Riverside Center for Rehabilitation and Nursing
June 19, 2018 Certification/complaint Survey

Standard Health Citations

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident, 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 for 6 (Resident #'s 3, 5, 15, 45, 48, and #79) of 20 residents reviewed during the recertification survey. Specifically: for Resident #'s 3 and 45, there was no comprehensive care plans (CCPs) that provided goals, measurable objectives and timeframes to meet the resident's needs for positioning; for Resident #5, a CCP was not developed to include goals, measurable objectives and timetables to meet the resident's identified needs for pain; for Resident #15, review of the resident's care plans did not include documented dates the interventions were initiated; for Resident #48, review of the Depression Care Plan did not include documented dates the interventions were initiated; and for Resident #79, there was no Care Plan for Discharge. This is evidenced by: The facility Policy and Procedure for Resident Care Plans revised (YEAR), documented each resident care plan will contain the resident's current level of functioning, behavior, medical problems, and activities of daily living. Resident #3: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 5/29/18, assessed the resident had severe cognitive impairment. It identified the resident had impairment in range of motion on one side in both upper and lower extremities. On 6/13/18 at 1:24 PM, the resident was observed with a tan AFO (ankle-foot orthosis) device on his right foot, black gloves on both hands and a foam arm trough with straps for his right arm. The resident was not wearing a Darco boot over the AFO. The medical record did not include a CCP for the resident's positioning needs. The Profile Card (used by aides to provide needed care) documented: gloves on both hands, AFO for transfers. Under the Heading Mobility Comment it documented: non-ambulatory; right elevating leg rest, dycem under right foot petal with right Darco boot on when in wheelchair. Pt is known to remove foot rest and Darco boot, please encourage to use. During interview on 6/18/18 at 3:46 PM, Registered Nurse Manager (RNM) #1 stated the resident does not have a CCP that addresses positioning needs, that are identified on the Profile Card. The resident has the tan AFO on that is all that she has seen. The Profile card calls for an AFO for transfers. She did not know anything about the Darco boot. During interview on 6/19/18 at 9:33 AM, the Physical Therapist stated the resident needs the AFO on any time he needs to transfer. He can wear it in the wheelchair. The Darco boot is put on over the AFO to prevent sliding when transferred. The Darco should always be on when the resident is transferred and should be on when in the wheelchair. She said the Profile card could be more clear about that. During interview on 6/19/18 at 10:23 AM, Certified Nursing Assistant (CNA) #2 stated the resident stand pivot transfers with a gait belt. He uses the AFO device on his right leg then stays in it all day. She did not believe he had anything else over the AFO. He doesn't wear a shoe over the brace. She has not seen anything over the AFO. She thought the Darco boot was the AFO device. The CNA went with surveyor to the resident's room and the resident had a Darco boot over the AFO on his right foot. CNA #2 said she has not seen that before. During interview on 6/19/18 at 11:19 AM, the Director of Nurses stated there are no care plans here for positioning, they use the profile cards. That is what they do here. Resident #5: This resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the electronic Medication Administration Record [REDACTED]. A Social Work Progress Note dated 6/06/18, documented the resident stated he had trouble sleeping 4 nights out of 14 from foot pain. A Medical Progress Note dated 6/11/18, documented the resident had worsening lower extremity pain and 2+ [MEDICAL CONDITION] from knees to feet bilaterally. Increased lower extremity pain most likely due to myelodysplasti[DIAGNOSES REDACTED] causing bone pain. During an interview on 06/13/18 at 01:49 PM, the resident stated his foot hurt at times and sometimes the pain medication did not work. During an interview on 06/18/18 at 11:10 AM, CNA #1 stated most of the time the resident said he was in pain and told her the location of the pain. She would then tell his nurse. During an interview on 06/19/18 at 09:32 AM, Licensed Practical Nurse (LPN) #1 stated last week the resident started to complain his foot and leg hurt. The resident had [MEDICAL CONDITION]. She told the nurse and the pain medication [MEDICATION NAME] was ordered. The resident stated he was not in pain when asked, but had non-verbal signs indicative of pain when touched. During an interview on 06/19/18 at 10:25 AM, Registered Nurse Manager (RNM) #1 stated the resident should have a Care Plan for Pain, but did not because she was not aware the resident was started on [MEDICATION NAME] twice a day. She had been on vacation and did not receive report the resident was started on a pain medication. She was not aware the resident had pain because he stated he had no pain when asked. Twenty-four hour sheets should have reflected the new order for pain medication, but did not. When she returned from vacation she received a report for only the last 4 days. Resident #15: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident as severely cognitively impaired and rarely understood what was said by others and was rarely understood. A physician's orders [REDACTED]. Review of resident's care plans did not reveal documented dates when the careplans were initiated with the exception of the At Risk for Bruising Careplan and At Risk for Alteration in Bowel Status Careplan. During an interview on 06/15/18 at 08:39 AM, Social Worker #4 stated that start dates should be on care plans when interventions are initiated. During an interview on 06/15/18 at 08:53 AM, the Assistant Director of Nursing stated the dates should have been initiated on the careplans. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedAugust 8, 2018

F656:
1. For residents #3 and #45 care plans have been written to provide goals, measurable objectives and timeframes to meet the resident?s needs for positioning. For resident #5 a CCP has been devised to include goals, measurable objectives and timeframes to meet the resident identified needs for pain. For resident #15 the CCP has been updated to include documented dates that the interventions were initiated. For resident #48 the depression CCP has been updated to include documented dates the interventions were initiated. For resident #79 a CCP has been devised for the discharge.
2. The unit managers will complete an audit of all residents CCP. The audit will include goals, measurable objectives and timeframes to meet the residents medical, nursing, and mental psychosocial needs of each need. The audit will be monthly.
3. Education will be provided for the interdisciplinary care planning team. Education will consist of creating a CCP with goals, measurable objectives and timeframes to meet the residents medical, nursing, and mental psychosocial needs.
4. The DON or designee will monitor the monthly audit to ensure the resident CCP are complete and accurate. The QAPI committee will evaluate the data and act on the information as needed.

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

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse as required by adopted regulations. Outside refuse storage areas are to be kept clean. Specifically, the trash compactor and area around the trash compactor were not clean. This is evidenced as follows. The trash compactor area was inspected on 06/13/2018 at 8:19 am. The trash compactor and wooden stairs leading to the compactor were soiled with black oily drip marks and stains. The Director of Plant Operations stated in an interview conducted on 06/13/2018 at 8:19 AM, that compactor and area should be kept clean, and it is on his preventive maintenance list, but has not yet had the opportunity to clean the area. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.150

Plan of Correction: ApprovedJuly 26, 2018

F814:
1. The trash compactor and area around the trash compactor were immediately cleaned and any items outside of the trash compactor were immediately discarded into the proper receptacle.
2. Education will be provided to maintenance, housekeeping, and dietary staff to keep the outside refuse storage areas clean, specifically the trash compactor and area surrounding the trash compactor.
3. An agreement was signed with a new waste company ? County Waste- as of (MONTH) 1, (YEAR). The compactor and wooden staircase will be eliminated and replaced with two 10 yard containers for trash and two 8 yard containers for recycling. The replacement garbage receptacles will be insect/rodent proof, covered, and placed on a hard level surface such as reinforced concrete or machine laid asphalt.
4. The Maintenance Director or designee will monitor daily for two weeks and then weekly through preventative maintenance procedures and report findings to the monthly QAPI committee. The QAPI committee will evaluate the data and act on the information as needed.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review during the recertification survey, essential equipment was not maintained in safe operating condition. The FDA Model Food Code and Chapter 1 Subpart 14 State Sanitary Code both state that automatic dishwashing machines (dish machine) are to sanitize food contact equipment and refrigerators are to maintain an ambient temperature at 41 degrees Fahrenheit (F) or less. Specifically, two food service equipment were not functioning properly. This is evidenced as follows. The main kitchen was inspected on 06/13/2018 at 8:19 am. When tested , the dish machine did not reach the required sanitizing temperature of 180 F. The Director of Food Service stated in an interview conducted on 06/13/2018 at 9:17 AM, that he was aware that the dish machine had been intermittently malfunctioning for the past week but has not yet submitted a work order with the maintenance department, the facility procedure to facilitate equipment repairs, to have it repaired. Observations of the refrigerator in the North Unit kitchenette (the refrigerator) on 06/13/2018 at 9:17 AM, revealed that the ambient temperature was 52 F, as measured by the refrigerator thermometer, and the refrigerator door gasket was not attached, loosely hanging off the bottom of the door. The Food Service Director stated in interview conducted on 06/13/2018 at 9:17 AM, that work orders had been submitted to repair the gasket on the refrigerator door; the unit remained in service as it seemed to recover from any high temperatures found during the morning check (approximately 8:00 am) if the door was kept closed; and the food was disposed if the refrigerator temperature was high. The Director of Plant Operations stated in an interview conducted on 06/13/2018 at 9:17 AM, that a new replacement refrigerator had been ordered but has not yet arrived. Record review of the refrigerator temperature logs, facility purchase orders, and facility work orders on 06/13/2018, revealed that the refrigerator temperatures were occasionally at or above 50 F since 01/22/2018, a new refrigerator was ordered on [DATE] (8 days prior to survey observations), and work orders dating from 01/23/2018 document issues with the refrigerator temperature and door seal (gasket). 10 NYCRR 415.5(e)(1)(2)

Plan of Correction: ApprovedJuly 26, 2018

F908:
1. No residents were in the area of the deficient practice therefore not affected.
2.
A. The automatic dishwashing machine was fixed by Northeastern Mechanical on Tuesday (MONTH) 26, (YEAR). Northeastern Mechanical changed out the motor and de-scaled lime build up, which caused malfunction. The automatic dishwashing machine operates within manufacture specifications.
B. The north unit refrigerator was immediately removed and the tuna fish sandwich was discarded. A new refrigerator had been ordered prior to annual survey and was delivered on Thursday (MONTH) 26, (YEAR). The new refrigerator was placed in the north unit kitchenette and temperatures read within regulatory guidelines.
3.
A. The maintenance director will perform monthly preventative maintenance on the automatic dishwashing machine to ensure that it operates within the manufacture specifications.
B. The north unit kitchenette refrigerator will be checked daily for freezer and refrigerator temperatures by the dietary department and any deficient temperatures reported to maintenance immediately. The maintenance director will perform monthly preventative maintenance on the refrigerators in the kitchenettes. All findings will be reported to the QAPI committee.

4. The Maintenance Director or designee will monitor through monthly preventative maintenance procedures and report monthly to the QAPI committee. The QAPI committee will evaluate the data and act on the information as needed.

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: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not adhere to adopted food safety regulations. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be refrigerated at not greater than 41 degrees Fahrenheit (F), and ready-to-eat foods may only be handled with sanitary food service gloves (gloves) or utensils. Specifically, the automatic dishwashing machine was not operating, in the main kitchen, within the manufacturer's specifications required to sanitize food surfaces, and on two of two units refrigerated TCS foods were warm, and ready-to-eat food was handled with contaminated gloves. This is evidenced as follows. The main kitchen was inspected on 6/13/2018 at 8:19 am. When checked, the automatic dishwashing machine final rinse was 114 F at 20 pounds per square inch (psi) water pressure and 0 parts per million (ppm) of available chlorine. The automatic dishwashing machine information date plate states that the minimal final rinse water temperature is to be 180 F at 20 psi 5 psi. The Food Service Director stated in an interview conducted on 6/13/2018 at 8:19 AM, that the automatic dishwashing machine had not been consistently working properly for the last week, and he had not yet contacted the maintenance department to have it checked. Finding North Unit A tuna fish sandwich found in the North Unit kitchenette refrigerator was 47 F when checked on 6/13/2018 at 9:17 AM. The label on the sandwich stated that it was prepared on 6/11/2018. The Food Service Director stated in an interview conducted on 06/13/2018 at 9:17 AM, that the tuna sandwich was both prepared and placed in the North Unit kitchenette refrigerator on 6/11/2018 and that as this refrigerator has not been working properly he has contacted the maintenance department to have it repaired. Finding South Unit During observation on 6/13/18 at 8:19 AM, Diet Aide #1 (DA) had gloves on. She handled numerous plates putting thumbs and fingers at least 2 inches beyond the rims. She used gloved hands to touch the plate cart and the ledge of the steam table numerous times. She did not change her contaminated gloves then picked up sausage and french toast repeatedly and put them on plates. During a dining observation on 06/13/18 at 12:26 PM, DA #1 picked up two grilled cheese sandwiches at 12:25 pm with gloved hands she had previously worn to serve food using kitchen utensils, handle plates, uncover food contained in the steam table, get temperatures of the food and to touch bins in the steam table. During a dining observation on 06/13/18 at 12:28 PM, DA #1 slid over and touched a peanut butter and jelly sandwich wearing the same gloves. During an interview on 06/13/18 at 12:33 PM, DA #1 answered question of what actions she should have taken before she touched the food with gloved hands by answering, wash my hands? During interview on 6/15/18 at 10:53 AM, Food Service Director #3 said the DA should have changed gloves after touching the cart and the ledge. Touching any other surface beyond the steam table would require hand washing and changing of gloves. The DA should use utensils for handling any food item, that is how they are trained. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.40(a), 14-1.80, 14-1.113

Plan of Correction: ApprovedJuly 26, 2018

1. No residents were in the area of the deficient practice therefore not affected.
2.
A. The automatic dishwashing machine was fixed by Northeastern Mechanical on Tuesday (MONTH) 26, (YEAR). Northeastern Mechanical changed out the motor and de-scaled lime build up, which caused malfunction. The automatic dishwashing machine operates within manufacture specifications.
B. The north unit refrigerator was immediately removed and the tuna fish sandwich was discarded. A new refrigerator had been ordered prior to annual survey and was delivered on Thursday (MONTH) 26, (YEAR). The new refrigerator was placed in the north unit kitchenette and temperatures read within regulatory guidelines.
C. Dietary Aide #1 was disciplined and immediately educated on washing hands and donning/doffing gloves after touching any other surface beyond the steam table. Dietary Aide #1 was further educated to use utensils for handling any food item.
3.
A. The maintenance director will perform monthly preventative maintenance on the automatic dishwashing machine to ensure that it operates within the manufacture specifications.
B. The north unit kitchenette refrigerator will be checked daily for freezer and refrigerator temperatures by the dietary department and any deficient temperatures reported to maintenance immediately. The dietary department will discard any food immediately when refrigerator temps are reported higher than regulation. The maintenance director will perform monthly preventative maintenance on the refrigerators in the kitchenettes. All findings will be reported to the QAPI committee.
C. All dietary aides will be educated on washing hands and donning/doffing gloves after touching any other surface beyond the steam table and educated to use utensils for handling any food item.
4. The Maintenance Director or designee will monitor the refrigerators through monthly preventative maintenance procedures and report findings monthly to the QAPI committee. The QAPI committee will evaluate the data and act on the information as needed.

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. The resident environment is to remain as free from accident hazards as is possible. Specifically, hot food service equipment was left unattended in an area in which confused residents had access. This is evidenced as follows: The South Unit resident dining room was inspected on 06/18/2018 at 11:08 am. The dining room door was opened, accessible to residents, and unattended. When checked, the water temperature in the steam table located in the dining room was 187 degrees Fahrenheit (F), and the metal surface temperatures of the steam table ranged from 117 F to 130 F. Additionally, all surfaces on the steam table were very hot to the touch. The Food Service Director and Licensed Practical Nurse (LPN #2) stated in an interview conducted on 06/18/2018 at 11:53 am, that after turning on the steam table for lunch service, the door to the dining room is to be closed and locked; and there are several wandering residents on the South Unit. During interview on 6/18/18 at 11:50 am, Dietary Aide #1 stated she had turned the steam table on at 10:30 am, set up the dining room and went on break. She went back to the South Unit dining room around 11:30 this morning. She forgot to lock the door this morning when she left. She said she had been trained to lock the door when she left the dining room. 483.25(d)

Plan of Correction: ApprovedJuly 26, 2018

F689:
1. No residents were in the area of the deficient practice therefore not affected.
2. The Unit Managers will audit the dining room doors on their units daily to ensure the doors are closed and locked at all times except when a resident activity or resident meal time is commencing.
3. The ADON provided immediate education to all staff on the importance of closing and locking the north and south unit dining room doors when leaving the area to ensure the residents are free from accidents and hazards, and that each resident receives adequate supervision to prevent accidents.
4. The Unit Managers or designee will audit the dining room doors on the north and south units to ensure the doors are closed and locked at all times except when a resident activity or resident meal time is commencing. The Unit Managers will report to QAPI meeting monthly on their findings. The QAPI committee will evaluate the data and act on the information as needed.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection control program to prevent the development and transmission of disease and infection determined for 2 of 3 dressing changes observed on one of two units. Also, the facility did not ensure personal care equipment was labeled on one of two units. Specifically, for Resident #5, the facility did not ensure standard precautions were maintained during a dressing change to the resident's stage 2 decubitus ulcer to his sacral area and an unstageable decubitus ulcer to his right heel. Specifically on South Unit, personal care equipment was not labeled for a resident in room [ROOM NUMBER]. This is evidenced by: Resident #5: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. The Policy and Procedure for Dressing Change with a revision date of 11/2009, documented the policy of following standard principles of asepsis per CDC. Clean technique and equipment is used to reduce or prevent the transmission of microorganisms from the environment to the wound or from the wound to the environment. Set up supplies needed for treatment and dressing on a clean field. Open dressings, using open package as a field. Assess need for antiseptic gel on a barrier on bedside stand, place if needed. Put on non-sterile gloves. If contamination occurs, discard and start over at step prior to the contamination point with new equipment and supplies. A physician's orders [REDACTED]. heel. Cover with a dry dressing and wrap with kling (a self adherent elastic wrap) every day shift. A physician's orders [REDACTED]. During an observation on 6/18/18 at 9:56 am, LPN #1 was observed providing a dressing change to the resident's sacral area. With gloved hands, she held the gauze package and pulled out the gauze and cleansed the wound. She did not remove her gloves, wash her hands or donn a new pair of gloves after touching the outside of the dressing package. The LPN then held the tube of hydrogel, squeezed out the gel and applied it to the wound. She did not remove her gloves, wash her hands or donn a new pair of gloves after touching the outside of the tube. She then pulled out the protective dressing by holding the outside of the package and placed it on the wound. She did not remove her gloves, wash her hands or donn new gloves after touching the outside of the protective dressing package. During an interview on 06/18/18 at 10:30 AM, LPN #1 stated she did not realize she should have squeezed out the appropriate amount of hydrogel prior to the dressing change and she did not realize she should not touch the outside package of dressing supplies with the same gloved hands used to change the dressing. During an observation on 6/19/18 at 1:50 pm, LPN #1 was observed providing a dressing change to the resident's right heel deep tissue injury wound as the resident was seated in his wheelchair without leg rests. The LPN did not place a barrier under the resident's heel. She removed the old dressing and cleansed the wound. As the LPN stood up to get dressing supplies, the resident put his foot down touching the floor. The LPN lifted the foot up, applied santyl ointment to the wound and covered it with the dry dressing. During an interview on 06/19/18 at 10:18 AM, LPN #1 stated she should have, but did not place a barrier under the resident's right foot prior to starting the dressing change. During an interview on 06/19/18 on 10:21 AM, Registered Nurse Manager (RNM) #1 stated the nurse should have been following a clean technique during dressing changes. This would include not touching the outside of dressing supply packages without removing gloves, washing hands and donning new pair of gloves. She stated a barrier should have been on floor and the LPN should have re-started the dressing change to clean his heel if it had touched the floor. During interview on 6/19/18 at 2:10 PM, the Staff Development /Infection Control Nurse stated nurses doing dressing or wound care are taught to use barriers particularly for a heel wound where the area could touch a surface after being cleaned. Anything from a container that needs to be applied during a dressing change should be put in a medicine cup and applied using a q-tip or tongue depressor. Hands should be washed and clean gloves applied when the old dressing is removed before cleaning the wound. Finding #1: South Unit During observation on 6/13/18 at 12:44 PM in room [ROOM NUMBER], a two person room, an unlabeled urinal was hanging on a bar by the toilet. During interview on 6/19/18 at 02:32 PM, the Infection Control Nurse said the urinal in the room and all personal care products need to be labeled with the residents name. 10NYCRR415.19(b)(4)

Plan of Correction: ApprovedAugust 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F880:
1. For resident #5, LPN #1 was educated on the proper procedure of a dressing change, proper hand washing hygiene and donning/doffing gloves throughout the dressing change procedure, and on placing a barrier when doing a dressing change or wound care, particularly for a heel wound where the area could touch a surface after being cleaned. For finding #1, the items found to be unlabeled were immediately discarded and new labeled items were placed in room [ROOM NUMBER] South Unit.
2. A dressing change/wound care LPN training will be completed and dressing change competencies with all LPN will be conducted by the Wound Nurse. A house audit will be completed to ensure all unlabeled product and supplies are discarded and new labeled products and supplies are placed. The Resident Assistants will conduct the audit which will include the following: one - any unlabeled supplies and products identified will be immediately discarded; two - new supplies and products will be placed in the identified resident rooms and labeled. The supplies audit will be monthly.
3. All nurses will be educated on the dressing change/wound care procedure, when to wash hands, donn/doff gloves, and provide a barrier when doing wound care. All RA/CNA will be educated on labeling personal hygiene products and supplies.
4. The ADON/Wound Nurse or designee will monitor the LPN dressing change competencies and resident supplies labeling audit through the monthly QAPI committee. The QAPI committee will evaluate the data and act on the information as needed.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not notify the resident and the resident's representative of transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 6 (Resident #'s 3, 15, 45, 48, 65, and #78) of 6 residents reviewed for hospitalization during the recertification survey. Specifically, there were no written discharge notices provided to Resident #'s 3, 15, 45, 48, 65, and #78 and or their representatives and Notice was not sent to the Ombudsman monthly for Resident's #'s 3, 15, 45, 48, and #78. This is evidenced by: Resident #78: The resident was admitted to the nursing home on 4/17/18 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessed the resident as having intact cognitive skills for daily decision making. The MDS dated [DATE] documented that the discharge was planned, the resident's return was not anticipated, and the discharge location was to an acute care hospital. A Medical Progress Note dated 4/27/18 at 4:19 PM, documented that the resident was very challenging and discharge was planned for this day as she was medically fit. The resident Gastric Tube(GT) (tube into stomach to receive liquid nutrition) was blocked and the facility arranged for transport to the hospital to have it replaced, but she refused. The resident stated that she preferred to extend her stay until 5/8 or 5/10/18. A Nursing Progress Note dated 4/27/18 at 4:26 PM, by RN #2, documented that the resident was refusing to go home without a [MEDICATION NAME] script (narcotic pain medication) and that 911 was called and the resident was sent to the emergency room via ambulance. During an interview on 06/19/18 at 2:04 PM, RN #2 stated that the doctor wanted her to go to the hospital to have her Gastric Tube (GT) unplugged, and she was supposed to come back. She did not know why a discharge/transfer notice was not given. During an interview on 06/19/18 at 2:28 PM, the Administrator stated that nurse managers were responsible for discharge planning and discharge/transfer notices, and the business office took care of bed holds. The resident's discharge was planned, with no anticipation of return and that she should have gotten a discharge notice with appeal rights and discharge instructions. The doctor did not want to send the resident home with a lot of narcotic scripts, and the resident became very abrasive. They called the police and 911 to get the resident to leave, and he was not aware that the discharge notice and discharge instructions were not completed and given to the resident. Resident #45: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set of 6/12/18 assessed the resident was severely cognitively impaired. MDS records documented a discharge on 3/28/18 and reentry on 4/3/18. A Nurses Note on 3/28/18, documented the resident had a boil on the inside of the right thigh. The surrounding tissue was red and tender to touch. The resident had an elevated temperature and redness had extended farther up the thigh. The Physician Assistant spoke to the Medical Director and order received to send the resident to the hospital. The medical record did not include documentation that a written discharge notice was given to the resident and representative and no documentation that the Ombudsman was notified. During interview on 6/18/18 at 9:52 AM, the Social Worker stated she does not send notices to the resident and family of hospitalization . She did not know who did, maybe nurses. During interview on 6/18/18 at 10:02 AM, the Registered Nurse Manager (RNM) stated she calls the family when a resident goes to the hospital, but does not send a written notice. During interview on 6/18/18 at 3:59 PM, the Administrator stated he was not aware of the regulation to give written notice to the resident and representative of discharge to the hospital. They call the family when a resident goes to the hospital. He said there was no policy and procedure for giving notice to a resident and the resident's representative or to the Ombudsman monthly. Resident #65: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS records documented a discharge on 5/8/18 and reentry on 5/10/18. Nursing Notes on 5/8/18 documented a return call from the Medical Director who was informed of abnormal laboratory values and the resident's status to inform to transfer to the hospital. The medical record did not include documentation that a written discharge notice was given to the resident and the resident's representative and did not include documentation that the Ombudsman was notified. During interview on 6/19/18 at 8:15 AM, the RNM stated a written notice of hospitalization was not given to the resident and the resident's representative. During interview on 6/18/18 at 3:59 PM, the Administrator stated he was not aware of the regulation for giving written notice to the resident and representative for discharge to the hospital. They call the family when a resident goes to the hospital. He stated there was no policy and procedure for giving notice to a resident and their representative or to the Ombudsman monthly. 10NYCRR415.3(h)(1)(iv)(a-e)

Plan of Correction: ApprovedJuly 26, 2018

Riverside Center for Rehabilitation and Nursing provides this plan of correction without admitting or denying the validity or existence of the alleged deficiencies. The plan of correction is prepared and executed solely because it is required by federal and state law.
F623:
1. For residents #3, 15, 45, 48, 65, and 78 a letter will be drafted and mailed to each resident or representative (certified mail) of the transfer or discharge with the reason for the move. The letter will be written in a manner and language they understand. A list of the residents transferred or discharged will be mailed to the representative of the office of the long term care Ombudsman on a monthly basis.
2. To identify other residents potentially affected an audit of all residents discharged or transferred to the hospital in the last 30 days will be completed and we will send a notice of discharge to those residents.
3. A notice of transfer or discharge policy and procedure will be drafted to include written content in section 483.15 (C) (3) (6) (8).
4. The Social Service Director or designee will monitor monthly for QAPI meeting. The QAPI committee will evaluate the data and act on the information as needed.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections [MEDICAL CONDITION] for one (1) (Resident #5) of two (2) residents reviewed. Specifically for Resident #5, the facility did not consistently document and monitor urine output from the resident's foley catheter. This is evidenced by: Resident #5: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. The Policy and Procedure for Indwelling Catheter, revision date of 11/2016, documented after emptying the drainage bag, drain urine into a container. Place paper towels on the bedside table and measure output on a level surface. Wash hands and record output. The drainage bag should be emptied at least once each shift (6 am, 2 pm, and 10 pm) and as ordered or indicated. A Medical Progress Note dated 5/14/18 at 8:16 am, documented the resident had a [DIAGNOSES REDACTED]. Progress Note dated 6/10/18 at 2:24 pm, documented resident continued on an antibiotic for a UTI. The resident's foley is patent and draining clear yellow urine. Urine output is 350 cc. Interdisciplinary Progress notes dated 6/12/18 at 1:17 pm, documented the resident returned from a urology appointment with new orders to have the foley discontinued. Voiding trial in place. Resident to be toileted every 2-3 hours during the waking hours. Bladder scan every shift for 3 days. If greater than 400 cc's, reinsert foley. An Interdisciplinary Progress note dated 6/13/18 at 4:57 pm, documented the resident's bladder scanned at 3:00 pm. Scan read 533 ml, patient given opportunity to void. Post void residual 430 cc. Staff to assist resident to void again with another post void residual of foul smell and cloudy urine. Interdisciplinary Progress notes dated 6/13/18 at 9:00 pm, documented resident's bladder scanned for 630 cc of urine. Foley catheter reinserted per MD order. Immediate return of thick cloudy urine. Noted to have 200 cc of urine. Foley continues to drain. Interdisciplinary Progress note dated 6/14/18 at 1:36 pm, documented resident [MEDICATION NAME](antibiotic) since April. Last culture done in March. Physician ordered a new urine culture and sensitivity and ordered the resident to continue on Cipro. The resident's cloudy, foul smelling urine was reported to MD . Nursing Progress Note dated 6/19/18, documented a urine culture & sensitivity obtained. Resident is currently [MEDICATION NAME](an antibiotic) for recurrent UTI's. Toileting Log from 6/01/18 to 6/18/18 did not document urine output from the resident's foley catheter on the following dates and shifts and/or did not include documentation at the end of the shift: 6/01/18 no documented output for day shift 6/05/18 documented output at 2:12 am, 10:39 am, 6:13 pm 6/06/18 documented output at 2:09 am, 11:53 am and 5:58 pm 6/07/18 documented output at 1:44 am, 9:23 am, 10:14 am 6/09/18 documented output at 3:06 am, 12:32 pm 6/10/18 documented output at 3:32 am, 9:32 am, 2:24 pm 6/11/18 no documented ouputs for day, evening and night shifts 6/12/18 documented output 5:15 am, -9:25 am, 10:29 pm 6/13/18 documented 6:40 am, 2:02 pm, no documented output at 6:05 pm 6/14/18 documented output at 2:37 am, 9:46 am, 11:30 am 6/16/18 documented output at 2:24 am, 9:23 am, 1:31 pm, 6/17/18 documented output at 5:51 am, 1:32 pm, 4:41 pm 6/18/18 documented output at 12:58 am, no documented output day or evening shifts During an interview on 06/19/18 at 10:29 AM, RNM #1 stated urine outputs should be charted by the nurses every shift and the LPNs are supposed to be checking it has been documented at end of their shift. The RNM would run a report in the morning which would show any missed documentation. After reviewing the Toilet Use log, she stated it is not being done every shift and that it should have been consistently documented. The CNAs empty the foley and document the output. Every morning after running a report when the RN sees the urine outputs have not been filled out, she addresses it with the CNA. Sometimes there is a late entry note. When there are blanks in the log, the amount does not reflect an accurate urine output for the resident, the RNM will inform the CNAs That they need to document. Interdisciplinary Progress Note documented the resident was seen by urology 3/27/18, 4/10/18, 6/13/18 and voiding trials were initiated. Nurses were to chart residuals. During an interview on 06/19/18 at 09:34 AM, LPN #1 stated she thinks the CNAs are charting output every shift, thinks the NM monitors the resident's output. She stated outputs are not charted when the resident is on a voiding trial. Residuals are charted. CNAs chart output, she will ask amount and put in report. Nursing Progress Note dated 6/19/18, documented a urine culture & sensitivity obtained. Resident is currently [MEDICATION NAME](an antibiotic ) for recurrent uti's. 10NYCRR 415.22(a)(1-4)

Plan of Correction: ApprovedJuly 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F842:
1. For resident #5 a foley order was placed including output each shift.
2. All residents with indwelling foley will have chart reviewed for orders for foley use and output each shift.
3. All new admissions will be reviewed each day in morning report to assure orders for foley and output each shift is in place. The Unit Managers will audit on all residents with indwelling foley to ensure orders are present and output is monitored. The audit will be conducted weekly and ask the following: One is there a physician order [REDACTED].
4. The DON or designee will monitor the audit to ensure the resident foley and output orders are complete and accurate through the monthly QAPI committee. The QAPI committee will evaluate the data and act on the information as needed.

Standard Life Safety Code Citations

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, doors with self-closing devices were maintained as required by adopted regulations. NFPA 101, Life Safety Code 2012 edition sections 19.2.2.2.7 and 7.2.1.8.2 require that hazardous area and smoke barrier doors (doors) be self-closing and remain in the closed position unless held open by devices that release upon activation of the fire alarm or sprinkler systems. Specifically, doors were held open with buckets and door chucks. This is evidenced as follows. Observations on 06/13/2018 at 8:00 AM and 10:00 AM and on 06/15/2018 at 8:50 AM and 9:30 AM, revealed that the stairwell door was chucked open with a putty knife, the paint room door was held open with a bucket, and the 1st floor smoke barrier door was impeded from closing with a tool bag. Additionally, the corridor door to the administrative office suite was held open with a door chuck, Business Office was held open with a chair, the door to resident room [ROOM NUMBER]-N was held open with a clothes hamper, and the door to resident room [ROOM NUMBER]-S was held open with a decorative door stop. The Administrator and Director of Plant Operations stated in an interview conducted on 06/18/2018 at 3:40 PM, that the 1st floor is a resident area, and paint contractors had been advised not to prop doors open. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.2.2.2.7, 19.3.6.3; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.2.2.2.6, 19.3.6.3, 7.2.1.8.2

Plan of Correction: ApprovedJuly 26, 2018

K223:
1. No residents were affected by the doors identified and identified doors were closed.
2. The business office door has been affixed with self-closing device connected to the fire alarm and sprinkler system. For rooms 115N and 117S the devices in front of those doors were immediately removed. All other doors identified the painting vendors were educated to not prop those doors open. All devices that held the doors in the open position have been removed.
3. Education will be given to all outside vendors prior to work commencing by the maintenance director to keep the identified doors closed at all times and not use any tools to prop the doors open. The business office door was modified with a self-closing device connected to the fire alarm and sprinkler system. All other doors identified will be monitored to ensure no devices are in front of them and that no devices are propping them open.
4. The Maintenance Director or designee will monitor the identified doors during monthly preventative maintenance and report any findings to the QAPI committee.

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall when used to energize appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, such as for communications equipment. Specifically, power strips were not secured to the walls. This is evidenced as follows. Observations on 06/18/2018 at 2:45 PM, revealed a power strip dangling loosely mid-air in resident room [ROOM NUMBER]-S. Observations during routine survey activities on 06/13/2018, 06/14/2018, 06/15/2018, 06/18/2018 and 06/19/2018, revealed that power strips used in resident rooms, the physical therapy room, and service and office areas were not secured to the wall. The Director of Plant Operations stated in an interview conducted on 06/18/2018 at 3:40 PM, that he was unaware that power strips needed to be secured to the wall. 42 CFR 483.70 (a) (1); 2011 NFPA 70 400.8, 400.7, 368.56(B); 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 70

Plan of Correction: ApprovedJuly 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K920:
1. For the resident in room [ROOM NUMBER] south unit the power strip that was found dangling was immediately removed and a stool installed for the residents fan.
2. For all other resident rooms, the therapy room, and office areas the power strips have been secured to the wall or piece of furniture. Additionally, all rooms in the facility will be addressed in securing the power strip to the wall or piece of furniture.
3. The maintenance director will audit all rooms monthly to assure that power strips are secured to the wall or piece of furniture.
4. The maintenance director or designee will monitor these rooms during preventative maintenance and report any findings to the QAPI committee.

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: June 19, 2018
Corrected date: August 18, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities maintain PCREE with consideration of the owner's manual. Specifically, PCREE was not maintained as prescribed in the owner's manual. This is evidenced as follows. Observations of the oxygen concentrator (concentrator) assigned to the resident in room [ROOM NUMBER]-S were conducted on 06/18/2018 at 2:45 PM. The resident was using the concentrator and was located directly next to both the night stand table and fabric easy chair. Review of the operator's manual for the concentrator on 06/18/2018, revealed that the unit is to be placed no closer than 3-inches from furniture. Observations on 06/18/2018 at 11:00 AM and 2:45 PM and again at 06/19/2018 at 2:20 PM, revealed the following: (1) nebulizers in resident rooms 112-N and 118-N were not in use, but were plugged into the electrical outlet, and (2) the cord for the [MEDICAL CONDITION] machine in resident room [ROOM NUMBER]-S was pinched with the night stand leg. Review of the nebulizer owner's manual on 06/19/2018, revealed that to reduce the risk of electrocution, the power cord is to be unplugged from the electric outlet immediately after using. The facility maintenance policy for PCREE was reviewed on 06/19/2018. This policy states that the manufacture's safety guidelines for the use of PCREE will be reviewed with personnel periodically. The Registered Nurse Educator stated in an interview conducted on 06/19/2018 at 5:05 PM, that to her knowledge since being hired recently, she is not aware of any education that is provided to staff on the safe use of PCREE. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3, 10.5; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedJuly 26, 2018

K921:
1. For the resident in 118-S we immediately moved the resident using the oxygen concentrator three inches from any object in the room. All other pieces of equipment identified were not in use and no residents were affected by the deficient practice.
2. All rooms will be audited to assure that patient care related electrical equipment (PCREE) is placed according to the owner?s manual.
3. The Staff Educator will review the PCREE Policy and provide education to all current and new staff on the safe use of -all- PCREE as per the owner's manuals.
4. The Staff Educator or designee will assure that the PCREE manufacture?s safety guidelines are reviewed at least annually with all staff.

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with all emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not include documentation of the method used for demonstrating knowledge of the training program. This is evidenced as follows. A review of the Emergency Plan, Training Program on 06/14/2018, revealed that the program did not include a method by which staff must demonstrate knowledge of the Emergency Plan, such as a written quiz or a question and answer session. The Administrator stated in an interview conducted on 06/14/2018 at 8:30 AM, that the Emergency Plan does not yet include a method to ascertain if staff have knowledge of their rolls in emergency procedures. 42 CFR: 483.73(d)(1)(ii)

Plan of Correction: ApprovedJuly 26, 2018

E037:
1. No residents were affected by the deficient practice.
2. The emergency plan training program has been updated to include a method by which staff can demonstrate knowledge of the emergency plan.
3. The Staff Educator has created a post test that will be used in orientation that will demonstrate knowledge of the emergency plan. Additionally, all current staff will be educated and given the post test to determine knowledge of the emergency disaster plan.
4. The Staff Educator of designee is responsible to give post-test at orientation sessions to ensure staff has knowledge of the emergency plan.

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on record review and staff interview during the recertification survey, the facility did not maintain the fire alarm system in accordance with adopted regulations. NFPA 72 National Fire Alarm Code 2010 edition section 14.2.1.2.2 requires that defects and malfunctions with the fire alarm system shall be corrected. Specifically, defective devices connected to the fire alarm system were not repaired. This is evidenced as follows. The fire alarm testing reports were reviewed on 06/19/2018. The 01/03/2018 Fire Alarm Test Report (testing report) documented that the spring and motor components of the elevator shaft top hatch connected to the fire alarm system require repair servicing for proper operation. No records were provided documenting that these components were yet repaired, a period of 5 months from survey record review. The Director of Plant Operations stated in an interview conducted on 06/19/2018 at 2:20 PM, that a company to repair the elevator hatch has not been contracted. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.6.1.3; 2010 NFPA 72 14.2.1.2.2; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101: 9.6.1.4; 1999 NFPA 72: 7-1.1.2

Plan of Correction: ApprovedJuly 26, 2018

K345:
1. No residents were affected by the deficient practice.
2. The spring and motor components of the elevator shaft top hatch connected to the fire alarm system will be repaired for proper operation.
3. The maintenance director will have a company contracted for routine services.
4. The Maintenance Director or designee will monitor the fire alarm system during quarterly preventative maintenance and report any findings to the QAPI committee.

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the staff was not familiar with the proper scheduling of fire drills at this facility. NFPA 101 Life Safety Code 2012 edition section 19.7.1 requires that fire drills (drills) shall be scheduled under varied conditions. Fire drills were not scheduled at various times, on the third shift of this facility. This is evidenced as follows. The fire drill evaluations were reviewed 06/18/2018. These documents revealed that 7 of the last 7 third shift quarterly drills were conducted between 4:05AM and 6:15 AM. The Director of Plant Operations stated in an interview conducted on 06/19/2018 at 5:00 PM, that he was hired about 1 month ago and was not aware of the requirement that the fire drills must be conducted at varied time periods during a shift. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7.1.2

Plan of Correction: ApprovedJuly 26, 2018

K712:
1. No residents were affected by the deficient practice.
2. The third shift fire drills will be held at varying expected and unexpected times under varying conditions at least quarterly. Fire drills during the third shift between 9pm and 6am will use a coded announcement instead of the audible alarm.
3. When running the third shift fire drills quarterly the maintenance director or designee will schedule the drills under varied conditions and varied times.
4. The maintenance director or designee will monitor the fire drill times quarterly and report any findings to the QAPI committee.

K307 NFPA 101:GAS EQUIPMENT - PRECAUTIONS FOR HANDLING OXYG

REGULATION: Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did protect pressurized oxygen cylinders (cylinders) from damage in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition Section 11.6.2.2 requires that oxygen cylinder shall not be draped with any materials. Section 11.6.2.3 requires that freestanding cylinders be properly chained or supported in a proper cylinder stand or cart. Specifically, freestanding cylinders were not properly supported, and cylinders were draped with cloth. This is evidenced as follows. The main oxygen storage room and the North Unit oxygen storage room were inspected on 06/18/2018 at 9:15 AM. Two cylinders in the main oxygen storage room were not supported in the stands provided, and several cylinders were draped with a cloth oxygen satchel. Four cylinders were not supported in a stand or cart in the North Unit oxygen storage room. The Emergency Preparedness Coordinator Registered Nurse stated in an interview conducted on 05/04/2018 at 12:00 PM, that all cylinders should be stored in the racks provided, should not have anything placed on them, and the empty cylinders will be placed in a marked area. The Administrator stated in an interview conducted on 06/18/2018 at 3:40 PM, that based on these survey observations, he will ensure both the nursing and maintenance staff are educated on the correct storage of oxygen cylinders. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.6.2; 10 NYCRR 415.29, 711.2(a)(26); 1999 NFPA 99 4-3

Plan of Correction: ApprovedJuly 26, 2018

K929:
1. No residents were affected by the deficient practice.
2. The two oxygen cylinders located in the main oxygen storage area on the North Unit that were not supported in a stand or cart were immediately placed in the standing up position and into a cart. The cloth oxygen satchel observed in the oxygen storage on the North Unit was immediately removed.
3. All nursing staff and maintenance staff will be educated on storing all oxygen cylinders in the racks provided and not have any other objects placed with them. The same noted staff will be educated on placing all empty cylinders in the racks marked empty and the full cylinders in the racks marked full, all cylinders to be standing up. An audit will be completed monthly by maintenance of all the O2 storage areas for complaint storage.
4. The Staff Educator or designee will monitor and assure that staff are adequately trained and report any findings to the QAPI committee. The maintenance director or designee will report findings of the audit to the QAPI committee monthly.

K307 NFPA 101:GAS EQUIPMENT - QUALIFICATIONS AND TRAINING

REGULATION: Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on staff interview during the recertification survey, the facility did manage pressurized oxygen cylinders in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1 requires that personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be trained and receive continuing education on the usage requirements and the risks associated with their handling and use. Specifically, the facility did not provide continuing education on the risks associated with the handling medical oxygen cylinders. This is evidenced as follows. The Registered Nurse Educator stated in an interview conducted on 06/19/2018 at 12:10 PM, that staff receive safety education on handling oxygen cylinders during new hire orientation, but not thereafter, and based on the current staff pool, 12 nurses and 3 maintenance employees have not received the safety education within the past year. 42 CFR 483.70 (a) (1); 2012 NFPA 99 11.5.2.1

Plan of Correction: ApprovedJuly 26, 2018

K926:
1. No residents were affected by the deficient practice.
2. The Staff Educator will extend her current practice from giving education on handling oxygen cylinders during new hire orientation to providing such training on an annual basis.
3. The personnel concerned with the application, maintenance, and handling of medical gases and cylinders will be trained on risks. The staff educator will provide at least annual education, to include safety guidelines and usage requirements of medical gases and cylinders. The training will also include the risks associated with the handling of O2 cylinders.
4. The Staff Educator or designee will monitor and assure that staff are adequately trained and report any findings to the QAPI committee.

LTC AND ICF/IID SHARING PLAN WITH PATIENTS

REGULATION: *[For ICF/IIDs at §483.475(c):] [(c) The ICF/IID must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years.] The communication plan must include all of the following: *[For LTC Facilities at §483.73(c):] [(c) The LTC facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.] The communication plan must include all of the following: (8) A method for sharing information from the emergency plan, that the facility has determined is appropriate, with residents [or clients] and their families or representatives.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

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 sharing emergency preparedness policies and procedures with residents and their families or representatives. This is evidenced as follows. A review of the Emergency Plan on 06/14/2018, revealed the communication plan did not include sharing relevant portions of the emergency preparedness plans and policies with family members and resident representatives. The Administrator and the Facilities Manager stated in an interview conducted on 06/14/2018 at 8:30 AM, that the Emergency Plan has not yet been communicated to residents or their families. 42 CFR: 483.73(c)(8)

Plan of Correction: ApprovedJuly 26, 2018

E035:
1. No residents were affected by the deficient practice.
2. On 6/14/2018 during the recertification survey a letter was sent out to all residents or their representatives sharing the emergency preparedness plan with them. The emergency disaster plan will be updated to include sharing the plan with residents or their responsible party. Additionally, the information will be shared in the admission packet.
3. At least annually a letter will be sent out to the resident or their representative to let them know of the emergency preparedness plan.
4. The Administrator and Safety Committee or designee will ensure that the policy will be reviewed annually by the safety committee.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation, record review, and staff interview during the recertification survey, the means of egress was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.3.1 requires that door assemblies in exit enclosures be tested not less than annually in accordance with Chapter 5 of NFPA 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition. Specifically, several fire doors were not inspected within the past year. This is evidenced as follows. Observations on 06/19/2018 at 1:30 PM, revealed that doors 003, 006, 008, 012, 112, 129, 146, and 2074 are fire rated doors located in fire walls or hazardous area walls. Record review of the facility Fire Door Inspection Log on 06/19/2018, reveal that doors 003, 006, 008, 012, 112, 129, 146, and 2074 were not included. The Director of Plant Operations stated in an interview conducted on 06/19/2018 at 1:30 PM, that he will have these doors inspected. 42 CFR 483.70 (a)(1); 2012 NFPA 101 19.2.1, 7.2.1.15; 2010 NFPA 80 Chapter 5; NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 8.2.3.2.1

Plan of Correction: ApprovedJuly 26, 2018

K211:
1. No residents were affected by the deficient practice.
2. Doors 003, 006, 008, 012, 112, 129, 146, and 2074 will be tested in accordance with both NFPA 101, Life Safety Code, 2012 Edition -and- NFPA 80 Standard for Fire Doors and Other Opening Protective, 2010 Edition, Chapter 5.
3. The identified fire doors will be inspected at least annually.
4. The Maintenance Director or designee will monitor the identified doors during monthly preventative maintenance and report any findings to the QAPI committee.

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include the use of volunteers, such as State and Federal health care professional to address surge needs, in an emergency. This is evidenced as follows. A review of the Emergency Plan on 06/14/2018 revealed that the facility's policies and procedures did not include the use of medical volunteers to address an influx of patients or residents and did not define the use of non-medical volunteers. The Administrator stated in an interview conducted on 06/14/2018 at 8:30 AM, that the facility Emergency Plan will be revised to include the use of both medical and non-medical volunteers. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedJuly 26, 2018

Riverside Center for Rehabilitation and Nursing provides this plan of correction without admitting or denying the validity or existence of the alleged deficiencies. The plan of correction is prepared and executed solely because it is required by federal and state law.
E024:
1. No residents were affected by the deficient practice.
2. The surge/emergency plan will be updated to include the use of medical and non-medical volunteers or other emergency staffing strategies.
3. The surge/emergency plan will be updated to include the use of medical and non-medical volunteers or other emergency staffing strategies.
4. The Administrator and Safety Committee or designee will ensure that the surge/emergency plan includes the use of medical and non-medical volunteers or other emergency staffing strategies. The policy will be reviewed annually by the safety committee.

K307 NFPA 101:SMOKING REGULATIONS

REGULATION: Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation, staff interview and record review during the recertification survey, the facility did not maintain smoking areas in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 19.7.4 requires that ashtrays of non-combustible design and metal containers with self-closing cover devices into which ashtrays can be emptied shall be provided in all smoking areas. Specifically, ashtrays and metal containers with self-closing cover devices into which ashtrays can be emptied were not provided in smoking areas. This is evidenced as follows. Observations of the trash compactor/employee entrance area on 06/13/2018 at 11:15 AM, found a live cigarette butt smoldering on the ground, cigarette butts in a plastic cup and in the waste receptacle, and ashtrays and a metal container with a self-closing cover device were not provided. The Director of Food Service was in this area during observations. The Administrator stated in an interview conducted on 06/18/2018 at 3:40 PM, that smoking is prohibited on the facility grounds. The facility smoking policy was reviewed on 06/13/2018. This policy prohibits smoking in all areas of the facility including the outdoor grounds. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.7.4; 10 NYCRR 415.29(a)(2), 711.2, 2000 NFPA 101 19.7.4

Plan of Correction: ApprovedJuly 27, 2018

K741:
1. No residents were affected by the deficient practice.
2. All identified areas that were littered with cigarette butts were cleaned and litter discarded appropriately.
3. The facility will remain a smoke free facility inside and outside the facility. We will alter our policy to allow the employees to smoke in their vehicles which will be the designated area of smoking. We have provided three ashtrays of non-combustible design with self-closing cover devices into which cigarette butts can be deposited. The three ashtrays of non-combustible design with self-closing cover devices into which cigarette butts can be deposited have been ordered and placed for cigarette butts to be deposited as employees come back from their vehicles and for any visitors/vendors coming in from the parking lot. They will be placed as follows: one just before the entrance of the facility, one located in the pavilion of the parking lot, and one in back of the facility by the back parking area. All staff will be educated on this procedure.
4. The Housekeeping Manager or designee will assure appropriate emptying of the receptacles and cleaning the parking lot and yard of any debris. The Housekeeping Manager will report findings to the QAPI committee monthly.

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: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows. Observations of the sprinkler system on 06/13/2018 at 11:00 AM, 06/15/2018 at 11:10 AM, and 06/18/2018 at 9:00 AM, revealed three sprinkler heads in car port and one sprinkler head each in the 1st floor and 2nd floor elevator lobbies were found with a coating of dust. The Director of Plant Operations stated in an interview conducted on 06/18/2018 at 3:40 PM, that he was not aware but will clean the dusty sprinkler heads. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedJuly 26, 2018

K353:
1. No residents were affected by the deficient practice.
2. All identified sprinkler heads with dust on them were cleaned and are free of dust.
3. The Maintenance Director will perform an initial audit of all sprinkler heads for dust or other foreign matter. The Maintenance Director will then perform a quarterly audit of all sprinkler heads for dust or other foreign matter during the preventative maintenance procedures.
4. The Maintenance Director or designee will monitor the sprinkler heads during quarterly preventative maintenance and report any findings to the QAPI committee.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Specifically, metal electrical boxes in 1 of 1 smoke barriers observed were not fire-protected as required. This is evidenced as follows. The South Unit smoke barrier wall (wall) was inspected on 06/18/2018 at 2:55 PM. Sixteen metal electrical boxes were within 24-inches of each other on opposite sides of the wall in resident rooms 117 and 118 and resident room 103 and 104. These metal electrical boxes were not fire separated with any listed materials. The Director of Plant Operations stated in an interview conducted on 06/18/2018 at 2:55 PM, that he will fire-protect the electrical boxes noted. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedJuly 26, 2018

K372:
1. No residents were affected by the deficient practice.
2. The sixteen metal electrical boxes that were identified as being 24 inches of each other on opposite sides of the wall in resident rooms 117 and 118 and resident rooms 103 and 104 will be fire protected.
3. The maintenance director will audit rooms that are opposite each other within smoke barriers to assure that electrical boxes are fire protected.
4. The Maintenance Director or designee will monitor these rooms during preventative maintenance and report any findings to the QAPI committee.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 19, 2018
Corrected date: August 18, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls including rated ceiling assemblies shall be continuous. Specifically, rated ceilings were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows. Observations of the floor-ceiling assembly in the boiler room on 06/18/2018 at 8:30 AM, revealed 8 unsealed penetrations for utility piping; the holes were 3-inchs to 4-inches wide. The Director of Plant Operations stated in an interview conducted on 06/18/2018 at 3:40 PM, that he was unaware, but will seal the holes found in the floor/ceiling assembly 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3

Plan of Correction: ApprovedJuly 26, 2018

K311:
1. No residents were affected by the deficient practice.
2. The eight unsealed penetrations for the utility piping that were identified in the floor ceiling assembly in the boiler room have been sealed.
3. The maintenance director will audit all rooms in the basement ceiling area for penetrations and documentation that unsealed penetrations are sealed.
4. The Maintenance Director or designee will monitor all rooms in the basement ceiling area for penetrations and documentation that unsealed penetrations are sealed during quarterly preventative maintenance and report any findings to the QAPI committee.