to increase the [MEDICATION NAME]. 10NYCRR415.12(I)(2)(ii)

Plan of Correction: ApprovedJune 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
Residents #131: The resident?s order for [MEDICAL CONDITION] medication has been reviewed and discussed with practitioner. The resident continues to receive the [MEDICAL CONDITION] medication as ordered with no ill effects.

II. Identification of Other Residents
1. The Directors of Nursing and Social Services reviewed the care plans of all residents receiving [MEDICAL CONDITION] medication to identify others for whom a gradual dose reduction was indicated, but not achieved.
2. Any negative audits had immediate corrective action by the Directors of Nursing and Social Services.
3. The Director of Social Services maintained a list of any corrections.
III. Systemic Changes
1. The Medical Director, Director of Social Services and the Director of Nursing reviewed the policy for [MEDICAL CONDITION] medication management and gradual dose reductions.
2. All Licensed Nursing staff will be in-serviced on this policy by the Director of Nursing/designee to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure that Residents receive [MEDICAL CONDITION] medications appropriately; gradual dose reductions are attempted; non-pharmacologic interventions are trialed; the responsibility to document the effects of the GDR and why attempts were or were not successful.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Nursing developed an audit tool to track compliance with the requirements for [MEDICAL CONDITION] medications and gradual dose reductions.
2. Audits will be done on any resident with a new/ changed order for [MEDICAL CONDITION] medication weekly x4, biweekly x2 and monthlyx4 by the Director of Nursing/designee.
3. All residents receiving a [MEDICAL CONDITION] medication will be monitored for gradual dose reduction (GDR) to include response/documentation to the GDR.
4. Audits with negative findings will have immediate correction by the Director of Nursing.
5. The QAPI committee continues to meet and monitors residents on [MEDICAL CONDITION] medications. The QAPI team will continue to monitor GDR attempts and will monitor the documentation during GDS's. The QAPI committee will continue communication with the DON, Medical Director, practitioner, and Pharmacy consultant. QAPI reports updates during QA meetings. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: DON

ZT1N 415.19:INFECTION CONTROL

REGULATION: N/A

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, employee health record review, and the Legionella Water Management Plan (WMP) review during the recertification survey, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease in accordance with adopted regulations. The facility must ensure staff that have not been vaccinated for influenza wear surgical masks. And Part 4, Protection Against Legionella, Section 4-2.3 requires that environmental assessment, updated annually, utilizing a form provided or approved by the New York State Department of Health, and Section 4-1.4(b) requires the development of a schedule for bacteriological culture sampling and analysis to assess microbiological activity while the building cooling system is in use (cooling tower Sampling Management Plan). Specifically, one of 10 employees that had not been vaccinated for influenza did not wear a surgical mask in resident areas, and the required environmental assessment and cooling tower Sampling Management Plan were not completed. This is evidenced by the following. On 04/18/2018 at 2:10 pm, Activities Aide #1 was observed in resident areas and was not wearing a surgical mask The employee health records for Activities Aide #1 were reviewed on 04/25/2018. These records document that she last received the influenza vaccination on 11/03/2016 and that her identification badge had a green dot sticker ([MEDICAL CONDITION]) The Infection Preventionist stated in an interview conducted on 04/25/2018 at 9:30 am, that due to a misunderstanding, Activities Aide #1 was believed to have received the influenza vaccine and that placing a green dot on the identification badge means this year's vaccine had been administered. The WMP was reviewed on 04/20/2018. The WMP did not include the required environmental assessment and a cooling tower Sampling Management Plan. The Administrator and Director of Facility Services stated in an interview conducted on 04/20/2018 at 9:00 am that the required assessment and sampling plan will be developed. 415.19

Plan of Correction: ApprovedJune 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate correction action:
1. The Activity Aide #1 was educated regarding the influenza vaccine, importance of adhering to wearing the mask during designated flu season and transmission of the [MEDICAL CONDITION].
2. The Infection Preventionist reviewed the Infection/Prevention Control Program to ensure that the regulations as stated in section 451.19 Infection Control to ensure that all employees are following the regulations in preventing the development and transmission of disease.
3. The RN that affixed the identifier (per employee influenza policy) on the Activity Aide #1 is no employed at the facility.
4. A representative from the Metro Group met with Director of Plant Operations/Administrator. The team drafted a cooling tower sampling plan. Included in this plan is scheduling the bacterial cultures and sampling/analysis to assess the microbiology activity while the building cooling system is in use (located under the facilities cooling tower Sampling Management Plan). Where greater than 30% of the samples come back positive, remediation includes a system flush and cleaning followed by re-testing. If greater than 30% of the samples again come back positive, remediation includes a long term control measure (i.e. chlorine [MEDICATION NAME] generator).

II. Identification of Other Residents
1. All Residents are potentially affected by the Infection Control and the WMP deficient practice.

III. Systemic Changes
1. The Infection/Preventionist reviewed the policy for the management of infection control in regards to Influenza.
2. The Infection Preventionist reviewed the Infection/Prevention Control Program to include the regulations as stated in 415.19.
3. All staff will be in-serviced on this policy by the Infection/Preventionist/designee to ensures IV understanding and compliance of Influenza Policy.
4. The lesson plan concentrates on the facility?s policy to identify employees who have not received the Influenza vaccine and maintain infection control protocol.
5. A copy of the lesson plan and attendance will be filed for validation.
6. All maintenance staff will be in-serviced on the WMP modifications by the Director of Plant Operations.
7. The lesson plan will concentrate on the inclusion of a written and flow chart description of the potable water system, and a description of the Legionella growth control measures.
8. A copy of the lesson plan and attendance will be filed for validation.

IV. QA Monitoring
1. The Infection Preventionist developed an audit tool to track compliance of employee?s medical records in regards to influenza administration utilizing the facility?s identifying procedure.
2. During Influenza season an audit will be conducted to ensure that employees have been appropriately identified as per facility policy. Those employees that have not received the Influenza vaccine must follow facility policy and an audit will be conducted to ensure compliance.
3. Audits with negative findings will have immediate correction by the Infection Preventionist/designee.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
5. The Director of Plant Operations developed an audit tool to track compliance with the requirements for WMP.
6. Audits will be done by the Director of Plant Operations to ensure compliance with the requirements for WMP.
7. Audits with negative findings will have immediate correction by the Director of Plant Operations.
8. Audit findings will be presented to the QA committee for evaluation and continuation.
Responsible Party:
Part One
Director of Infection Control
Part two
Director Plant Ops

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically for 1 (one) (Resident #106) of 2 (two) residents reviewed, the facility did not ensure Resident #106's foley bag was covered and kept off the floor. Additionally, the facility did not develop a Water Management Plan (WMP) in accordance with adopted regulations. This is evidenced by: Finding #1: The facility's Policy and Procedure for Infection Control related to Urinary Catheters revised on 9/01/17, documented to not allow the catheter tubing, bag, or spigot to touch the floor. Resident #106: The resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented resident was severely impaired for cognition, he could usually understand others and could usually be understood. During an observation on 4/18/18 at 12:05 pm, the resident was sitting in the dining room. His foley bag was not covered. During an observation on 4/19/18 at 12:39 pm, the resident was sitting in the dining room. The resident's foley bag was sticking out from his pant leg, was uncovered and resting on the floor. During an interview on 4/24/18 at 11:12 am, NM #4 stated foley bags should not be on the floor and should be covered at all times. During an interview on 04/24/18 at 11:30 am, LPN #1 stated the staff were inserviced last month to keep foley bags off the floor and covered. 10NYCRR415.19(a)(1-3) Finding #2: The WMP was reviewed on 04/20/2018. The WMP did not include a description of the potable water system with a flow chart and written description, and does not describe Legionella growth control measures. The Administrator and the Director of Facility Services stated in an interview conducted on 04/20/2018 at 9:00 am, that the WMP will be modified to include a written and flow chart description of the potable water system and will include a description of the Legionella growth control measures. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f)

Plan of Correction: ApprovedJune 1, 2018

Resident #106:
1. The Resident?s foley bag was immediately repositioned to maintain infection control practices and covered to ensure privacy.
2. Nurse Manager #4, LPN #1, and the CNA responsible for the care of this Resident were educated by the Director of Nursing/designee to ensure that the Resident?s foley bag was properly maintained to include infection control and dignity.
3. The Resident currently resides in the facility with all needs met and privacy maintained.
Water Management Plan:
1. The Administrator and Director of Plant Operations reviewed and revised the WMP to include a written and flow chart description of the potable water system, including a description of the Legionella growth control measures.
II. Identification of Other Residents
1. The Director of Nursing/ Nurse Managers identified and reviewed all Residents with foley bags in regards to infection control and maintenance of dignity (covering Foley bags).
2. Any negative findings had immediate corrective action by the Director of Nursing/designee.
3. The Director of Nursing will maintain a list of any corrections.
4. All Residents are potentially affected by the WMP deficient practice.
III. Systemic Changes
1. The Director of Nursing reviewed the policy for the management of infection control in regards to foley bags.
2. The Infection Preventionist reviewed the Infection/Prevention Control Program to include the regulations as stated in 483.80.
3. All Licensed Nurses and Certified Nursing Assistants will be in-serviced on this policy by the Director of Nursing/designee to ensure understanding and compliance.
4. The lesson plan concentrates on the responsibility to maintain the Resident?s privacy and dignity, proper placement, and infection control standards.
5. A copy of the lesson plan and attendance will be filed for validation.
6. All maintenance staff will be in-serviced on the WMP modifications by the Director of Plant Operations.
7. The lesson plan will concentrate on the inclusion of a written and flow chart description of the potable water system, and a description of the Legionella growth control measures.
8. A copy of the lesson plan and attendance will be filed for validation.

IV. QA Monitoring
1. The Director of Nursing in conjunction with the Infection Preventionist developed an audit tool to track compliance of foley bags/ infection control practices.
2. Audits will be done on all Residents with foley bags weekly x4, biweekly x2 and monthly x4 by the Director of Nursing/Infection Preventionist/designee.
3. Audits with negative findings will have immediate correction by the Director of Nursing/Infection Preventionist/designee.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
5. The Director of Plant Operations developed an audit tool to track compliance with the requirements for WMP.
6. Audits will be done by the Director of Plant Operations to ensure compliance with the requirements for WMP.
7. Audits with negative findings will have immediate correction by the Director of Plant Operations.
8. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: Infection Preventionist

FF11 483.10(a)(1)(2)(b)(1)(2):RESIDENT RIGHTS/EXERCISE OF RIGHTS

REGULATION: §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure each resident was treated in a dignified manner for three (Resident #'s 94, 72 and #106) of thirty-six residents reviewed. Specifically: Resident #106's foley bag was lying on the floor uncovered and; Residents #'s 94 and 72, stated staff do not knock on their doors prior to entering their rooms. This is evidenced by: Finding #1: The facility did not ensure foley bags were covered and did not rest on the floor. Resident #106: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severely impaired for cognition, could usually understand others and could usually be understood. During an observation on 4/18/18 at 12:05 pm, the resident was sitting in the dining room. The resident's foley bag was not covered. During an observation on 4/19/18 at 12:39 pm, the resident was sitting in the dining room. The resident's foley bag was sticking out from his pant leg, on the floor, uncovered. During an interview on 4/24/18 at 11:12 am, Nurse Manager (NM) #4 stated foley bags should be kept off the floor and covered at all times. Finding #2: The facility did not ensure that staff knocked on residents' doors prior to entering their rooms. Resident #94: During an interview on 4/18/18 at 9:51 am, Resident #94 stated she did not know the staff were supposed to knock prior to entering her room. Resident #72: During a interview on on 4/18/18 at 10:12 am, Resident #72 stated the staff usually do not knock before entering her room. She stated this is because her door is always open. Resident #143: During an observation on 4/20/18 at 8:45 am, Licensed Practical Nurse (LPN) #2, while administering medications, walked into room [ROOM NUMBER] without first knocking on the door. During an interview on 4/20/18 at 8:55 am, LPN #2 stated she usually knocks when she goes into the room to give medication. Resident #107: During an observation on 4/20/18 at 9:00 am, while administering medications, LPN #1 walked into room [ROOM NUMBER] without first knocking on the door. During an interview on 4/20/18 at 9:05 am, LPN #1 stated she should have knocked on the door. She stated I know I should have knocked. 10NYCRR415.3(c)(1)(i)

Plan of Correction: ApprovedJune 1, 2018

I. Immediate Corrective Actions
Resident #106:
1. Resident #106 foley bag was immediately repositioned properly off the floor and covered to ensure privacy and infection control.
2. Nurse Manager #4 and the CNA responsible for the care of this Resident were counseled by the Director of Nursing for failure to ensure that the Resident?s foley bag was properly secured and covered. A copy of the counseling was filed for validation.
3. The Resident currently resides in the facility with all needs met and privacy maintained.
Residents #94, 72, 143, 107:
1. The Director of Social Services met with each of the Residents and reviewed their rights including privacy, dignity and respect. The Residents were informed that staff are to knock on their door before entering their private room.
2. These discussions were documented in the social work progress notes.
3. LPN #2 and LPN #1 were counseled by the Director of Nursing for failure to knock on the Resident?s door before entering his/her room. A copy of the counseling was filed for validation.
4. These Residents currently reside in the facility. No residents were negatively impacted by this deficient practice and all needs continue to be met and privacy maintained.

II. Identification of Other Residents
All Residents with Foley bags have the potential to be affected by this deficient practice.
1. The Director of Nursing identified and audited all Residents with foley bags to ensure all foley bags were covered and proper infection control practices were maintained.
2. Any negative findings had immediate corrective action by the Director of Nursing/designee.
3. The Director of Nursing/Infection Preventionist will maintain a list of any corrections.
4. All Residents are potentially affected by staffs? failure to knock on doors before entering a Resident?s room.
5. Social Workers identified all interviewable residents with a BIMS of 13-15, and interviewed each resident. All residents that have been identified and interviewed have not been negatively impacted by this deficient practice.
6. The Director of Social Services maintained a list of identified Residents.

III. Systemic Changes
1. The Infection Control Policy concerning foley bags was reviewed/revised.
2. Licensed Nurses and Certified Nursing Assistants will be in-serviced on this policy by the Director of Nursing/designee to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to maintain the Resident?s privacy and dignity, proper placement, and infection control standards.
4. A copy of the lesson plan and attendance will be filed for validation.
5. The Director of Social Services reviewed/revised the policy for Resident Rights, specifically knocking on a Resident?s door before entering the room and found same compliant.
6. All staff will be in-serviced on this policy to ensure understanding and compliance.
7. The lesson plan concentrates on the responsibility to maintain the Resident?s privacy and dignity, specifically knocking on a Resident?s door before entering the room.
8. A copy of the lesson plan and attendance will be filed for validation.
9. As part of the Resident admission process the resident/responsible party will continue to be informed and receive a copy of the Resident Rights.
10. The Resident?s Rights posters will continue to be posted and available on each floor across from the elevators.
11. The Director of Social Services will meet with the Residents? Council to provide education on Residents? rights, specifically that staff are to knock before entering a Resident?s room.

IV. QA Monitoring
1. The Director of Social Services developed an audit tool to track compliance of foley bag placement and privacy covers.
2. Audits will be done on all Residents with foley bags weekly x4, biweekly x2 and monthly x4 by the Director of Nursing/designee.
3. Audits with negative findings will have immediate correction by the Director of Nursing/designee.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
5. The Directors Social Services developed an audit tool to track compliance with Residents? Rights, specifically knocking on a Resident?s door before entering the room.
6. Resident Rights audits will include interviews/observation of 10% of residents weekly x4 weeks, biweekly x2 and monthly x4.
7. Audits with negative findings will have immediate correction by the Director of Social Services/designee.
8. Audit findings will be presented to the QA committee for evaluation and continuation.
V.
Responsible Party: SW Director

FF11 483.45(f)(2):RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a recertification survey the facility did not ensure all residents were free from significant medication errors for 1 (Resident #498) of 5 residents reviewed. Specifically, the facility did not ensure the resident received significant medications in a timely manner upon admission. This was evidenced by: Resident #498: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Resident is alert and oriented to person, place and time. The first progress note dated 4/17/18 at 6:50 pm, and signed by the Registered Nurse Supervisor (RNS) #5 documented; Resident admitted from hospital. Discharge orders placed no change to orders per MD (Medical Doctor) on call. The time of admission was not included in the note. The Hospital Discharge Instructions documented the following medications to be administered the evening of admission on 4/17/18: [MEDICATION NAME] (treat and prevent heartburn) 150 milligrams (mg) given twice per day (bid); [MEDICATION NAME] (maintain a healthy digestive balance) 250 mg bid and; Carvedilol (treat high blood pressure and heart failure) 6.25 mg bid. The Order Summary Report on 4/17/18 at 9:20 pm, documented the resident orders were completed. The following medications documented a start date of 4/18/18: [MEDICATION NAME] 150 mg; [MEDICATION NAME] 250 mg and Carvedilol 6.25 mg. The electronic Medication Administration Record [REDACTED]. During an interview on 04/23/18 at 02:10 pm, RNS # 2 stated I don't know why this occurred, the cubex (a dispenser of backup medications) has most of the drugs in there. This is not a normal problem here. During an interview on 04/23/18 at 02:26 pm, the Director of Nursing (DON) stated for all new admissions the RNS or Registered Nurse Managers look at the medications and follows the medication regime-we make sure the resident receives their medications as ordered. During an interview on 04/23/18 at 02:35 pm, the Administrator stated that it is not acceptable that a new admission did not receive medications on the evening of their admission. If the RNS needed help to finish the orders timely, she should have called for help from another RN. During an interview on 4/24/18 at 3:20 pm, RNS #5 stated I think I had a couple of admissions that day. I think I spoke to the MD who said to give it the next day. She was in pain, I offered her Tylenol and she did not want it. I should have written a note.

Plan of Correction: ApprovedJune 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
Residents #498:
1. The Director of Nursing in conjunction with the Unit Managers reviewed the physician orders [REDACTED]. Physician was notified of deficient practice and resident had no ill effects.
2. Nurse Supervisor #5 was counseled by the Director of Nursing for failure to ensure that the Resident received significant medications in a timely manner upon admission. A copy of the counseling was filed for validation.
3. Currently the Resident resides in the facility with all needs met.

II. Identification of Other Residents
1. The Director of Nursing in conjunction with the Nursing Supervisors/Nurse Managers will review the Physician?s orders for new admissions and readmissions in the past 30 days to identify any additional Residents impacted.
2. Any negative findings will have immediate corrective action by the Director of Nursing/designee.
3. The Director of Nursing will maintain a list of any corrections.


III. Systemic Changes
1. The Director of Nursing reviewed the policy for medication management, specifically with regard to ensuing that a Resident receives significant medications in a timely manner upon admission.
2. All Licensed Nursing staff will be in-serviced on this policy by the Director of Nursing/designee to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure the review and validation of Physician orders; accurate transcription and documentation of administration; and the responsibility to ensure timely and accurate administration of all prescribed medications.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Nursing developed an audit tool to track compliance with the requirements that a Resident receives medications in a timely manner as ordered upon admission.
2. Audits will be done on all new and readmitted Residents weekly x4, biweekly x2 and monthly x4 by the Director of Nursing/designee.
3. Audits with negative findings will have immediate correction by the Director of Nursing/designee.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: DON

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for two (2) residents (Residents #143 and Resident #187) of four (4) residents reviewed. Specifically: For Resident #143, the facility did not ensure physician's orders [REDACTED].#187, the facility did not ensure an oxygen tank attached to the resident's wheelchair used to deliver oxygen to the resident, was not empty. Additionally, the physician order [REDACTED]. The Policy and Procedure for Oxygen, General Principles Storage and Administration (undated) documented to check the physician's orders [REDACTED].e., flow rate, indications for use). The Policy and Procedure for Transcription of Orders, with a revision date of 12/18/15, documented to copy the treatment order onto the appropriate treatment administration record (eTAR). Resident #143: This resident was admitted on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderately impaired cognition, was able to understand others and was able to be understood. Finding #1: The facility did not ensure physician's orders [REDACTED]. A physician's orders [REDACTED]. The electronic Treatment Administration Record (eTAR) dated 2/11/18, documented the resident received 3 liters of oxygen. Nursing Progress Note dated 2/28/18 at 2:45 pm, documented the resident returned from the hospital with [DIAGNOSES REDACTED]. The eTAR dated 2/28/18, documented 3 liters of oxygen was given. The eTAR dated 3/2018, documented oxygen at 3 liters was given to the resident on 3/02-3/06/18 on all shifts, 3/07 on day shift, 3/09 on day shift 4 liters, and 3 liters on evenings and nights; 3/10 3.5 liters of oxygen were given; 3/14 3 liters on day shift; 3/16 3 liters on days and nights; 3/19 and 3/20 3 liters all shifts; 3/21 3 liters day shift; 3/23 3 liters day shift; 3/24 all shifts; 3/25 3 liters day shift; 3/26 and 3/27 3 liters all shifts; 3/28 through 3/31 3 liters all shifts. Transfer to Hospital Summary note dated 4/12/18 at 5:43 pm, documented the resident was transported to the hospital for right 7th rib fracture and right upper lung pneumothorax per x-ray. Admission Summary note dated 4/18/18 at 2:34 pm, documented the resident was readmitted to the nursing home. Resident chronically on oxygen at 2 liters. The eTAR dated 4/2018, documented oxygen at 3 liters of oxygen was given to the resident on 4/01 on day shift; 4/02 on day shift; 4/03 on all shifts; 4/04 on day shift; 4/18 on evening and night shifts; 4/19 on all shifts; 4/20 on day shift. Review of physician's orders [REDACTED]. There is no evidence of a Health Provider Progress Note for 4/18/18. Progress Note dated 4/20/18 at 1:33 pm, documented the resident was seen by the physician for readmission. The physician gave an order to decrease oxygen to 2 liters via nasal cannula due to the resident's oxygen saturation of 96% on 2 liters. Finding #2: The facility did not ensure physician's orders [REDACTED]. A physician's orders [REDACTED]. The eTARs dated 12/2017, 1/2018, 2/2018, 3/2018, and 4/2018, did not document transcription of the Physician order [REDACTED]. Finding #3: The facility did not ensure a respiratory assessment was conducted per physician order. A physician's orders [REDACTED]. The eTAR dated 12/2017, 1/2018 and 2/2018, did not reveal documentation of oxygen saturation levels taken per physician order [REDACTED]. A Nursing Progress Note dated 2/11/18 at 10:27 pm, documented the resident was sent to the emergency room for worsening oxygen saturation level of 80-87%. The eTAR dated 2/11/18 for evening shift documented the resident received oxygen at 3 liters. A physician's orders [REDACTED]. During an interview on 4/23/18 at 9:00 am, Licensed Practical Nurse (LPN) Nurse Manager #4 telephoned Nurse Practitioner #5 to discuss a conversation regarding the resident's oxygen orders when the resident was readmitted back to nursing home on 4/18/18. NM #4 stated NP #5 stated she had bumped the resident up to 3 liters of oxygen because she was doing well on 3 liters as indicated by recorded oxygen saturations levels. She stated the resident should not have been receiving 3 liters of oxygen in (MONTH) and (MONTH) because the physican's order was for 2 liters. She stated the order for 2 liters of oxygen should have been transcribed into the eTAR. She stated the resident was admitted on evening shift and it was the responsibility of the evening supervisor to transcribe the order into the eTAR. NM #4 stated on Friday the physician bumped the resident down to 2 liters of oxygen. During an interview on 4/23/18 at 9:34 am, NP #5 stated she is unable to recall discussion if she gave order to bump the resident up to 3 liters of oxygen. She stated the resident's primary physician would be seeing her on Friday 4/20/18. During an interview on 4/24/18 at 8:56 am, the acting Director of Nursing (DON), stated whenever the nurses receive a telephone order they should write the order on paper and read it back to the physician to verify accuracy. The order is then transcribed. The DON stated the resident's oxygen should not have been bumped up to 3 liters because the physician order [REDACTED]. The order to give 2 liters should have been transcribed into the eTAR. The Oxygen saturation level order also should have been transcribed into the eTAR and the results should have been documented in the resident's medical record. Resident #187: The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. Finding #1: The oxygen tank attached to the wheelchair used to deliver oxygen to the Resident, was empty. The physician's orders [REDACTED]. The eTAR dated (MONTH) (YEAR) documented Document use of Oxygen and flow liters per minute on treatment sheet every shift @ 1 liter per minute (1L/M), every shift related to Acute [DIAGNOSES REDACTED], start date 3/21/18. During an observation on 04/18/18 at 11:46 am, the resident was in the dining room sitting in her wheelchair with an oxygen tank attached. The gauge on the oxygen tank was pointed to empty, indicating the resident was not receiving oxygen. LPN #5 was asked to observe the oxygen, the LPN stated the tank was empty, then changed the oxygen tank and resumed the residents oxygen administration. During an interview on 4/18/18 at 11:53 am, LPN #5 stated that she was not assigned to this resident. The oxygen tanks should be checked every 2 hours to make sure they do not run out. The nurse in charge of this resident is on her break. During an interview on 4/24/18 at 9:40 am, Registered Nurse Manager (RNM) #4 stated, the resident's oxygen tank should not have gone empty, the unit nurses should check oxygen tanks every 2 hours to avoid oxygen tanks going empty. Finding #2: The facility did not ensure that the physician order [REDACTED]. The physician's orders [REDACTED]. The eTAR dated 4/1/2018 through 4/20/2018 documented; Document use of Oxygen and flow liters per minute on treatment sheet every shift @ 1 liter per minute (1L/M), related to Acute [DIAGNOSES REDACTED]. The resident was to receive 1 liter of oxygen continuous on the day, evening and night shifts. The eTAR documented the resident received 1 liter of oxygen on 79 shifts, 2 liters of oxygen on 10 shifts and 4 liters of oxygen on 1 shift. The nursing progress notes from 4/1/2018 through 4/20/2018, did not include documentation to support the increase in oxygen or a physician order [REDACTED]. During an interview on 04/24/18 at 09:40 am, RNM #4 stated nurses should be documenting when the oxygen liters administered are different than the physician order. The documentation should include why the increase in oxygen was necessary and the medical personnel they contacted. A Licensed Practical Nurse (LPN) cannot make the decision to change oxygen liters administered, on their own. 10NYCRR415.12(k)(6)

Plan of Correction: ApprovedJune 1, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions
All residents in need of respiratory care (oxygen) were ensured the plans were current and accurate.
Resident #143:
1. The Resident?s physician orders [REDACTED]. Clarification obtained from physician regarding the order for obtaining and notifying physician of resident?s oxygen saturation.
2. The RN who readmitted the resident back to the facility on [DATE] is no longer employed at the facility.
3. The nurses involved in not documenting the resident?s oxygen saturation levels as per physician order [REDACTED].
Resident #187:
1. The resident?s physician orders [REDACTED]. On 4/18/18 the resident?s oxygen tank was changed and resident?s oxygen administration was resumed as per order.
2. Nurse responsible for making sure the oxygen tank was not empty was educated.
3. The nurses involved in not following the physician oxygen order (Physician order [REDACTED].
4. The nurses involved in not including documentation in the nursing progress notes from 4/1/2018 through 4/20/2018 to support the increase in oxygen liters and the medical personnel contacted were educated.

II. Identification of Other Residents
1. The Director of Nursing in conjunction with the Nursing Supervisors/nurse managers identified and reviewed the care plans of all residents in need of respiratory care to ensure the plans were current and accurate.
2. Any negative findings had immediate corrective action by the Director of Nursing.
3. The Director of Nursing maintained a list of any corrected records.

III. Systemic Changes
1. The Director of Nursing reviewed/revised the policy for Oxygen Administration and Transcription of Orders.
2. All Licensed Nursing staff will be in-serviced on these policies by the Director of Nursing to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to ensure practitioner orders are accurately transcribed into the eTAR and the plan of care revised to reflect the correct treatment; and that oxygen tanks are properly maintained.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Nursing developed an audit tool to track compliance with the requirements of oxygen administration, transcription of orders and oxygen tank levels.
2. Audits will be done on all Residents in need of oxygen administration including oxygen tank levels weekly x4, bi-weekly x2, and monthly x4.
3. Audits will be conducted on all Residents? transcription of practitioner orders for completeness and accuracy to include practitioner and nursing documentation.
4. Audits with negative findings will have immediate correction by the Director of Nursing/designee.
5. Audit findings will be presented to the QA committee for evaluation and continuation.

V
Responsible Party: DON

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

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on record review, staff interview and facility policy review during the recertification survey, the facility did not take appropriate actions after the termination of employees as required by adopted regulation. Of any employee who was subject to, and underwent, a criminal history record check (CHRC) and is no longer employed, the provider must immediately, but within no later than 30 calendar days after the event, notify the New York State Department of Health (The Department), and document such notification occurred. Specifically, the facility did not notify The Department within 30 calendar days of the termination of employment or consideration for employment of 1 of 3 provisional employees reviewed. The review of the personnel records for Activities Aide #2 on 04/20/2018 revealed that she was terminated from employment on 01/12/2017 and that The Department was notified on 03/13/2018, 60 calendar days after the event. The Administrator stated in an interview conducted on 04/20/2018 at 2:20 pm, that other than a change in the Human Resources Department, she cannot account as to why The Department notification was late. The facility policy General Background Investigation and Criminal History Record Check was reviewed on 04/20/2018. This policy is silent as to when The Department will be notified after an employee is terminated or no longer considered for employment. 10 NYCRR 402.7(a)(2)(i)

Plan of Correction: ApprovedJune 1, 2018

I. Immediate Corrective Actions
1.The CHRC policy and procedure was reviewed/revised to include the notification to the DOH must be done immediately , but no later than 30 calendar days after the termination of employee?s employment.
2. The activity aide #2 was terminated and DOH was notified.
3. Audit will be conducted on all termed employees from 1/1/18 ? present to ensure that the DOH was notified of termination.
4. Any negative findings will be immediately corrected.

II. Identification of Other Residents
No resident's identified. All employees terminated from the facility have the potential to be affected by this deficient practice.

III. Systemic Changes
1. A system was developed to ensure compliance with the regulation in regards to the responsibility of the provider in notifying the Department of Health when an employee who was subject to, and underwent, a criminal history background check is no longer employed at the facility.
IV. QA Monitoring
1. Audits will be done on all termed employees for compliance in notification to DOH, weekly x4, biweekly x2 and monthlyx4 by the Director of Human Resources/designee.
2. Audits with negative findings will have immediate correction by the Director of Human Resources
3. Audit findings will be presented to the QA committee for evaluation and continuation.
V.
Responsible Party: Director of HR

FF11 483.10(g)(10)(11):RIGHT TO SURVEY RESULTS/ADVOCATE AGENCY INFO

REGULATION: §483.10(g)(10) The resident has the right to- (i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-- (i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation and interview the facility did not ensure it posted notice of the availability of survey reports in areas of the facility prominent and accessible to the public. Specifically: During a meeting with residents, the residents' stated they did not know where survey results were located. This is evidenced by: During a meeting with a group of 5 residents on 4/20/18 at 10:00 am, the residents stated they did not know where the survey report was located. On 4/20/18 at 10:30 am, after the resident meeting this surveyor went to the first floor and lobby area. The survey results were not readily available. This surveyor asked the Acting Director of Nurses (ADON) where the survey report was. The ADON took surveyor to the lobby entrance to the hallway to the units. There was a small alcove that had a shelf in it. There was a binder laying flat on the shelf. A folded wheelchair was in front of the shelf. There was no sign or posting that the survey results were in the binder on the shelf. On 4/25/18 at 8:30 am, the binder was still on the shelf in the alcove. There was no wheelchair in the alcove and no sign that the survey results were there. During interview on 4/20/18 at 10:32 am, the ADON stated he had reviewed where the survey results were at the Resident Council Meeting in (MONTH) or February. (The minutes verified the residents were told the survey results were in the lobby.) He stated the survey results used to be on a table in the lobby, but they got moved. 10NYCRR415.3(c)(1)(v)

Plan of Correction: ApprovedJune 1, 2018

I. Immediate Corrective Actions
1. The current survey reports are located in prominent areas (lobby, and on each floor across from elevators) and are accessible to all residents and families.

II. Identification of Other Residents
1. All Residents are potentially affected by failure to provide appropriate access to survey reports.
2. The appropriate signage regarding current survey reports is located on Resident bulletin boards, at the front entrance and on all floors across from the elevators.

III. Systemic Changes
1. Residents will be informed of the right to access the DOH survey reports and the locations within the facility. (i.e. Discussion in Resident Council, information placed on the individual Resident activities calendar and Admissions Packet)
2. All staff will be in-serviced on the locations, availability and Resident Right for access of the DOH survey reports.
3. The lesson plan concentrates on the Residents? rights to access this information and the facility?s responsibility to ensure access.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. An audit tool will be developed to track compliance with the accessibility of current survey reports.
2. Audits will be done weekly x4 and monthly thereafter.
3. Audits with negative findings will have immediate correction by the Administrator.
4. Audit findings will be presented to the QA committee for evaluation and continuation.
V
Responsible Party: Administrator

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

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that floors and tables were clean on 4 of 6 resident units. This is evidenced as follows. The floors and equipment were spot checked on 04/24/2018 at 9:15 am. The corridor and common area floors next to walls had dirt and a brown build-up and food particles were under tables on the A-1 unit, B-2 unit, A-3 unit, and B-3 unit. The floors in resident rooms A-133, A-138, B-220, and B-221 were soiled with a brown build-up next to the walls. The Director of Environmental Services stated in an interview conducted on 04/24/2018 at 11:10 am, that the soiled floors and tables should have been kept clean. 483.10(i)(2)

Plan of Correction: ApprovedJune 1, 2018

I. Immediate Corrective Actions
1. On 4/24/18 the Director of Environmental services had the tables and equipment in the common areas on units A-1, B-2, A-3, and B-3 cleaned.
2. On 4/24/18 the floors in Resident rooms A-133, A-138, B-220, and B-221 were cleaned.
3. On 4/25/18 the corridor and common area floors next to walls were cleaned and the build-up was removed.
4. The Director of Environmental Services developed a plan to prevent excess build-up and thoroughly clean the corridor floors and common area floors on all nursing units.
5. The Administrator educated the Director of Environmental Services to ensure the proper care and cleanliness of the environment.

II. Identification of Other Residents
1. The Administrator, Director of Environmental Services, and Director of Plant Operations conducted environmental rounds to identify other areas in need of attention.
2. The Director of Environmental Services will maintain a list of any identified areas.

III. Systemic Changes
1. The Director of Environmental Services reviewed the policies for maintaining the cleanliness of the environment.
2. All Environmental Services staff will be in-serviced on this policy by the Director of Environmental Services to ensure understanding and compliance.
3. The lesson plan concentrates on the responsibility to follow proper procedures in the cleaning and maintenance of the environment, floor maintenance, and proper cleaning and sanitation of tables and equipment.
4. A copy of the lesson plan and attendance was filed for validation.

IV. QA Monitoring
1. The Director of Environmental Services developed an audit tool to track compliance with the requirements for maintaining the cleanliness of the environment and equipment.
2. Audits will be done on all units weekly x4, bi-weekly x2 and monthly x4 by the Director of Environmental Services /designee.
3. Audits with negative findings will have immediate correction by the Director of Environmental Services.
4. Audit findings will be presented to the QA committee for evaluation and continuation.

V.
Responsible Party: Environmental Services

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review during the recertification survey, the facility did not protect all cooking facilities in accordance with adopted regulations. NFPA 17A Standard for Wet Chemical Extinguishing Systems 2009 edition section 7.3.3 requires that at least semiannual maintenance to be conducted on kitchen fire-extinguishing systems in accordance with the manufacturer's listed installation and maintenance manual. Specifically, the kitchen fire extinguishing system was not tested semi-annually. This is evidenced as follows. The kitchen fire extinguishing system test reports were reviewed on 04/19/2018. The documentation provided for tests conducted as of the last recertification survey revealed that the kitchen fire extinguishing system was tested on [DATE], 08/14/2017, and 02/07/2018. The Director of Facility Services stated in an interview conducted on 04/19/2018 at 3:00 pm, that he did not know as to why the kitchen fire extinguishing system was not tested semi-annually between 12/2016 and 08/2017. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.2.3; 2011 NFPA 96; 2009 NFPA 17A 7.3.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.2.6; 1998 NFPA 96; 1998 NFPA 17A 5-3.1.1(e)

Plan of Correction: ApprovedMay 29, 2018

Cooking Facilities
1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
The facility will maintain the NFPA 17A Standard for Wet Chemical Extinguishing Systems 2009 edition section 7.3.3 by conducting semi-annual maintenance on the Kitchen fire-extinguishing systems in accordance with the manufacturer?s listed installation and manual.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
To ensure that the facility stays in compliance with all inspections and are conducted in the time frame required an inspection form has been developed to monitor the required testing.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The inspection form will have due dates marked for semi-annual inspections of the kitchen fire extinguishing systems per maintenance manual.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Plant Operations will review the inspection form monthly to ensure all inspections are completed in the time frame required and remain in compliance. The schedule for all inspections will be reviewed at the Safety Committee meeting.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Completion date: (MONTH) 25, (YEAR)

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the exit discharges to the public way were not free of all impediments for full instant use. NFPA 101 Life Safety Code 2012 edition section 7.1.10.1 requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Specifically, 3 of 12 exit discharges were not free from impediments for full instant use under all weather conditions. This is evidenced as follows. The exit discharges were inspected on 04/23/2018 at 11:40 am. The exit discharges from exits #9, #11, and #12 terminate outdoors onto soft-earth ground that when wet from heavy rain or snow melt can become an impediment. Maintenance Technician #1 stated in an interview conducted on 04/23/2018 at 11:40 am, that these areas had been addressed with hard-packed stone but the ground had been scrapped from snow blowing and the area now can become soft in wet weather during the spring 42 CFR 483.70 (a) (1); 2012 NFPA 101 7.1.10.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 7.1.10.1

Plan of Correction: ApprovedMay 30, 2018

1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
The Director of Plant Operations has met with paving contractors to obtain bids to black top the exits #9, #11, #12. The facility has scheduled the repairs for the exit discharges to be completed the week of (MONTH) 11-15, (YEAR).
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected, exits will be maintained free of all obstructions or impediments to full instant use in case of fire or other emergency.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
A contractor will be scheduled to come and repair the 3 exits. An inspection of all Exits will be done each spring, and any repairs will be completed accordingly.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The maintenance staff will inspect the Exits each spring to ensure the integrity of the ground and ability to evacuate residents without any impediments. This will then be reported to the safety committee, and any needed repairs will be completed.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Completion date: (MONTH) 24, (YEAR)

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on employee interview and record review during the recertification survey, the facility did not conduct testing and maintenance protocols of patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.5.2.1 requires that facilities develop policies and protocols for the type of test and intervals for testing PCREE. Specifically, inspection or testing of electric beds was not conducted and no protocols were established for testing electric beds. This is evidenced as follows. The Director of Facility Services stated in an interview conducted on 04/24/2018 at 1:15 pm, that no electric beds utilized by the facility have been inspected or tested . The facility policy Medical Equipment was reviewed on 04/24/2018. This policy states PCREE will be maintained and checked in accordance with the manufacturer's instructions. The manufacturer's service manuals for 3 types of electric beds utilized by this facility were reviewed on 04/24/2018. These manuals require inspections either every 6 months or annually respective to the manufacturer. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.5.2.1; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5

Plan of Correction: ApprovedJune 4, 2018

1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
All residents currently residing in the facility have the potential to be affected this deficient practice. The facility will audit all PCREE to ensure compliance with NFPS 99 and the owner's and service manuals. The Director of Plant Operations has contacted a company to come in and do an electrical inspection on all electrical beds in the facility as per the NFPA 101 Electrical Equipment testing and maintenance requirements, which will occur on 6/6/18.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by the deficient practice. All electrical beds will be inspected on 6/6/18 to ensure compliance of the NFPA 101 Electrical Equipment testing and maintenance requirements.
All electrical equipment brought to the facility for patient care must be tested and inspected per the facility?s electrical policy and procedures and/or manufacturer?s recommendations.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The maintenance team will maintain tracking logs on the cleaning, maintenance and quality assurance checks per manufacturer?s instructions on the electric beds to ensure safety of all residents.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
Director of Plant Operations will review the logs to ensure the inspections are completed as per the manufacturer?s manual. He will report his findings at the Safety Committee Meetings and QA meeting.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Correction date: 6/24/18

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, it was determined that the facility did not test the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm and Signaling Code 2010 Edition Section 14.4.5 requires that initiating devices, such as smoke detectors, heat detectors, and manual pull stations (fire alarm system), require annual tests. Specifically, the fire alarm system was not tested annually. This is evidenced as follows. The fire alarm testing records were reviewed on 04/19/2018. This review revealed that the fire alarm system was tested on [DATE] and next on 12/13/2017, a period of 14 months and 21 days. The Director of Facility Services stated in an interview conducted on 04/19/2018 at 3:00 pm, that he does not know why fire alarm test was late as he was not employed when the testing was next due. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 9.6.1.3; 1999 NFPA 72: 14.4.5; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-2.2, 7-3.2

Plan of Correction: ApprovedMay 29, 2018

Fire Alarm Testing and Maintenance
1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
This facility will test and maintain the Fire Alarm System as per NFPA 70, National Electric Code and NFPA 72, National Alarm and Signaling Code. The next Fire Alarm Test will be scheduled between 11/15/18- 12/13/18.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
To ensure that the facility stays in compliance with the NFPA 72 section 14.4.5 that requires annual testing of the Fire Alarm System, a yearly inspection form has been developed to monitor all annual inspections.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The inspection form will have due dates marked for annual testing of the smoke detectors, heat detectors, and manual pull stations.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
The Director of Plant Operations will review the annual inspection form to ensure all smoke detectors, heat detectors, and manual pull stations inspections are completed in the time frame required and remain in compliance. Safety committee will review and discuss the upcoming inspections that need to be scheduled.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Completion date: (MONTH) 25, (YEAR)

K307 NFPA 101:PATIENT SLEEPING ROOM DOORS

REGULATION: Patient Sleeping Room Doors Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 18.2.2.2, 19.2.2.2, TIA 12-4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 7.2.1.15 requires that door assemblies in exit enclosures be tested and inspected not less than annually in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition (NFPA 80) Chapter 5 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protectives, 2010 Edition (NFPA 105) as is applicable. NFPA 80 section 5.1.5 and NFPA 105 section 5.1.4 both require that defects, damage, and impairments shall be corrected. Specifically, the annual fire door inspection revealed defects that have not yet been corrected. This is evidenced as follows. The fire-rated door inspection documentation, reviewed on 04/19/2018, revealed that 69 of 85 fire-rated or smoke barrier doors did not pass inspection. The Director of Facility Services stated in an interview conducted on 04/19/2018 at 3:00 pm, that the repairs to the fire-rated and smoke barrier doors are in progress and that he does not know why the work is not yet finished. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.2.1, 7.2.1.15; 2010 NFPA 80 Chapter 5; 2010 NFPA 105 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.2.1, 7.2.1

Plan of Correction: ApprovedMay 18, 2018

1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
In accordance with the adapted regulations NFPA 101 Life Safety Code 2012 edition section 7.2.1.15 requires Fire Doors to be tested annually. The annual inspection denotes the need for door closures and miscellaneous work to be completed on the Fire/Smoke doors. All 31 Fire Doors and 54 Smoke doors will be brought into compliance by completing the required work as stated in the Fire/Smoke Door report.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents can be affected by this deficient practice, therefore a monthly audit form will be completed to ensure all Fire /Smoke doors are in compliance. The annual Door Inspection and Inventory will be completed per regulation.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
Upon completion of future Fire/Smoke Door inspections, the Director of Plant Operations will review the findings with the administrator. The Director of Plant Operations will assign tasks and timeline to complete all needed repairs. A weekly update will be conducted with the administrator and final inspection within 30 days will be completed by the Director of Plant Operations.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
A monthly Preventative Maintenance program will be developed to ensure that all Fire/Smoke rated doors are in compliance with the NFPA 101 Life Safety code section 7.2.1.15. All results of any non-compliance issues will be discussed in the Safety Committee meeting and reported to the monthly QA meeting.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
RP: Director of Plant Operations
Completion Date: 6/25/18

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, communication plan did not include provisions for the care and treatment of [REDACTED]. This is evidenced as follows. A review of the Emergency Plan on 04/19/2018 revealed that the policies and procedures did not include provisions for the care and treatment of [REDACTED]. The Administrator and the Director of Facility Services stated in an interview conducted on 04/19/2018 at 9:00 am, that the Emergency Plan does not currently have, but will be revised to include provisions for care at alternate site. 42 CFR: 483.73(b)(8)

Plan of Correction: ApprovedMay 29, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
This facility will include an alternate non healthcare site in the event a waiver is declared. This will include the provisions for care and treatment for [REDACTED].
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by this deficient practice. The facility Emergency Preparedness plan will be updated to include provisions for resident care and treatment at a non-medical site.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
This facility has been in contact with the Health Educator at Saratoga County Emergency Preparedness Program.
Contacts will also be made with the local Red Cross and facility vendors for emergency supplies.
The facility?s contracted pharmacy will be notified to package a minimum of 72 hour supply of medication and deliver per the Incident Command Leader.
This facility is participating in the Saratoga County Coalition regarding Emergency Preparedness and mutual aid/ambulance corps.
Staff education on facility Emergency Preparedness at a non- medical site.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
Review of the facility?s updated Emergency Preparedness Plan will be conducted during the Safety Meeting. Any changes per regulation will be included and logged in the Table of Revisions Log.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Completion date: 6/25/18

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not installed in accordance with adopted regulations. NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.1.1 requires automatic sprinkler protection throughout the premises, and Section 8.6.5.1.2 permits certain limitations on obstructions to the sprinkler system discharge pattern. Specifically, automatic sprinkler protection was not provided in all areas, and unacceptable obstructions encumbered sprinkler head discharge patterns. This is evidenced as follows. A spot check of the sprinkler system was conducted on 04/23/2018 at 12:10 pm. Automatic sprinkler protection was missing in the maintenance office closet and over the housekeeping storage area in the Central Supply room. Metal support beams obstructed sprinkler head discharge patterns in the Central Supply Room. The Director of Facility Services stated in an interview on 04/23/2018 at 12:10 pm, that he will address the obstructions and missing sprinkler head found. 42 CFR 483.70 (a) (1); 2012 NFPA 101: 19.3.5, 9.7; 2010 NFPA 13: 8.1.1, 8.6.5.1.2

Plan of Correction: ApprovedMay 30, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Sprinkler System Installation
1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
The Director of Plant Operations has contacted the Sprinkler Company to provide the facility with a quote to install two sprinkler heads and to have one sprinkler head lowered due to the metal support beam that obstructs water flow. This work will be (has been) completed on [DATE].
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A facility wide sprinkler audit will be completed to ensure the safety of all residents.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The Sprinkler Company has been contacted by the Director of Plant Operations to complete a facility wide house audit to ensure the building is fully sprinkled.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
Any findings from the Sprinkler Company will be remedied / discussed at the Safety Committee Meeting /QA meeting.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Completion date:[DATE]

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: April 25, 2018
Corrected date: June 24, 2018

Citation Details

Based on staff interview and review of inspection records during the recertification survey, the automatic sprinkler system was not tested in accordance with adopted regulations. NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition section 5.3.3.1 requires that alarming devices servicing sprinkler systems shall be tested quarterly, and Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, 1 of the past 4 required sprinkler system flow alarm device tests was not conducted. This is evidenced as follows. The sprinkler system inspection records were reviewed on 04/19/2018. The records showed that the flow alarm devices were not tested during the second quarter of (YEAR). Observations of the sprinkler system on 04/11/2018 at 9:15 am, and again on 04/23/2018 at 3:45 pm, revealed three sprinkler heads in the main kitchen, 3 sprinkler head in the physical therapy room, and one sprinkler head in the 2nd floor air handler room that were found with a coating of dust. The Director of Facility Services stated in an interview conducted on 04/23/2018 at 3:45 pm, that he will have the sprinkler heads cleaned and will ensure the required sprinkler flow alarm testing is not missed. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5, 9.7.7, 9.7.8; 2011 NFPA 25 5.2.1.1.1, 5.3.3.1; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.6, 4.6.12, 9.7.5; 1998 NFPA 25 2-2.1.1, 2-3.3

Plan of Correction: ApprovedJune 1, 2018

1. What corrective actions will be accomplished for those residents found to be affected by this deficient practice?
The automatic sprinkler system flow alarm devices will be tested quarterly in accordance with the adopted regulation, and the 3 sprinkler heads in the physical therapy room and one in the air handler room have been cleaned. The sprinklers will be cleaned bi-annually ( July/ January) and as needed.
2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have a potential to be affected by this deficient practice, therefore, a preventative maintenance schedule has been completed to ensure quarterly testing of the sprinkler system and ensure sprinkler heads are free of foreign materials.
House wide audit will be conducted to ensure all sprinkler heads are free of foreign materials including dust. And the cleaning schedule will consist of a bi annually cleansing of sprinkler heads and/or as needed.
3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur?
The Director of Plant Operations will review the inspection form to ensure quarterly sprinkler inspections are completed per regulation and remain in compliance.
4. The corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice.
Safety committee will review and discuss the quarterly inspections and cleanliness of sprinklers. Any negative findings will be corrected.
5. Date for correction and the title of the person responsible for corrections of each deficiency.
PR: Director of Plant Operations
Completion date: 6/24/18