The Center for Nursing and Rehabilitation at Hoosick Falls
June 20, 2017 Certification Survey

Standard Health Citations

E3BP 402.7(a)(2)(i):DEPARTMENT CRIMINAL HISTORY REVIEW

REGULATION: Section 402.7 Department Criminal History Review. (a) After reviewing a criminal history record of an individual who is subject to a criminal history record check pursuant to this Part, the Department and the provider shall take the following actions: ...... (2) Where the criminal history information of a prospective employee reveals a felony conviction at any time for a sex offense, a felony conviction within the past ten years involving violence, or a conviction for endangering the welfare of an incompetent or physically disabled person pursuant to section 260.25 of the Penal Law, or where the criminal history information concerning such prospective employee reveals a conviction at anytime of any class A felony, a conviction within the past ten years of any class B or C felony, any class D or E felony defined in articles 120, 130, 155, 160, 178 or 220 of the Penal Law or any crime defined in sections 260.32 or 260.34 of the Penal Law or any comparable offense in any other jurisdiction, the Department shall propose disapproval of such person's eligibility for employment unless the Department determines, in its discretion, that the prospective employee's employment will not in any way jeopardize the health, safety or welfare of patients, residents or clients of the provider. (i) The Department shall provide to the provider and the prospective employee, in writing, a summary of the criminal history information along with the notification identified in this paragraph. Upon the provider's receipt from the Department of a notification of proposed disapproval of eligibility for employment, the provider shall not allow the prospective employee to provide direct care or supervision to patients, residents, or clients of such provider until receipt of a final determination of eligibility for employment from the Department.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

Based on record review and staff interview, it was determined that the facility did not take appropriate actions after receiving criminal history information on a new employee. Chapter 10 of the New York State Codes Rules and Regulations Section 402.7(a)(2)(i) Department Criminal History Review requires that, for a prospective employee, upon receiving notification from the NY State Department of Health of proposed disapproval of eligibility for employment (notice), the facility shall not allow the prospective employee to provide direct care to patients. Specifically, the facility did not remove from direct care to residents, a prospective employee having a notice within the past 4 months from the NY State Department of Health (The Department). This was evidenced by: The personal records of Housekeeping Aide #1 were reviewed on 06/19/2017. The records showed that the notice of Pending Denial to Provider from The Department was dated 11/10/2016. The supervision records showed that the employee worked 26 days after the date of the notice. The Environmental Services Supervisor stated in an interview conducted on 06/19/2017 at 11:30 am, that Housekeeping Aide #1 worked on the nursing units 26 days from (MONTH) 11, (YEAR) through (MONTH) 24, (YEAR). The Administrative Assistant stated in an interview conducted on 06/19/2017 at 11:30 am, that she did not realize that persons receiving a pending denial from The Department could not work on the nursing units even though supervision was documented. 10 NYCRR 402.7(a)(2)(i)

Plan of Correction: ApprovedJuly 14, 2017

Housekeeping Aide #1 was terminated prior to annual survey.

To determine if other residents were affected by the deficient practice; No employees are currently employed with ?pending Denial to Provider? from The Department.

To ensure the deficient practice does not recur; all employees with ?Pending Denial to Provider? from The Department will immediately be terminated. The policy and procedure for ?Steps to Hiring an Employee? was revised to include the following changes; implementation of a ?new hire and termination checklist.? The ?new hire checklist includes State nurse registry check, office of professions, finger prints, CHRC date entry, CHRC determination letter, CHRC termination, and payroll.
To monitor the corrective action to ensure that the deficient practice will not recur; All new hires personnel files will be audited weekly for 15 weeks for completion CHRC. The results will be reviewed at the QAPI meeting on 7/27/17 at 0800 and again at the next quarterly meeting on 10/26/17, and the need for continued monitoring will be reviewed.
Person responsible for compliance; Administrative Assistant

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review during a recertification survey, the facility did not ensure that the medication regimen for seven (7) (Residents #'s 10, 28, 38, 41, 49, 68, and #69) of ten (10) residents reviewed for unnecessary medications was free from unnecessary medications. Specifically: For Residents #'s 10, 28, 38, 49, and 69 as needed (PRN) pain medications were prescribed and were not adequately monitored to determine the effectiveness of the medications and the need for their continued use; For Resident #68, medication prescribed PRN for pain and for respiratory difficulty was not adequately monitored to determine the effectiveness of the medication and the need for its continued use; For Resident #41, a PRN anti-anxiety medication prescribed was not adequately monitored to determine the effectiveness of the medications and the need for its continued use. This is evidenced by: A Policy and Procedure for a Comprehensive Pain Management Program with a revision date of 4/19/16, documented the pain management plan included an individualized pain management program for the resident, including pharmacological and non-pharmacological approaches. Nursing was to use nursing progress notes, pain screening forms, pain flow sheets and comprehensive pain assessment forms as a means of communication of pain management. A Pain Rating Scale shall be completed and documented to identify and monitor the level of pain and/or the effectiveness of treatment modalities until the resident achieves consistent pain relief control AHRQ, National Guideline Clearinghouse. Health Care Association of New Jersey (NCANJ): (MONTH) 18.23. Resident #10: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 6, indicating moderate cognitive impairment. The resident was assessed to being able to make self understood to others and the resident is usually able to understand others. The Comprehensive Care Plan (CCP) for pain related to left [MEDICAL CONDITION], repair, and immobility with an evaluation date of 3/25/17, documented that the CCP for pain was implemented. The outcome section dated 3/27/17, documented an entry that the resident denied pain at the time and stated that pain was only present with movement. A physician's orders [REDACTED].) 1 tablet by mouth every 4 hours as needed for pain. The Medication Administration Record [REDACTED]. one tablet by mouth every 4 hours as needed on 5/9/17 at 10:30 am, 5/10/17 at 7:45 am, 5/11/17 at 9:45 am and 2:00 pm, 5/12/17 at 8:20 am and 1:30 pm, 5/15/17 at 8:45 am, and 5/17/17 at 9:15 am. Nursing Progress Notes documented the following with administration of [MEDICATION NAME] for pain: 5/9/17 - [MEDICATION NAME] 10 mg by mouth for pre- physical therapy pain management given at 10:30 am with little relief noted during therapy. 5/10/17 - [MEDICATION NAME] 10 mg by mouth for pre-physical therapy pain management given at 7:45 am with little relief noted during therapy. 5/11/17 - [MEDICATION NAME] 10 mg 1 tablet by mouth given at 9:45 am prior to therapy with little effect. There was no documentation in the nursing progress notes regarding the [MEDICATION NAME] 10 mg given at 2:00 pm. 5/12/17 - [MEDICATION NAME] 10 mg by mouth given at 8:20 am prior to therapy for anticipating pain with little effect. [MEDICATION NAME] 10 mg 1 tablet given at 1:30 pm prior to therapy for anticipating pain. No post pain scale number could be found for either time for pain relief on 5/12/17. 5/15/17 - [MEDICATION NAME] 10 mg 1 tablet by mouth given at 8:45 am prior to therapy and doctor's appointment with some effect during therapy. 5/17/17 - [MEDICATION NAME] 10 mg 1 tablet by mouth given at 9:15 am for anticipating pain prior to therapy with effect pending. The Pain Management Flow Sheet for Cognitively Intact (PMF) dated 5/9/17 to 5/17/17 documented the resident received [MEDICATION NAME] 10 mg for back/hip pain with the current intensity numeric scale as 3 (prior to administering medication) on 7 occasions. The follow-up monitoring of effective intervention intensity of pain on these 7 occasions documented the resident had little relief in therapy, little relief, with effect, little effect, and a blank entry. No post- scale numeric pain scale was used to indicate level of pain after administration of the pain medication During interview on 6/20/17 at 10:00 am, the Director of Nursing (DON) stated that the follow-up pain scale using terms like effective and non-effective does not provide an accurate and consistent means of the pain the resident is experiencing. The Pain Management Flow Sheet was developed so that the post- administration pain scale, like the pre-administration pain scale would provide the more accurate and consistent means of measuring the resident's pain. The DON stated that the post-administration pain scale was not used and needs to be used to measure the resident's pain. Resident #41: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition and could usually understand others and usually could be understood. The Comprehensive Care Plan (CCP) for Psychoactive Drug use documented the resident will show an improved mood state and will have a psychiatric consult as ordered by physician and treatment. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED] 5/2017 - the resident received PRN [MEDICATION NAME] on 29 occasions. The was no documentation indicating the reason the medication was given or the effect of the medication upon follow-up. 6/2017, documented the resident received PRN [MEDICATION NAME] on 26 occasions. There was no documentation indicating the reason the medication was given or the effect of the medication upon follow-up. Flow sheets dated 5/2017 and 6/2017, documented anxiety or anxiousness without describing the resident's symptoms on 2 occasions as reason for administration of PRN [MEDICATION NAME]. Flow Sheets did not document administration of PRN [MEDICATION NAME] on 9 occasions. Nursing Progress Notes on 5/2017 and 6/2017, documented, anxiety, anxiousness, nerves and given on 9 occasions without describing the resident's symptoms prior to administration of PRN [MEDICATION NAME]. On 6 occasions, good effect, no effect, relief, and appears effective was documented as follow-up to giving the medication and did not describe the resident's symptoms. Nursing Progress Notes did not document the administration of PRN [MEDICATION NAME] on 9 occasions. During an interview on 6/16/17 at 1:43 pm, LPN #1 stated prior to administering PRN [MEDICATION NAME], non-pharmological interventions should be attempted and effectiveness of the interventions charted in nursing progress notes. Symptoms the resident is presenting prior to administration of PRN [MEDICATION NAME] should be charted either on the flow sheet or in nursing progress notes. The LPN stated the effectiveness of giving the medication should be charted as a follow up note explaining the resident's response to the medication. During an interview on 6/16/17 at 2:05 pm, the Director of Nursing (DON) stated the nurses should be charting a nurses note documenting the resident's symptoms prior to giving PRN [MEDICATION NAME]. The DON stated a more detailed follow-up note should document the effectiveness of the medication including symptoms the resident exhibited. Resident #68: This resident was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on 3/27/17. The Minimum Data Set ((MDS) dated [DATE], documented the resident was moderately impaired for cognition, was usually able to understand others and sometimes was able to be understood. The Hospice Comprehensive Assessment Update dated 3/29/17, documented the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. Resident was discharged back to the nursing home. The resident was to receive PRN [MEDICATION NAME] for comfort, air hunger and respiratory issues. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED] 3/2017 - the resident received PRN [MEDICATION NAME] on 6 occasions. There was no documentation indicating the reason the medication was given or the effect of the medication upon follow-up. 4/2017 - the resident received PRN [MEDICATION NAME] on 11 occasions. There was no documentation indicating the reason the medication was given or effect of the medication upon follow-up. Nursing Progress Notes documented: 4/1/17 at 11:55 pm - PRN [MEDICATION NAME] was given at 2:10 pm, and 6:30 pm, for increased respirations and labored breathing. Effectiveness of the medication documented positive result. 4/2/17 at 2:55 pm - PRN [MEDICATION NAME] was given for comfort at 8:45 am, 10:40 am, and 2:00 pm for comfort measures. There was no documentation of the effectiveness of the medication. 4/2/17 at 10:00 pm - PRN [MEDICATION NAME] was given for shallow respirations at 20 per minute. There was no documentation of effectivenesss of the medication. 4/3/17 at 3:00 am - PRN [MEDICATION NAME] was given at 12:00 am and 3:00 am, for comfort measures prior to turning and positioning. Effectiveness of the medication documented as with good effect. 4/3/17 at 9:20 am - documented PRN [MEDICATION NAME] was given at 9:20 am and 11:40 am for increased respirations. There was no documentation of the effectiveness of the medication. 4/3/17 at 1:50 pm - documented the resident was pronounced dead at 1:40 pm During an interview on 6/16/17 at 9:31 am, LPN #1 stated prior to administering PRN [MEDICATION NAME] for respiratory difficulty, the nurse should look for signs/symptoms of the resident experiencing difficulty breathing; uncomfortable facial expressions and fidgeting. The nurse should chart what she is seeing. LPN #1 stated the nurse should definitely follow up and chart effectiveness if the medication was given for labored breathing. The LPN stated when giving the medication PRN for discomfort, the resident should be asked the severity of their pain using the numeric pain scale. The pain scale should be charted before and after administration of the medication. During an interview on 6/16/17 at 9:39 am, Registered Nurse Manager (RNM) #1 stated the nurses should be using the PRN pain flow sheet, but that she did not see one being used for the resident. The nurses should be writing a nurses note documenting the numeric pain scale before and after giving the PRN medication for pain. The RNM stated the nurses should chart the respiratory symptoms before and after administering the medication to effectively monitor the resident's condition. During an interview on 6/16/17 at 1:58 pm, Registered Nurse Manager #2 stated prior to administering a PRN pain medication, the nurse should ask the resident the severity of their pain using the numeric pain scale if the resident is able to respond. The RNM stated that pain is whatever the resident says it is. The RNM stated a pain scale should be used prior to administration of a PRN pain medication and the numeric scale can be used after medication administration or the nurses can chart whatever the resident says it is. Effectiveness should be charted on the pain flow sheets or in nursing. notes. During an interview on 6/16/17 at 2:10 pm, the Director of Nursing (DON) stated the nurses should use a numeric pain scale or system of using facial expressions before and after administration of a PRN pain medication. If the numeric pain scale is used prior to medication administration it should also be used post-medication administration. If the resident is sleeping they should not be woken up. The resident sleeping would be charted as effectiveness of the medication. The nurses should be charting why the medication was given as well as the effectiveness. 10NYCRR415.12(1)(1)

Plan of Correction: ApprovedJuly 14, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** To ensure that the each resident?s drug regimen was free from unnecessary drug by ensuring adequate monitoring to determine the effectiveness of the medication and the need for their continued use, the following actions have been taken;
Resident #68 expired prior to the completion of this survey. Resident #38 and #69 was discharged prior to the completion of this survey. Resident #10, #28, and 49 new pain assessment completed on [DATE]. These assessments did not reveal the need for a MDS ?significant change assessment.? Comprehensive care plans were reviewed for appropriateness. For Resident #41 a new psychopharmacological assessment completed on [DATE]. This assessment did not reveal the need for a MDS ?significant change assessment.? Comprehensive care plans were reviewed for appropriateness.

To determine if other residents were affected by this deficient practice; The ?Pain Management flow sheet? and the ?PRN Psychoactive Flow sheet? of all other residents will be audited for adequate monitoring to determine the effectiveness of the medication and the need for their continued use will be audited. The findings were documented on the ?unnecessary drug investigation tool? and to be completed by [DATE]. The ?unnecessary drug investigation tool? includes the name of the drug, indications of use/diagnosis, documentation for supporting/opposing the use of the drug regimen, effectiveness and the gradual drug reduction attempts. A separate binder was designated to each med-pass cart on each unit, containing a ?Pain Management Flow Sheet? or ?PRN [MEDICAL CONDITION] Flow sheet? to ensure timely documentation for current pain intensity, behavior, non-pharmacological intervention, and 1 hour follow-up monitoring after medication administration. Upon completion of the ?unnecessary drug investigation tool? if it is determined that the deficient practice affected another resident a new pain/psychopharmacological assessment will be completed, assess the need for a MDS ?significant change assessment?, and assess need for comprehensive care plan review for medication appropriateness.
To ensure the deficient practice does not recur: The policy and procedure for the ?comprehensive pain management program? and ?PRN medication administration? administration were revised to include the updated ?Pain Management Flow Sheet? and the ?PRN [MEDICAL CONDITION] Flow Sheet.? The ?Pain Management Flow Sheet? includes the date, time, current pain intensity FACES/ BOS/ numeric scale, discomfort indicator, pain goal, non-pharmacological intervention, medication/dosage, 1 hour follow-up monitoring of pain intensity/FACES/BOS/numeric scale. The ?PRN [MEDICAL CONDITION] Flow includes the date/time, non-pharmacological intervention, description of behavior, medication/dosage, and 1 hour follow-up monitoring. Nursing will be educated at the next mandatory meeting scheduled [DATE] at 1400.
To monitor the corrective action to ensure that the deficient practice will not recur: The results of the ?unnecessary drug investigation tool? completed for [DATE] will be reviewed at the next QAPI meeting on [DATE] at 0800. 5 Resident?s medical chart from each unit every week for 12 weeks will be audited using the ?unnecessary drug investigation tool? The results of the ?unnecessary drug investigation tool? will be reviewed at the next quarterly QAPI meeting on [DATE] at 0800 where the need for continued monitoring will be reviewed.
Person responsible for compliance; Director of Nursing or her designee.

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

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not adhere to generally accepted food safety practices. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Part 14, the community standard for food service establishments operating in New York State both state that potentially hazardous foods, such as soups, be reheated within certain specifications and the label directions, and that food temperatures thermometers are to be calibrated. Specifically, the Italian Wedding soup was not heated in accordance with the label directions and food temperature thermometers were not calibrated. This is evidenced as follows. The temperature of Italian Wedding soup was 63 degrees Fahrenheit (F) when measured on 06/19/2017 at 9:15 am. Dietary Aide #1 stated in an interview conducted on 06/19/2017 at 9:15 am, that the Italian Wedding soup would be used for the dinner meal and was reconstituted from a frozen concentrate at 8:45 am, but not brought to a boil. The temperature of Italian Wedding soup was 77 F when measured on 06/19/2017 at 11:55 am. The label directions on the Italian Wedding soup were reviewed on 06/19/2017. These directions stated that to reconstitute, the soup is to be brought to a boil then served immediately. The calibration of three food temperature thermometers was checked in an ice bath on 06/19/2017 at 8:45 am; 32 F would be the calibrated correct temperature. The thermometers read as follows: 29 F, 28 F, and 18 F. The Acting Supervisor stated in an interview conducted on 06/19/2017 at 11:55 am that the Italian Wedding soup was not reheated immediately to 165 F, and the thermometers need to be checked for calibration more often. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.83, 14-1.85

Plan of Correction: ApprovedJuly 14, 2017

The FDA guidelines and part 14, the Community Standards for food service establishments operating in New York State both state that potentially hazardous foods such as soups be reheated within certain specifications and the label directions. To ensure the above guidelines are followed the following actions have been taken:
1. The cooking staff have been instructed to properly thaw frozen soups in the refrigerator for 1-2 days prior to scheduled use.
2. The instructions on the package of the soup are to be followed.
3. Soup is to be reconstituted and brought to specified temperature on instructions with no interruption of cooking process prior to scheduled service of the menu item.
4. Temperature is to be checked prior to transfer to steam table.
To monitor the corrective action to ensure that the deficient practice will not recur, the Cook preparing soup for evening meal will record:
1. Time started cooking Process
2. Final temperature of soup.
3. Time final temperature according to directions is achieved.
Registered Dietitian or Acting Food Service Director will review above information on a weekly basis and report at QAPI on JULY 27, (YEAR) and then quarterly until 100% compliance.
Food temperature thermometers will be calibrated by Acting Food Service Director or designee on a weekly basis. If a thermometer has been dropped, it will be calibrated immediately. The ice point method is used. Outcome is documented on a chart for each Bimetallic stemmed thermometer.
Registered Dietitian or Acting Food Service Director will review above information on a weekly basis and report at QAPI on JULY 27, (YEAR) and then quarterly until 100% compliance.
The person responsible for ensuring that the corrective action was implemented and monitored is the Registered Dietician and/or their designated representative.

FF10 483.12(a)(3)(4)(c)(1)-(4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: 483.12(a) The facility must- (3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the recertification survey, it was determined that the facility did not conduct the minimum required background checks on new employees. Facilities may not employ individuals with a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Specifically, required State nurse aid registry checks (NAR) were not conducted on 1 of 5 new employees reviewed. This is evidenced as follows. The personnel files for Licensed Practical Nurse #1 were reviewed on 06/19/2017; this record review revealed that the facility had not conducted State nurse aid registry check for this individual. The Administrative Assistant stated in an interview conducted on 06/19/2017 at 11:15 am, that State nurse aid registry checks are not conducted on licensed employees. The facility policy Pre-Employment Requirements was reviewed on 06/19/2017. This policy states that as a pre-employment requirement, the Administrative Assistant will conduct a NAR check. 483.13(c)(1)

Plan of Correction: ApprovedJuly 14, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** To ensure that the Center does not employ individuals with a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED].
Employee #1 was not employed at the time of survey. A State nurse aide registry check will be completed on all new hires. A ?new hire and termination checklist? was implemented on 7/10/2017.
To determine if other residents were affected by the deficient practice; All current licensed employee personnel files will be audited to ensure they contain a State nurse aide registry check. It was determined that all current employees have a State nurse aide registry check completed. This was completed 7/13/17.
To ensure the deficient practice does not recur; the policy and procedure ?Steps to Hiring an Employee? was revised to include the following changes; implementation of a ?new hire and termination checklist.? The ?new hire checklist includes State nurse registry check, office of professions, finger prints, CHRC date entry, CHRC determination letter, CHRC termination, and payroll.
To monitor the corrective action to ensure that the deficient practice will not recur:
All new hire personnel files will be audited weekly for 15 weeks for completion of State nurse aide registry check. The results will be reviewed at the QAPI meeting on 7/27/17 at 0800 and again at the next quarterly meeting on 10/26/17, and the need for continued monitoring will be reviewed.
Person responsible for compliance; Administrative Assistant

Standard Life Safety Code Citations

K307 NFPA 101:COOKING FACILITIES

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

Based on staff interview during the recertification survey, it was determined that the facility did not protect all cooking facilities in accordance with adopted regulations. NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Section 11.1.4 requires that instructions for manually operating the kitchen fire-extinguishing system shall be reviewed with employees by the management. Specifically, 2 of 3 kitchen staff interviewed did not know how to manually activate the kitchen fire-extinguishing system and the facility management had not reviewed the procedure with the employees. This is evidenced as follows. When interviewed on 06/19/2017 at 9:30 am, the Dietary Aide #1 stated that she had been provided written instructions only on the manual activation of the kitchen fire suppression system and, when asked, did not know how to manually operate the kitchen fire-extinguishing system. When interviewed on 06/19/2017 at 9:33 am, Dietary Aide #2 did not know how to manually activate the kitchen fire suppression system and stated that she had not received instruction on how to manually operate the system. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.2.3; 2011 NFPA 96 11.1.4; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.2.6; 1998 NFPA 96

Plan of Correction: ApprovedJuly 14, 2017

To correct the deficiency as listed in Tag K324 and to ensure that the Center for Nursing and Rehabilitation at Hoosick Falls protects all cooking facilities in accordance with regulations according to NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition Section 11.1.4 the following steps have been taken:
1. Instructions for manually operating the kitchen fire extinguisher system are now posted on the wall with the manual pull system.
2. All new employees at the Center are shown the location of the manual pull system as part of Facility Fire and Safety Orientation. A new hire orientation checklist will be enacted by 7/21/17, with instruction and evaluation codes, the date instructed, and the manager and employee?s initials. The form will be kept in the employee HR file.
3. All new Dietary Employees are shown the location of the Ansul System during Orientation.
4. All current employees have been instructed on location and use of manual pull system.
5. Instructions for manually operating the kitchen fire extinguishing system shall be reviewed with employees by management on a yearly basis.
To monitor the corrective action to ensure that the deficient practices will not recur 5 employees each week will be questioned on purpose, location and use of manual kitchen fire extinguishing system. This will be done by the Registered Dietitian and reported at QAPI quarterly meeting on 7/27/17 and quarterly thereafter until 100% compliance.
The person responsible for ensuring that the corrective action was implemented and monitored is the Dietary Director and/or their designated representative.

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 20, 2017
Corrected date: August 15, 2017

Citation Details

Based on employee interview and policy record review during the recertification survey, it was determined that the facility did not develop maintenance policies for and provide records for all testing and repairs of all patient-care electrical equipment in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.5.2.1 requires that facilities shall establish policies and protocols for the type of test and intervals of testing for patient care-related electrical equipment (PCREE). Specifically, the facility did not develop maintenance policies for all patient-care related electrical equipment. This is evidenced as follows. The facility maintenance policies and records were reviewed on 06/20/2017. No comprehensive maintenance records or policy for PCREE was available for survey review. The Maintenance Director stated in an interview conducted on 06/20/2017 at 10:30 am, that the facility does not have a specific maintenance policy for PCREE, but a policy will be developed that includes all required testing and maintenance. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.5.2.1.1, 10.5.6; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3

Plan of Correction: ApprovedJuly 14, 2017

To correct the deficiency for Tag K921, 101 Life Safety Code Electrical Equipment ? Testing and Maintenance Requirements, policies and procedures are being enacted along with audit checklists for testing of all patient care-related electrical equipment (PCREE). These policies and procedures, and education of Maintenance and applicable staff will be completed by (MONTH) 31, (YEAR), to be in compliance with the Life Safety Code for Testing and Maintenance of Electrical Equipment.
A record of such testing and/or repairs or modifications will be kept and filed in the Maintenance Office for review at any time. Service Manuals, instructions and procedures are on file for all equipment in accordance with 10.5.3.1.1. All electrical Equipment and Instructions will be readily available and safety labels and operating instructions on the appliance legible.
Personnel will be trained as new equipment or modified equipment comes in. Any equipment associated with the proper testing for the equipment needed will be on hand for such testing.
To monitor the corrective action to ensure that the deficient practice will not recur, The Testing and Maintenance Requirements policies and procedures will be reviewed at least yearly, and staff re-educated on testing procedures when changes occur.
The results of the testing will be reviewed at the QAPI meeting on 7/27/17 at 0800 and again at the next quarterly meeting on 10/26/17. Thereafter, a report will be provided at each safety meeting.
The person responsible for ensuring that the corrective action was implemented and monitored is the Director of Maintenance and/or their designated representative.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey it was determined that 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 (heads) be free of foreign materials, such as dust. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows. An assessment of the sprinkler system was conducted on 06/19/2017 at 8:45 am, and again on 06/20/2017 at 10:10 am. Two sprinkler heads in the main kitchen, 6 sprinkler heads in the main dining room, 3 heads in the A-Unit nurse station, 2 heads in the lobby, 2 heads in the physical therapy room, and one head each in the B-Unit nourishment room, B-Unit staff wash room, B-Unit corridor, and resident rooms 100, 106, 194, 195, 196, and 197 were found with a coating of dust. The Maintenance Director stated in an interview conducted on 06/20/2017 at 10:10 am, that the building itself is dusty, but he will clean the dusty sprinkler heads at least quarterly. 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 14, 2017

To correct the deficiency as listed in Tag K 353, NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Based Fire Protection Systems 2014 Edition and to ensure that all sprinklers are installed and properly maintained and clear of all obstructions, including dust and/or any other obstruction. The Center's maintenance staff have audited all sprinklers in compliance with the regulation.
To monitor the corrective actions to ensure that the deficient practice will not recur, the maintenance staff will monitor and ensure continued compliance with NFPA 25, Testing and Maintenance of Water Based Fire Protection Systems, with a quarterly inspection which will be added to the already in-place inspection done at present. This will be listed and noted on the inspection sheet, ?Sprinkler Head Audit?, clean of dust and/or any other foreign obstruction of any kind.
All sprinkler heads within the facility have been cleaned and cleared of dust and any other obstructions at the last Sprinkler Inspection performed on 6/27/2017. The results of the Sprinkler Inspections will be reviewed at the QAPI meeting on 7/27/2017 at 0800 and again at the next quarterly meeting on 10/26/17.
The person responsible for ensuring that the corrective action was implemented and monitored is the Director of Maintenance and/or their designated representative.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 15, 2017

Citation Details

Based on observation and staff interview during the recertification survey, it was determined that the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 8.5 requires that smoke barriers shall be continuous from floor to the underside of the roof and through all concealed spaces, and penetrations and miscellaneous openings be sealed with materials capable of maintaining the smoke rating of the smoke barrier wall. Specifically, 1 of 1 smoke barriers observed were not continuous and penetrations were not sealed. This is evidenced as follows. The A-Unit north smoke barrier wall (wall) was inspected on 06/20/2017 at 9:00 am. Viewing from above the ceiling, an 8-foot length of 4-inch by 3-inch spaces were found where the wall did not meet the underside of the roof. The Maintenance Director stated in an interview conducted on 06/20/2017 at 9:00 am, that he did not know why the wall did not meet the underside of the roof and that it could be from original construction. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedJuly 14, 2017

To correct the deficiency as listed in Tag K 372, NFPA 101, Subdivision of Building Spaces ? Smoke Barrier, all smoke barriers will be audited to ensure they are continuous from the floor to the underside of the roof as per regulation. Those found not meeting the underside of the roof decking will be done and/or re-done to ensure compliance with the NFPA 101 Life Safety Code 2012 edition section 8.5.
To monitor the corrective actions to ensure that the deficient practice will not recur, all smoke barrier walls will be audited by (MONTH) 31, (YEAR), and any penetrations will be sealed with materials capable of maintaining the smoke barrier wall. A contractor and/or the Maintenance staff will complete the improvements of applicable deficit smoke and fire walls within the facility by (MONTH) 15, (YEAR), to ensure continued compliance. Yearly audits will be conducted to ensure continued compliance. The results will be reviewed at the QAPI meeting on 10/27/17, and at the next meeting following inspections.
The person responsible for ensuring that the corrective action is implemented and monitored is the Director of Maintenance and/or their designated representative.