The Grand Rehabilitation and Nursing at River Valley
February 2, 2017 Certification Survey

Standard Health Citations

FF10 483.45(b)(2)(3)(g)(h):DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

REGULATION: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-- (2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

Based on observation, interview and record review conducted during a recent recertification survey, it was determined during review of the facility's medication storage, for two of four floors (2nd and 4th Floors), that current acceptable standard of practice regarding storage of insulin injection was followed. Specifically, multiple multi-dose vials of Humalog and Lantus insulin injections were opened and not dated. The findings are: 1. Observation of the 4th Floor medication storage was conducted on 2/2/17 at 2:52 PM. Opened, undated multi-dose Humalog Insulin vials assigned to Residents #129 and #203, respectively, were found in the West Side medication cart. The medication Licensed Practical Nurse (LPN #1) was interviewed on 2/2/17, at the time of the observation, and stated she had no idea why both insulin vials were opened and not dated. LPN #1 further stated both insulins were in use, good for 30 days, should have been dated when opened, and discarded after the expiration date. 2. Observation of the 2nd Floor East side medication cart was conducted on 2/2/17 at 3:22 PM. Noted were an opened multi-dose Lantus Insulin vial, assigned to Resident #85, with a date 1/1/17 written on the side of the vial, and included a pharmacy dispense date of 8/29/16 inscribed on its label and an opened Lantus Insulin vial assigned to Resident #30, with a date 1/1/17 written on the side of the vial, and a pharmacy dispense date of 8/29/16 inscribed on its label. The 1/1/17 dates on both insulin vials were not identified as the date they were opened or the date they would be discarded. LPN #2 was interviewed on 2/2/17 at the time of the observation and stated that the insulins should have been dated when opened, and discarded after 28 days of opening. LPN #3 was interviewed on 2/2/17 following the above observations and stated that she did not know if the dates represented the dates the vials were opened or the dates it should be discarded. LPN #3 stated that the insulin vials should have been dated when opened, and discarded after 28 days after opening. The manufacturer of Humalog and Lantus insulins recommended that used (opened) and unrefrigerated insulin must be dated when opened and discarded after 28 days, even if the vials still contain the medicine. 415.18 (d)

Plan of Correction: ApprovedFebruary 27, 2017

F 431:
Corrective Action:
Open insulins from the 4th and 2nd floor were removed and discarded. The nurses involved were re- in serviced by the Director of Nursing on proper storage of insulin, which included dating when opened and following the institutional policy on discarding all insulin after 28 days. Residents #129, #203 #30, #85 were assessed to ensure they had no untoward effect, there were none. All medication carts were checked for open multi vials, to ensure that they were dated, focus was placed on Insulins. Those that were identified, were removed, and on the spot in service was given.
Residents at Risk for Same Practice:
A report was run on the facility's EMR to obtain a list of all residents receiving insulin. All residents receiving insulin were identified as being at risk for this deficient practice.
Systemic Changes:
Re- in service was given to all licensed nurses on proper storage of insulin, along with the institutional policy on dating multi vials when opened and discarding of insulin after 28 days.
This will be taught during orientation to all hired nurses. And will be re enforced during our quarterly medication in services.
All nurses were instructed to inspect the insulin prior to administration of insulin injection for appropriate date on vial. If no open date is noted, the nurses were instructed to immediately discard. Medication carts will be checked daily each shift by the Medication Nurse to ensure all medication, including insulin are dated and stored appropriately. Weekly inspections will also be conducted randomly by the Nurse Manager/ Designee to ensure compliance. This will all be done in addition to the existing inspections being conducted by the Consulting Pharmacist.
Monitoring for Corrective Action:
The facility will develop an audit tool to be utilized by the Medication Nurses and the Nurse Manager/Designee to ensure all medications, including insulin are appropriately dated and stored. The Nurse Manager will report the results of their respective units audits to the Director of Nursing on a monthly basis. The Director of Nursing will report the results of all units' audits to the QAPI Committee on a quarterly basis for one year.
Person Responsible & Date of Completion:
The person responsible is the Director of Nursing and the date of completion is 4/1/2017.

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

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recent recertification survey, the facility did not ensure that each medication administered had adequate indications for use for one of five residents reviewed for unnecessary medications (Resident #9). Specifically, the use of a diuretic did not include adequate indications to justify its use at all times when being administered. The findings are: Resident #9 is an [AGE] year old male with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) of 12/30/16 indicated the resident scored 13 out of 15 on the Brief Interview for Mental Status which suggested the resident was cognitively intact. The (MONTH) (YEAR) physician's orders [REDACTED]. The current comprehensive care plan (CCP) noted that the resident is at risk for fluid overload (excess fluid intake and/or retention) and renal impairment. The interventions to address these risks included observing for signs and symptoms of hypovolemia (a condition in which the liquid portion of the blood (plasma) is too low) and monitoring labs. This care plan made no reference to monitoring the resident's fluid intake. The food consumption records for the month of (MONTH) (YEAR) revealed that for the 30 days available, food and fluid intake data was missing for 71 of the 90 meals served. The data available for the remaining meals revealed that the resident's intake at meal times varied from 120 cc to 360 cc. The laboratory reports dated 1/23/17 revealed that the resident's blood urea nitrogen (BUN) level and BUN/creatinine ratio (possible indicators for renal function and hydration status) were elevated. BUN was noted to be 83 (normal range is 8-23) and BUN/creatinine ratio was 56.8 (normal range is 10-28). There was no documented evidence that the adequacy of the resident's fluid intake was determined and the need to continue the above diuretics was re-evaluated. The Registered Dietitian (RD) was interviewed on 2/2/17 at 2:22 PM and stated she was aware that food and fluid intakes were not being monitored frequently. The attending physician was not available for interview. 415.12(1)(1)

Plan of Correction: ApprovedFebruary 27, 2017

F 329:
Corrective Action:
Resident #9 was examined and assessed by the RN and MD. There were no negative effects on the resident noted. MD confirmed the adequacy and justification of the diuretics that are being used for resident #9. Resident intake is being documented by the CNA every shift on the Kiosk and checked each shift by the Charge Nurse for completion.
Residents at Risk for Same Practice:
All residents receiving diuretics were identified as being at risk for the same deficient practice A report for all residents receiving diuretics was obtained from the facility EMR. All residents who are on a diuretic were reviewed and will be assessed by RN/MD/Dietician. Indications/justification for use will be evaluated and confirmed to be adequate.
Systemic Changes:
RN?s, LPNs, CNA's were re- in serviced by the Director of Nursing on the importance on documentation of food/fluid intake for all residents. At the end of each shift, the Charge Nurse will check to ensure that residents receiving diuretics are charted by the CNA for intake on that shift. Audits will be done daily by the Nurse Manager/Designee to ensure that residents are receiving adequate intake of food and fluid. Any resident on a diuretic that is found to have a poor intake over a three day period will be evaluated by the clinical team for poor nutrition and hydration. On a monthly basis, each NM will review with MD all residents that are on diuretics to ensure appropriate indications for continuation are in place.
Monitoring for Corrective Action:
The Charge Nurse will audit the food/fluid consumption sheets on a daily basis for all residents receiving diuretics as they are considered to be at risk. Residents with poor P.O. intake over a three day period will be evaluated by the Clinical Team including the M.D., RN and Dietician. The results of their audits will be reported to the DNS on a weekly basis. The DNS/Designee will report the results of their findings to the QAPI Committee on a quarterly basis for a period of six months and ongoing if needed.
Person Responsible & Date of Completion:
The DNS is responsible and the date of completion is 3/31/17

FF10 483.45(c)(1)(3)-(5):DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

REGULATION: c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (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. (4) The pharmacist must report any irregularities to the attending physician and the facility?s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility?s medical director and director of nursing and lists, at a minimum, the resident?s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident?s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident?s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recent recertification survey, the facility did not ensure for two of five residents reviewed for unnecessary medications (Residents #11 and #196) that recommendations made by the pharmacist during a monthly MRR (Medication Regimen Review) were acted upon by the medical director or the attending physician and the Director of Nursing (DON). The findings are: 1. Resident #11 was admitted with [DIAGNOSES REDACTED]. The monthly MRR revealed the following recommendations by the consultant pharmacist: - 9/22/16 - Resident is on Fosamax. The consultant pharmacist documented: (1) it should be the first medication, food, drink of the day and should be scheduled 30 minutes before all other medications; (2) add weekly pulse monitoring; and (3) add to Advair order to rinse mouth with water after use and spit out, should be dosed every 12 hours, and to change the order; - 10/30/16 - (1) charting omissions on multiple medications; - 11/29/16 - (1) resident on a PPI, (Proton Pump Inhibitor; used to treat heartburn and acid reflux) which should be administered 30 to 60 minutes before breakfast and to change the administration time; Further review of the MRR revealed no evidence that these recommendations were acted upon by the DON or the attending physician or the medical director. 2. Resident #196 was admitted with [DIAGNOSES REDACTED]. The 10/30/16 MRR by the consultant pharmacist revealed charting omissions on multiple medications. There was no documented evidence that this recommendation was acted upon by the DON or the attending physician or the medical director. The DON was interviewed on 2/2/17 at 2:00 PM and stated she had been employed for only a few weeks and had no idea why these recommendations were not acted upon. The medical director and the attending physician were not available for interview. 415.18(c)(1)

Plan of Correction: ApprovedFebruary 27, 2017

F 428:
Corrective Action:
All recommendations from the consultant pharmacist was reviewed and were immediately addressed. Residents that were affected by this deficient practice were seen by their attending physician. The nurses that were directly involved were educated on proper time of administering certain medications. Omission of medications were also addressed. The Director of Nursing conducted the in-services.
Residents at Risk for Same Practice:
All residents have the potential of being affected by this deficient practice. All pharmacy recommendations for the month of (MONTH) and (MONTH) were reviewed by the physician and DNS and recommendations were followed where appropriate.
Systemic Changes:
In service will be given by the consulting pharmacist to all nurses to explain the rationale/importance for recommendations from the pharmacist. This in service will be recorded, so that it will be a part of our continuing education for all nurses.
A list of medications that require specific times, or specific instructions i.e ( medications that should be taken 30 minutes before all other medications; medications that requires rinse of mouth after use; etc) are being sent from the pharmacy and being placed on each unit for reference.
The nurse will indicate the specific instruction beside each medication when ordered.
All Pharmacy reports pertaining to administration will be addressed /discussed by the Nurse Manager at the unit level with the nurses.
Monitoring for Corrective Action:
To ensure compliance, the Director of Nursing will review the MRR on a monthly basis upon receiving from the Consulting Pharmacist. The results of the MRR will be audited on a monthly basis by the Director of Nursing to ensure that all recommendations are followed as needed by the M.D. and Nurses. An audit tool will be developed to monitor compliance with Pharmacist recommendations.
An audit will be conducted on a daily basis to monitor all medication omissions. The information for the audits will be obtained from the facility's EMR. The results of these daily audits will be shared with the Nurse Managers on a daily basis to allow them to educate/discipline their Medication Nurses and follow up with the MD to notify regarding omissions and to follow up as needed. The results of the audits will be reported to the QAPI Committee on a quarterly basis by the Director of Nursing for a period of one year.
Person Responsible & Date of Completion:
The person responsible is the Director of Nursing and the date of completion is 4/1/2017.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

Based on observation and interview conducted during a recent recertification survey, the facility did not ensure that food was stored in accordance with professional standards for food service safety. The kitchen and food storage areas were not maintained in a clean and sanitary manner. Specifically: (1) the thermometers in two nourishment refrigerators on 2 of 3 floors (2nd and 5th) did not register the proper temperature; (2) kitchen electric fans had excessive accumulation of dust; and (3) the floors in the walk-in freezer and refrigerator were soiled with spillage and littered with debris. The findings are: 1. An initial inspection of the kitchen was conducted in the morning of 1/30/17. The floors in the walk-in freezer and refrigerator were noted with spillage and were littered with debris. The regional director of food service stated at that time the floors would be cleaned. During a follow-up visit to the kitchen on 2/2/17, two out of four wall-mounted electric fans had an accumulation of dust. The walls adjacent to the fans were also noted to be dusty. 2. The thermometer in the nourishment refrigerator on the 5th Floor registered 46 degrees Fahrenheit (F) during an inspection on 2/2/17 at 3:15 PM. At 3:50 PM, the thermometer in the nourishment refrigerator on the 2nd Floor registered at 60 degrees F. Both refrigerators contained snacks and nourishments including milk and commercially-prepared milkshake. The unit Registered Nurse manager on the 2nd Floor was interviewed at the time of the observation and stated that it was the responsibility of the dietary staff to monitor the refrigerators. The New York State Department of Agriculture's Food Storage Guidelines recommend that food must be refrigerated at 40 degrees F or below to prevent spoiling and prevent food-borne illness. 415.14(h)

Plan of Correction: ApprovedFebruary 27, 2017

F 371:
Corrective Action:

All areas and utilities in the kitchen were cleaned the same day they were observed to be soiled and dusty.
All dietary staff were in-serviced by the Director of Culinary Services about adherence to kitchen cleanliness.
All refrigerators in the clean utility rooms were inspected by the Director of Building Services and adjusted accordingly to within accepted range of 34-41 degrees. They are now keeping appropriate temperature within approved range.
All building service staff were in-serviced by the Director of Building Service Director about maintaining appropriate temperatures in all refrigerators.
Residents at Risk for Same Practice:
All residents have been identified as potentially being affected by this deficient practice.
Systemic Changes:
The Director of Culinary Services or their designee will monitor the kitchen on a daily basis to ensure it is appropriately cleaned. Criteria will include monitoring all kitchen fans, appliances, refrigerators/freezers and general kitchen cleanliness.
The Director of Maintenance or their designee will monitor all nourishment refrigerators to ensure they are maintaining good temperatures.
Monitoring for Corrective Action:
The Director of Culinary Services/Designee will be responsible to audit the kitchen cleanliness on a daily basis to ensure compliance with kitchen protocol. The Director of Culinary Services will report their finding to the QA committee on a quarterly basis for six moths and ongoing as needed.
The Director of Maintenance will be responsible to audit the temperature logs to ensure compliance and appropriateness of kitchen cleanliness and refrigerator temperatures. The Director of Culinary Services will report their finding to the QA committee on a quarterly basis for six months and ongoing as needed.
Person Responsible & Date of Completion:
The person responsible for the kitchen cleanliness is the Director of Culinary Services & the date of completion is (MONTH) 31, (YEAR).
The person responsible for the temperature logs is the Director of Maintenance and the date of completion is (MONTH) 31, (YEAR).

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

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

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

Based on observation, interview and record review conducted during a recent recertification survey, the facility did not provide adequate housekeeping services necessary to maintain a clean and comfortable environment. Specifically, multiple residents' wheelchairs on 3 of 4 floors (3rd , 4th and 5th) were not maintained in clean and sanitary condition. The findings are: 1. During observation of a lunch meal on 1/30/17, on the 5th Floor dining room, nine wheelchairs occupied by residents were noted to have accumulation of dried residue, dust and dirt on the wheels and spokes. These wheelchairs included those that were owned and occupied by Residents #95, #105 and #145. A follow-up observation was made on 2/2/17 during another lunch meal. Eleven wheelchairs which were being used by Residents #145 and #105 were noted to have build up of dried residue, dust and dirt. During a lunch meal observation on 1/31/17, two wheelchairs in use on the 4th Floor dining room and one on the 3rd Floor dining room were observed to be soiled with residue, dust and dirt. The director of housekeeping was interviewed on 2/2/17 at about 11:45 AM and stated the wheelchairs are cleaned weekly every Wednesday according to floors. The month begins on the 5th Floor and ends on the 2nd floor. The director of housekeeping presented the schedule for (MONTH) (YEAR) and was consistent with what was reported by this director during this interview. The director of housekeeping further stated the wheelchairs were cleaned more often if requested by nursing. Additional observation was conducted on the 5th Floor on 2/2/17 at 12:30 PM, with the director of housekeeping, where eleven wheelchairs were noted to be soiled as mentioned above. Following this observation, the director of housekeeping stated that the wheelchairs have not been cleaned as scheduled. She stated the housekeeper assigned to perform this task should have informed her that the wheelchairs were not cleaned according to the schedule. The housekeeper assigned to clean the wheelchairs was not available for interview. 415.5(h)(2)

Plan of Correction: ApprovedFebruary 27, 2017

F 253:
Corrective Action:
All wheelchairs were cleaned the same day they were observed to be soiled. All housekeeping staff were re-inserviced by the Director of Housekeeping about adherence to existing wheelchair cleaning schedule.
Residents at Risk for Same Practice:
All residents that use wheelchairs were identified as being at risk to be affected by the same deficient practice. All wheelchairs in the facility were checked to ensure that the deficient practice did not exist elsewhere. All chairs that were found to be out of compliance were cleaned.
Systemic Changes:
The Housekeeping Director will monitor all units' wheelchairs after a scheduled cleaning day to ensure compliance with schedule. The Housekeeping Director will go to the respective units to visually inspect each chair that was scheduled for cleaning. The Housekeeping Director will ensure that the wheelchair is properly cleaned and sanitized in it's entirety; including the leg rests, cushions and cup holder.
Monitoring for Corrective Action:
The Director of Housekeeping will be responsible to audit no less than 10 wheelchairs per unit on a weekly basis and as needed to ensure compliance and appropriateness of wheelchair cleaning schedule. The Director of Housekeeping will report their finding to the QA committee on a quarterly basis for one year.
Person Responsible & Date of Completion:
The person responsible is the Director of Housekeeping & the date of completion is (MONTH) 31 , (YEAR).

FF10 483.55(b)(1)(2)(5):ROUTINE/EMERGENCY DENTAL SERVICES IN NFS

REGULATION: (b) Nursing Facilities The facility- (b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; (b)(2) Must, if necessary or if requested, assist the resident- (i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; (b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recent recertification survey, the facility did not ensure that each resident was provided the necessary assistance to address the need for dentures. This was evident for one of three residents (Resident #95) reviewed for dental care. Specifically, the resident was partially edentulous and the need for possible use of dentures was not addressed by the interdisciplinary team. The findings are: Resident #95 is 67-years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (a resident assessment tool) of 11/26/15 revealed that the resident had no cognitive impairment. The dentist examined the resident on 6/14/16 and documented on his consultation report that the resident had no bottom teeth. This consultation report did not address the resident's need for any dentures. The most recent comprehensive care plan documented that the resident had dental problems related to missing teeth. This care plan did not address the need for any dentures. The resident was interviewed on 1/31/17 at 9:08 AM and was asked if she had any problems with dentures. The resident stated she did and that she was waiting to get false teeth. Observation at this time revealed the resident to have missing teeth. The unit Registered Nurse (RN) manager was interviewed on 2/2/17 at 12:30 PM and 1:10 PM and stated she was not aware of any plan to provide the resident with any dentures. The unit RN manager then went to speak to the resident and stated that her discussion with the resident revealed that while the resident was residing at an assisted living facility, the use of dentures was discussed. There was no documented evidence that the facility addressed or discussed with the resident the need for possible use of dentures. 415.17(c)

Plan of Correction: ApprovedFebruary 27, 2017

F 412:
Corrective Action:
After resident #95 was identified the resident was seen by the dentist on 2/14/17 and the process for getting dentures has begun.
Identification of Other Potentially Affected Residents:
All residents that are edentulous or have broken poor fitting dentures have the potential to be affected by the same deficient practice. An assessment of all residents that are in this category was done to ensure that no other residents were affected. None were identified.
Systemic Changes to Prevent Recurrence:
Upon admission, all residents will be assessed for poor/loose fitting dentures by the Nurse completing the admission assessment. If noted upon assessement, a referral will be made to be seen by the Dentist. The Dentist is on-site at the facility on a weekly basis. All referrals to the Dentist will be audited on a weekly basis by the Unit Clerk to ensure they have been seen by the Dentist within the two week time frame. The nurse manager for each unit will ensure that these residents are seen and follow up care is done when applicable.
Monitoring of Corrective Action:
The facility will develop an audit tool to ensure that all new residents are seen by the Dentist within 2 weeks if edentulous (or with loose fitting/poor fitting dentures) & that follow up care is provided as needed. The Unit Clerk will report the results of their audits on a weekly basis to the NM. The NM will report their audit findings to the DNS who will report to the QA committee on a quarterly basis for a six moth period and ongoing as needed.
Person Responsible & Date of Completion:
The Director of Nursing will be responsible and the date of completion is 3/31/17.

Standard Life Safety Code Citations

K307 NFPA 101:RUBBISH CHUTES, INCINERATORS, AND LAUNDRY CHU

REGULATION: Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

5.2.3.2 Chute Discharge Doors 5.2.3.2.2 The bottom of a linen chute shall be protected by an approved automatic closing or self- closing door in accordance with 5.2.3. Based on observation and staff interview, the facility did not ensure that the bottom of the soiled linen chute was protected by an approved automatic closing or self- closing door. The findings are: On 1/31/2017 at approximately 11:50 AM, a tour of the soiled linen chute discharge room in the basement was conducted and it was noted that the door at the bottom of the linen chute was not self-closing or automatic closing. It was observed that the door had to be closed manually. In interviews conducted at the time of the findings, the Director of Maintenance stated that the door is not spring loaded, and the Director of Housekeeping stated that the door will be adjusted to ensure that it self closes. 2009 NFPA 82: 5.2.3.2.2 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedFebruary 24, 2017

K 541:
Corrective Action:
The laundry chute door was repaired and is now functioning properly. All building service and housekeeping staff were re-serviced about maintaining linen and laundry chute doors so they latch properly in their frames.
Date of Correction:
The date of correction is 3/17/2017
Systemic Change to Prevent Reoccurrence:
Audit tools for environmental records were updated to include all linen and laundry chute doors on a weekly basis. This is to ensure that doors are free from impediments, latch appropriately and fit in their frames properly.
Monitoring of Corrective Actions:
The results of the audit tool will be presented to the QA committee by the Director of Maintenance on a quarterly basis for one year.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 2, 2017
Corrected date: April 1, 2017

Citation Details

2011 NFPA 25 Chapter 8 Fire Pumps 8.3* Testing 8.3.1. Frequency 8.3.1.2* Electric- motor driven fire pumps shall be operated monthly. 8.3.2.3 The electric pump shall run a minimum of 10 minutes. 8.3.2.8 The pertinent visual operations or adjustments specified in the following checklists shall be conducted while pump is running: (2) Electrical system procedures as follows: (a) Observe the time for motor to accelerate to full speed (b) Record the time controller is on first step (for reduced voltage or reduced current starting) (c) Record the time pumps runs after starting (for automatic stop controllers). Based on record review and interview, the facility did not ensure that the automatic sprinkler system was maintained in accordance with NFPA 25, as evidenced by documentation for the required testing of the electric motor driven fire pump that was not provided. The findings are: During the review of routine sprinkler maintenance documentation on 1/31/17 at approximately 9:00 AM, it was noted that records for the annual test of the electric motor driven fire pump were provided. However, documentation of the required monthly churn test for this fire pump was not provided. In an interview at that time, the Director of Maintenance stated that he was not aware that monthly churn reports for the electric fire pump were required. 2012 NFPA 101 2011 NFPA 25: 8.3.1.,8.3.1.2*, 8.3.2.3, 8.3.2.8 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedFebruary 24, 2017

K 353:
Corrective Action:
The sprinkler service company has been contracted to do a monthly churn test for the fire pump.
Date of Correction:
The date of correction is 4/1/2017
Systemic Change to Prevent Reoccurrence:
Audit tools for environmental records were updated to include all monthly churn tests. This is to ensure that the monthly churn test for the fire pump is being done.
Monitoring of Corrective Actions:
The results of the audit tool will be presented to the QA committee by the Director of Maintenance on a quarterly basis for one year.